Adverse Effects When Injecting Facial Fillers

Adverse effects of the aesthetic use of botulinum toxin and dermal fillers on the face: a narrative review

OBJECTIVE

To evaluate the adverse effects of facial aesthetic treatments using botulinum toxin and biomaterial implants.

METHODS

The bibliographic research for this narrative review considered articles published in journals from the Medline, Pubmed, Embase and Lilacs databases with the following terms: "dermal fillers AND complications, vascular complications AND dermal fillers, adverse reaction, AND toxin botulinum and adverse reaction AND dermal fillers". Inclusion criteria were articles available in English on adverse events with the aesthetic use of botulinum toxin and dermal fillers/biostimulators.

RESULTS

The demonstration of complications increases simultaneously with the progressive performance of facial aesthetic procedures. Quantitative statistics of the procedures and the countries that use them are skillfully classified, as well as the prosperity trends of these procedures. Complications do not receive the same relevance. There is a deficiency in dissemination of the information by the scientific community, or in other words, there is a publication bias in favor of successful results as opposed to adverse events.

CONCLUSION

The lack of knowledge about complications arising from so widely publicized and performed procedures prevents the development of evidence-based guidelines. Complications in aesthetic procedures have become a public health problem, an epidemic that occurs under the supervision of health authorities. Mandatory reporting of adverse events occurring in aesthetic procedures that require medical care aims to fill this gap. With reliable and technical data, it will be possible to identify the causes and perform interventions capable of minimizing irreversible sequelae and deaths. Complications should be promptly recognized by the dermatologist so that, when possible, they can be reversed or adequately managed.

TFOS Lifestyle: Impact of cosmetics on the ocular surface

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

Patterns of Filler-Induced Facial Skin Ischemia: A Systematic Review of 243 Cases and Introduction of the FOEM Scoring System and Grading Scale

BACKGROUND

The incidence of facial skin necrosis has increased considerably because of the growth in the popularity of dermal fillers. This study describes the patterns and severity of facial skin ischemia, along with associated neuro-ophthalmologic injuries, in the published literature through the introduction of the facial artery, ophthalmic artery, distal external carotid artery, internal maxillary artery (FOEM) facial angiosome scoring system and grading scale.

METHODS

A systematic review of all photographic cases of facial skin ischemia attributable to vascular occlusion with dermal fillers and injectable materials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 243 cases were identified, with 738 digital clinical photographs retrieved. The facial artery (58% of cases) and ophthalmic artery (48% of cases) angiosomes were most commonly affected. The frontonasal and angulonasal territories were the most common facial skin segments injured by filler-induced vascular occlusion. Cutaneous involvement of the ophthalmic angiosome was significantly associated with neuro-ophthalmologic complications [vision loss, 39% versus 0.8% ( P = 0.00001); stroke, 8% versus 0.8% ( P = 0.0085)]. Injuries with greater cutaneous surface area or cross-angiosome involvement were associated with a higher incidence of severe visual deficits and bilateral stroke.

CONCLUSIONS

Facial skin necrosis attributable to vascular occlusion is a rapidly growing problem that has remained poorly characterized in the literature. This study provides the largest descriptive analysis of published photographic reports of skin ischemia to date and proposes a novel scoring system and grading classification to aid in future reporting.

Complicated Facial Fillers: Management Algorithm

Background:

Various materials have been developed as skin fillers to correct wrinkles of the face. Dermal fillers are classified based on their biodegradability into bioresorbable versus nonbioresorbable. All dermal fillers have a potential risk of complications, which can be classified as early and late onset events. Among all the complications of filler injections, inflammatory nodules and granulomas are the most annoying and disfiguring. The purpose of the study was to provide a surgical treatment algorithm that allows us to deal with the complications of facial fillers through three surgical techniques.

Methods:

Thirty-one patients with complaints of facial contour abnormalities after filler injection, three surgical techniques were adopted according to the presenting case including face lift incision, needle aspiration and intraoral excision after preoperative preparation of the case with postoperative follow-up for 6 months.

Results:

Among our studied patients treated by these surgical techniques, dissection was difficult owing to the fibrosis and the granulomatous reaction post complicated filler injection. There were two cases of hematoma, 1 case of seroma, and 1 case of facial nerve injury that improved after 4 months, in which marked improvement of facial contour and skin quality was observed.

