Arterial embolization caused by injection of hyaluronic acid (Restylane)

Efficacy of Superselective Intra-arterial Recanalization of Embolized Arteries Resulting from Facial Hyaluronic Acid Injection

BACKGROUND

Arterial embolism