Conclusions:

The use of the facelift technique as a surgical treatment for post filler complication granuloma excision provides a useful and satisfactory method for patients complaining of major facial deformities following repeated complicated filler injections. Despite being more difficult than other techniques it is more satisfactory in facial rejuvenation post complicated facial fillers.

Hyaluronic Acid Fillers Enriched with Glycine and Proline in Eyebrow Augmentation Procedure

Background

The eyebrow area is a clinically critical district due to the anatomical complexity and the propensity to aging-related atrophy. Hyaluronic acid fillers have been proposed to recover the dermal volume of the facial and lips regions.

Aim

The aim of the present investigation was to evaluate hyaluronic acid fillers enriched with glycine and proline for the treatment of eyebrow augmentation.

Methods

A total of 15 healthy patients were treated with eyebrow augmentation procedure. The distance between mid-bipupil to lateral eyebrow and mid-eyebrow to the medial eyebrow was measured before, immediately after treatment and at follow-up of 6 months.

Results

The healing period was uneventful, and no evidence of inflammation or swelling associated with the treatment was reported. No macroscopical alteration was reported in the surrounding tissues with no evidences of visible wheals or lumps in the treated sites at the follow-up. Before treatment, the angle was equal to 9.32 ± 0.2°, while after treatment it was 11.21 ± 0.4° (p < 0.01); after three and 6 weeks, it was, respectively, 10.66 ± 0.2° (p<0.05) and 10.02 ± 0.3°(p > 0.05).

Conclusions

The study results suggest that the hyaluronic acid fillers enriched with glycine and proline treatment resulted as being a useful procedure for augmentation, contour and volume definition and elevation of the eyebrow region with a high-level aesthetic result.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Complications and Disasters After Minimally Invasive Tissue Augmentation with Different Types of Fillers: A Retrospective Analysis

BACKGROUND

The interest in youthful appearance and rejuvenating procedures is unbroken in our society. Besides surgical procedures, permanent fillers are utilized. The incorrect and unprofessional use of these substances, auto-injections in particular, have devastating results for patients and are challenging for the plastic surgeon. The aim of this retrospective study was to delineate the differences between permanent and non-permanent filler complications and appropriate treatment options.

METHODS

We conducted a retrospective study and researched the hospital information system in the time period from 2001 to 2020. Patients with unprofessional use of permanent fillers, auto-injections and injections of unformulated substances were determined. Age, gender, localization, complications, length of hospital stay, comorbidities, histopathological workups and surgical salvage procedures were noted. Descriptive statistics were calculated.

RESULTS

Seventeen patients were identified from 2001 till 2020. In four cases, auto-injections by the patients were the cause, whereas in the other patients the injections were performed by medical staff. Ages range from 18 to 57 years. Fourteen patients were female and three were male. The injected substances could be recognized as synthol, silicone, vaseline, fat tissue, hyaluronic acid as well as non-medical substances. Surgical procedures were necessary in eleven cases. One patient died because of the underlying diseases.

CONCLUSION

Our results indicate different sequels of filler materials injected in an unprofessional way, possible complications, conservative and surgical techniques to resolve these rare complications. We suggest a staged therapy adjusted to the clinical symptoms. Milder symptoms can be handled conservatively, whereas severe infections, skin breakdowns or persistent granuloma are justifying indications for surgical treatment.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Physicians' and patients' self-perceptions of hyaluronic acid-based facial volumization: Are they compatible?

BACKGROUND

Facial filling based on hyaluronic acid (HA) is an esthetic procedure that is widely performed worldwide.

METHODOLOGY

Fifty patients underwent facial filling based on HA, and 10 board-certified dermatologists evaluated clinical photographs before and after the procedure and completed a questionnaire to provide information about the procedure.

RESULTS

All doctors and 96% of patients were agreed about the pre- and postprocedural photographs. Physicians were more aware of the possibility of frequent pain and erythema. Both groups showed agreement in their responses on the following topics: the possibility of hematoma and edema, a lack of secretion, improvement in patients' self-confidence, recognition of the procedure by third parties, and knowledge of the procedure by the dermatologists themselves. However, physicians tend to overestimate the possibility of erythema, pain, and edema; they also tend to minimize the duration and discomfort of postprocedural edema and the risk of third parties noticing patients' HA filling and how much it bothers patients when third parties do notice.

CONCLUSION

Doctors and patients disagree on some questions about what actually happens and what is supposed to happen in facial filling procedures based on HA.

Nonvascular Complications of Injectable Fillers-Prevention and Management

Injectable filler treatments have increased in popularity because of enhanced safety profile and improved physical characteristics. ISAPS (International Society of Plastic Surgery) put out global data showing 3.7 million hyaluronic acid (HA) filler procedures in 2018, making it the second most often performed procedure in the world, after botulinum toxin. And these are only ‘those’ performed by qualified plastic surgeons. There was a concomitant increase in both the nonvascular and vascular complications, which coincided with the number and type of filler procedures performed. Filler complications were reviewed from existing literature, and an attempt was made to understand etiology, elucidate clinical features, and clarify optimum treatment strategies for each. Complications can be early or delayed in presentation, early consisting of injection site complications like bruising, edema, and hypersensitivity, Tyndall effect, and intravascular injection. Delayed complications included hypersensitivity type IV, acute infections like cellulitis, abscesses, and herpes and delayed ones like granulomas, biofilms, and atypical mycobacterial infections. These were analyzed and treatment options, protocols, and consensus guidelines were suggested. A clear understanding of facial anatomy, physical characteristics of all fillers used, early recognition, and treatment options of complications will ensure optimum outcomes.

Non-surgical Rhinoplasty and Use of Hyaluronic Acid Based Dermal Filler-User Experience in Few Subjects

This study was intended to assess the utility of hyaluronic acid dermal fillers in patients who do not wish surgery in addition to the patients with minor post-surgery asymmetries. This was a prospective study which included post-surgery patients for minor nasal asymmetries, patients unwilling for surgery and those waiting for revision surgery. It is of great use in candidates who do not wish surgery but had the desire for different nasal appearance especially for important life events like marriage etc. This study included 20 patients with follow up period of 18 months. The results were compared on Nasal Imperfection Scale and Rhinoplasty Outcome Evaluation along with pre and post injection photographs. Nasal Imperfection Scale difference of 5 and Rhinoplasty Outcome Evaluation Scale differential of 50 is considered to be significant, which was observed in all individual cases. The growing need of medical rhinoplasty by the patient as well as surgeons has led to the introduction of fillers. Hyaluronic acid fillers are safe, easy and effective dermal fillers for patients undergoing all the expected indications of medical rhinoplasty. There is also growing number of candidates who wish for a 'nose job' for desired changes without coming under surgeon's scalpel. Our clinical experience with 20 patients has been described with satisfactory results.

Management of noninflammatory nodule in chin after a large volume bolus injection of hyaluronic acid filler

As most Asian women desire to have an "inverted triangle" appearance for face, there is an increasing trend to give a large volume bolus (LVB) injection in the submental region of the chin for its lengthening. Hyaluronic acid (HA) dermal fillers are very popular for facial contouring and reshaping, including the chin area. Filler injection in the submental area has been a popular method to lengthen the chin. Placing an LVB of HA filler material at one place can present as the formation of lump or nodule after injection. We present a case of formation of a nodule in the submental area after injection of a single LVB of filler. The nodule was injected with hyaluronidase 3 months after its formation, and a near-complete resolution was seen immediately. Complete disappearance of the nodule was found at follow-up after 10 days. LVB of HA filler can give rise to the formation of noninflammatory nodules after filler injection in the immediate post-injection period. Knowledge of the type of filler material and presenting features can help in instituting the correct line of treatment for the resolution of signs and symptoms. Also 0.5 mL of filler can be recommended as maximum size of single LVB, based on the mathematical calculations.

Management of Lip Complications

This article discusses complications that may occur after procedures on the lips, specifically focusing on injectable fillers. Evidence-based guidelines and suggested methods to manage these complications are presented in a systematic format.

Periocular hyaluronic acid fillers: applications, implications, complications

PURPOSE OF REVIEW

The use of dermal filler in the periocular area is increasing - both for functional and aesthetic indications. Hyaluronic acid fillers dominate the market; these treatments offer an alternative to some surgical procedures with the advantage of instant results, minimal healing time and low complication rates. However, success depends on judicious selection of patients, products and procedures to achieve favourable outcomes. This article reviews current understanding of the principal complications in the periocular area and their management.

RECENT FINDINGS

Hyaluronic acid is a ubiquitous, biodegradable, nonspecies-specific molecular substrate with limited potential for immunogenic reactions. However, in the periocular area, such products can migrate and last significantly longer than the expected filler lifespan. Contamination or subsequent immune stimulation can trigger delayed-onset inflammatory reactions. Though minor vascular occlusions are not uncommon, cases of blindness secondary to facial filler injections are thought to be rare. Timely enzymatic degradation with injectable hyaluronidase can be effective in the treatment of some such complications. But recent studies demonstrate lack of penetration through arterial walls and optic nerve sheath, casting doubt on the role of retrobulbar hyaluronidase in the management of vision loss because of embolism with hyaluronic acid filler.

SUMMARY

Hyaluronic acid fillers represent an emerging and important addition to the armamentarium of the oculofacial plastic surgeon with their use in the aesthetic field also expected continue to rise. The oculoplastic facial surgeon, armed with a thorough knowledge of facial anatomy, safe injection planes and the means of minimizing and treating complications is in the best position to lead clinically in the use of this well tolerated and effective treatment modality.

Practical Approach and Safety of Hyaluronic Acid Fillers

Supplemental Digital Content is available in the text.

Soft-tissue filler use has grown considerably related to the increasing popularity of minimally invasive cosmetic procedures. Hyaluronic acid products are currently the most utilized soft-tissue fillers. Proper working knowledge of individual products, limitations to use, and anatomic principles can improve outcomes. Prevention is key to minimize complications; however, when present, complications must be managed methodically. Complications are categorized based on the timing of presentation and include early, late, and delayed. Vascular compromise and tissue necrosis are among the most devastating complications seen with filler use. Nodules can be related to an inflammatory or infectious etiology but should be distinguished as treatment varies. Hyaluronidase is mandatory to have available as a reversal agent for hyaluronic acid products and can be used in treatment for many complications and untoward sequela.

Upper Eyelid Filling Approach [U.E.F.A.] Technique: State of the Art After 500 Consecutive Patients

BACKGROUND

Lately, it has become evident that eye physical aging is mainly due to depletion of the upper eyelid fat causing laxity and wrinkles of the eyelid skin, and new therapeutic strategies aimed at solving the volume loss have appeared in the literature. The aim of this study is to provide a clear classification of upper eyelid aging after 500 consecutive cases and to present a standardization of the therapeutic approach to be adopted when using hyaluronic acid (HA) as fillers or a surgical approach.

METHODS

The upper eyelid aging process of a total of 500 patients was classified based on the measurement of the pre-tarsal skin show m and the pre-septal skin show N. A total of 382 patients were treated exclusively with HA injections in the upper eyelid, 45 patients both with blepharoplasty surgery and HA filling, whereas only 73 patients underwent blepharoplasty only.

RESULTS

Patient satisfaction and at least 1-year clinical follow-up were used to evaluate the results. Pre-treatment and post-treatment photographic assessment was considered as well. A total of 447 patients were women, whereas 53 were men. The correct ratio between m and N was restored in all cases.

CONCLUSIONS

HA filling can be used as either the only volumization procedure or together with blepharoplasty to restore upper eyelid volume loss. The correct strategy has to be selected on the basis of a clear classification. The upper eyelid filling approach is a safe, manageable, lasting and low-cost technique providing excellent results when the correct procedure is followed.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Complications of glans penis augmentation

Despite the controversy regarding penile augmentation (PA), glans penis augmentation (GPA) is used in penile reconstructive surgery in selected patients with small glans penis. Since 2003, injectable hyaluronic acid (HA) gel has been used for GPA. The attractiveness of HA gel fillers and interest in this technique have led to the use of other fillers for GPA, particularly irreversible fillers that improve the longevity of HA gels. Conversely, indirect glans augmentation via implantation of dermofat grafts or scaffolds between the corpus spongiosum and the distal tip of the corpus cavernosum is used to overcome poor longevity of the gel and glans surface undulation, which are the primary limitations of GPA using HA gel. Unfortunately, these implants form hard painful lumps over time in most patients and are difficult to remove. Blunt dissection is an invasive procedure that may cause vascular compromise and consequent glans necrosis in a few patients. We present our review regarding the current status of GPA for a more comprehensive understanding of this subject. Additionally, we have discussed a few complicated cases that were referred to us.

A 10-point plan for avoiding hyaluronic acid dermal filler-related complications during facial aesthetic procedures and algorithms for management

The recent rapid growth in dermal filler use, in conjunction with inadequate product and injector control, has heralded a concerning increase in filler complications. The 10-point plan has been developed to minimize complications through careful preconsideration of causative factors, categorized as patient, product, and procedure related. Patient-related factors include history, which involves a preprocedural consultation with careful elucidation of skin conditions, systemic disease, medications, and previous cosmetic procedures. Other exclusion criteria include autoimmune diseases and multiple allergies. The temporal proximity of dental or routine medical procedures is discouraged. Insightful patient assessment, with the consideration of ethnicity, gender, and generational needs, is of paramount importance. Specified informed consent is vital due to the concerning increase in vascular complications, which carry the risk for skin compromise and loss of vision. Informed consent should be signed for both adverse events and their treatment. Product-related factors include reversibility, which is a powerful advantage when using hyaluronic acid (HA) products. Complications from nonreversible or minimally degradable products, especially when layered over vital structures, are more difficult to control. Product characteristics such as HA concentration and proprietary cross-linking should be understood in the context of ideal depth, placement, and expected duration. Product layering over late or minimally degradable fillers is discouraged, while layering of HA of over the same brand, or even across brands, seems to be feasible. Procedural factors such as photographic documentation, procedural planning, aseptic technique, and anatomical and technical knowledge are of pivotal importance. A final section is dedicated to algorithms and protocols for the management and treatment of complications such as hypersensitivity, vascular events, infection, and late-onset nodules. The 10-point plan is a systematic, effective strategy aimed at reducing the risk of dermal filler complications.

Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations

Background

Dermal fillers have been increasingly used in minimally invasive facial esthetic procedures. This widespread use has led to a rise in reports of associated complications. The aim of this expert consensus report is to describe potential adverse events associated with dermal fillers and to provide guidance on their treatment and avoidance.

Methods

A multidisciplinary group of experts in esthetic treatments convened to discuss the management of the complications associated with dermal fillers use. A search was performed for English, French, and Spanish language articles in MEDLINE, the Cochrane Database, and Google Scholar using the search terms “complications” OR “soft filler complications” OR “injectable complications” AND “dermal fillers” AND “Therapy”. An initial document was drafted by the Coordinating Committee, and it was reviewed and modified by the experts, until a final text was agreed upon and validated.

Results

The panel addressed consensus recommendations about the classification of filler complications according to the time of onset and about the clinical management of different complications including bruising, swelling, edema, infections, lumps and bumps, skin discoloration, and biofilm formation. Special attention was paid to vascular compromise and retinal artery occlusion.

Conclusions

Clinicians should be fully aware of the signs and symptoms related to complications and be prepared to confidently treat them. Establishing action protocols for emergencies, with agents readily available in the office, would reduce the severity of adverse outcomes associated with injection of hyaluronic acid fillers in the cosmetic setting. This document seeks to lay down a set of recommendations and to identify key issues that may be useful for clinicians who are starting to use dermal fillers. Additionally, this document provides a better understanding about the diagnoses and management of complications if they do occur.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Development of "Core Syllabus" for Facial Anatomy Teaching to Aesthetic Physicians: A Delphi Consensus

Background:

A detailed understanding of facial anatomy, specifically the vascular framework, is crucial for delivering safe nonsurgical aesthetic procedures. To date, there is no core document based on consensus for the teaching of facial anatomy to aesthetic physicians exists. The aim of this study was to ascertain the most critical anatomical structures for avoiding disastrous complications during nonsurgical aesthetic procedures.

Methods:

After a detailed literature review, Delphi questionnaire was developed listing 154 anatomical structures of the face and neck for consensus review. Thirty-five international experts in surgical and nonsurgical facial aesthetics were invited to complete an online survey designed to rank the relevance of each anatomical element on a Likert scale from 1 (not at all important) to 4 (very important) or 5 (no opinion). Consensus for items included in the core syllabus was predefined as achieving a Cronbach’s α ≥ 0.90 and an agreement score of ≥ 80%.

Results:

Thirty-four international experts (97.14%) completed the iterative online Delphi survey. The consensus among the specialists polled was achieved after 1 round of the survey (Cronbach’s α = 0.94). The expert panel reached an agreement score of ≥ 80% on 137 of the 154 anatomical structures listed.

Conclusion:

The outcome of this Delphi study represents an essential first step in systematizing an evidence-based facial anatomy “Core Syllabus” for the teaching of aesthetic physicians and practitioners. This “Core Syllabus” will act as a blueprint for the educators while crafting a program.

Dermal filler-associated malar edema: Treatment of a persistent adverse effect

A 72-year-old Caucasian female presented for evaluation of bilateral lower eyelid "fluid filled" bags that had been present and slowly worsening for 7 years. She reported a history of lower eyelid blepharoplasty in her 40s, as well as hyaluronic acid tear trough fillers 8 years prior to presentation. Her malar edema completely resolved following injection of hyaluronidase. To our knowledge, this is the longest reported interval for presentation and treatment of hyaluronic acid associated malar edema.

A novel combination regimen with intense focused ultrasound and pressure- and dose-controlled transcutaneous pneumatic injection of hypertonic glucose solution for lifting and tightening of the aging face

BACKGROUND

Intense focused ultrasound (IFUS) has demonstrated moderate efficacy for facial laxity of the aging face. Pressure- and dose-controlled transcutaneous pneumatic injections of hypertonic glucose solution (TPIG) are a minimally invasive way to deliver solution into the skin for therapeutic purposes. Recently, its application around temporal areas is known to exert early-onset lifting effects with facial contour rejuvenation.

AIMS

We sought to evaluate the safety and efficacy of this novel combination regimen with IFUS and TPIG for lifting and tightening of aging face.

PATIENTS AND METHODS

Twenty-two Korean subjects with mild-to-moderate facial skin laxity were evaluated after receiving a sequential single session of IFUS and TPIG treatments. Dermatologists' objective assessments for general appearance, and mid- and low faces based on photographic images were performed at 1- and 12-week post-treatment follow-ups. Patients' subjective assessments were also conducted. Skin biopsies were taken at baseline and the last visit.

RESULTS

Among 22 subjects, twenty (91%) demonstrated improvement after 12-week follow-up. We also observed similarly improved state just after 1 week of treatments (82%: 18/22). Specifically, improvement of the mid-face was evident from the first week, while the progress of the low face improvement was observed at the twelve week. Subjective assessments paralleled these findings. No seriously adverse effect was observed during procedures. Histologic evaluation showed greater dermal collagen fibers throughout the dermis after treatments.

CONCLUSION

Combination treatment with IFUS and TPIG has beneficial effects for skin lifting and tightening with early-onset time.

Durability of Three Different Types of Hyaluronic Acid Fillers in Skin: Are There Differences Among Biphasic, Monophasic Monodensified, and Monophasic Polydensified Products?

Background

Hyaluronic acid fillers are used for facial rejuvenation and are classified as non-cross-linked or cross-linked (monophasic mono- or polydensified).

Objectives

To histologically assess the intradermal durability of three types of fillers (biphasic, monophasic monodensified, and monophasic polydensified), to compare the durability of the products over 6 months, and to evaluate the structural changes after application.

Methods

In all, 25 volunteers received injections of three different fillers in the dermis of the right lumbar region (in one line), and equal amounts of the fillers were injected into three different sites (in the same column), yielding nine points of application in each patient. Each line was biopsied on days 2, 92, and 184; these skin samples were analyzed histologically, and the presence or absence of these fillers was verified by a dermatopathologist.

Results

The histological analysis showed that over 182 days, the amount of the injected monophasic polydensified, monophasic monodensified, and biphasic filler products decreased by 62.5%, 25%, and 12.5%, respectively.

Conclusions

The biphasic and monophasic monodensified fillers presented greater intradermal durability than did the monophasic polydensified filler at 6 months after intradermal injection.

Level of Evidence 2

Nonsurgical Rejuvenation of the Eyelids with Hyaluronic Acid Gel Injections

There has been an increased recognition for the role volume deflation plays in the aging periorbital area, and as such, rejuvenation strategies to augment and restore volume have developed and evolved. Hyaluronic acid fillers provide an efficient option for volume augmentation with good efficacy, longevity, and safety. An understanding of the changes in the upper and lower periocular area due to aging, the meticulous identification of focal hollows, and the precise delivery of filler to these areas can smooth contours and restore a rejuvenated periorbital area.

Dermal fillers in aesthetics: an overview of adverse events and treatment approaches

BACKGROUND

The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.

OBJECTIVE

To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance.

METHODS

Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors' extensive experience, recommendations for avoiding and managing complications are provided.

RESULTS

Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique.

CONCLUSION

For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.

Complications in the Cosmetic Dermatology Patient: A Review and Our Experience (Part 1)

BACKGROUND

Over recent decades, the options available to patients for cosmetic rejuvenation have expanded dramatically. The range of options commonly available to patients now includes neuromodulators, fillers, sclerotherapy, chemical peels, liposculpture, lasers, and lights and other energy devices and continues to grow. As with all therapeutic interventions, these cosmetic dermatologic procedures are not without risk. Timely recognition of complications and intervention are paramount for optimal patient outcomes.

OBJECTIVE

Part 1 of this review will focus on the common complications of injectable cosmetic procedures, such as neuromodulators, fillers, and sclerotherapy. The second part will discuss the complications of chemical peels, lasers, light and energy devices, and fat removal procedures.

MATERIALS AND METHODS

A MEDLINE search was performed on cosmetic dermatology complications from 1989 to 2015, and results are summarized. Practical considerations of these complications are also provided.

RESULTS

Reports of complications after neuromodulator, injectable hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, polymethylmethacrylate, sclerotherapy, fat transfer, liposuction, cryolipolysis, chemical peels, lasers, and light sources, such as Q-switched laser, intense pulsed light, nonablative and ablative resurfacing lasers, were found.

CONCLUSION

Review of the literature revealed multiple management options for potential complications of the multitude of cosmetic dermatology procedures now available to patients.

Patient factors influencing dermal filler complications: prevention, assessment, and treatment

While rare, complications do occur with the esthetic use of dermal fillers. Careful attention to patient factors and technique can do much to avoid these complications, and a well-informed practitioner can mitigate problems when they do occur. Since cosmetic surgery is usually an elective process, requested by the patient, clinical trials are complex to organize and run. For this reason, an international group of practicing physicians in the field of esthetics came together to share knowledge and to try and produce some informed guidance for their colleagues, considering the literature and also pooling their own extensive clinical experience. This manuscript aims to summarize the crucial aspects of patient selection, including absolute contraindications as well as situations that warrant caution, and also covers important considerations for the pre- and posttreatment periods as well as during the procedure itself. Guidance is given on both immediate and long-term management of adverse reactions. The majority of complications are related to accepting patients inappropriate for treatment or issues of sterility, placement, volume, and injection technique. It is clear that esthetic practitioners need an in-depth knowledge of all aspects of treatment with dermal fillers to achieve optimal outcomes for their patients.

MRI in the evaluation of facial dermal fillers in normal and complicated cases

OBJECTIVES

To ascertain by MRI the presence of filler injected into facial soft tissue and characterize complications by contrast enhancement.

METHODS

Nineteen volunteers without complications were initially investigated to study the MRI features of facial fillers. We then studied another 26 patients with clinically diagnosed filler-related complications using contrast-enhanced MRI. TSE-T1-weighted, TSE-T2-weighted, fat-saturated TSE-T2-weighted, and TIRM axial and coronal scans were performed in all patients, and contrast-enhanced fat-suppressed TSE-T1-weighted scans were performed in complicated patients, who were then treated with antibiotics. Patients with soft-tissue enhancement and those without enhancement but who did not respond to therapy underwent skin biopsy. Fisher's exact test was used for statistical analysis.

RESULTS

MRI identified and quantified the extent of fillers. Contrast enhancement was detected in 9/26 patients, and skin biopsy consistently showed inflammatory granulomatous reaction, whereas in 5/17 patients without contrast enhancement, biopsy showed no granulomas. Fisher's exact test showed significant correlation (p < 0.001) between subcutaneous contrast enhancement and granulomatous reaction. Cervical lymph node enlargement (longitudinal axis >10 mm) was found in 16 complicated patients (65 %; levels IA/IB/IIA/IIB).

CONCLUSIONS

MRI is a useful non-invasive tool for anatomical localization of facial dermal filler; IV gadolinium administration is advised in complicated cases for characterization of granulomatous reaction.

KEY POINTS

• MRI is a non-invasive tool for facial dermal filler detection and localization. • MRI-criteria to evaluate complicated/non-complicated cases after facial dermal filler injections are defined. • Contrast-enhanced MRI detects subcutaneous inflammatory granulomatous reaction due to dermal filler. • 65 % patients with filler-related complications showed lymph-node enlargement versus 31.5 % without complications. • Lymph node enlargement involved cervical levels (IA/IB/IIA/IIB) that drained treated facial areas.

Dermal fillers in aesthetics: an overview of adverse events and treatment approaches

Background

The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.

Objective

To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance.

Methods

Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors’ extensive experience, recommendations for avoiding and managing complications are provided.

Results

Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique.

Conclusion

For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.

The pivotal role of vascularization in tissue engineering

Vascularization is one of the great challenges that tissue engineering faces in order to achieve sizeable tissue and organ substitutes that contain living cells. There are instances, such as skin replacement, in which a tissue-engineered substitute does not absolutely need a preexisting vascularization. However, tissue or organ substitutes in which any dimension, such as thickness, exceeds 400 μm need to be vascularized to ensure cellular survival. Consistent with the wide spectrum of approaches to tissue engineering itself, which vary from acellular synthetic biomaterials to purely biological living constructs, approaches to tissue-engineered vascularization cover numerous techniques. Those techniques range from micropatterns engineered in biomaterials to microvascular networks created by endothelial cells. In this review, we strive to provide a critical overview of the elements that must be considered in the pursuit of this goal and the major approaches that are investigated in hopes of achieving it.

Complications following injection of soft-tissue fillers

BACKGROUND

Soft-tissue filler injection is a very common procedure in the United States. Although the safety profile is favorable, adverse events (AE) can occur, ranging from mild to severe in intensity.

OBJECTIVES

The authors performed a literature search to identify the facial sites most prone to severe complications. They review the course of these complications and discuss preventive measures.

METHODS

The National Library of Medicine, the Cochrane Library, and Ovid MEDLINE were searched, and relevant articles (published through August 2012) were retrieved based on prespecified inclusion criteria. The complications reviewed were limited to "severe" events, such as soft-tissue necrosis, filler embolization, visual impairment, and anaphylaxis. The filler materials included were those approved by the US Food and Drug Administration at the time of this study.

RESULTS

Forty-one articles, representing 61 patients with severe complications, were identified. Data collected from these case reports included filler type, injection site, complication site, symptom interval, symptom of complication, time to therapy, modality of treatment, and outcome. The most common injection site for necrosis was the nose (33.3%), followed by the nasolabial fold (31.2%). Blindness was most often associated with injection of the glabella (50%). An estimated incidence of 0.0001% for developing a severe complication was calculated by reviewing society-based filler data and case reports within same time period.

CONCLUSIONS

Although soft-tissue fillers are a popular choice for minimally invasive rejuvenation of the face, physicians should be aware of the serious potential adverse effects, recognize their presentations, and have appropriate treatments readily available.

Complications of minimally invasive cosmetic procedures: prevention and management

Over the past decade, facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular. Office-based, minimally invasive procedures can promote a youthful appearance with minimal downtime and low risk of complications. Injectable botulinum toxin (BoNT), soft-tissue fillers, and chemical peels are among the most popular non-invasive rejuvenation procedures, and each has unique applications for improving facial aesthetics. Despite the simplicity and reliability of office-based procedures, complications can occur even with an astute and experienced injector. The goal of any procedure is to perform it properly and safely; thus, early recognition of complications when they do occur is paramount in dictating prevention of long-term sequelae. The most common complications from BoNT and soft-tissue filler injection are bruising, erythema and pain. With chemical peels, it is not uncommon to have erythema, irritation and burning. Fortunately, these side effects are normally transient and have simple remedies. More serious complications include muscle paralysis from BoNT, granuloma formation from soft-tissue filler placement and scarring from chemical peels. Thankfully, these complications are rare and can be avoided with excellent procedure technique, knowledge of facial anatomy, proper patient selection, and appropriate pre- and post-skin care. This article reviews complications of office-based, minimally invasive procedures, with emphasis on prevention and management. Practitioners providing these treatments should be well versed in this subject matter in order to deliver the highest quality care.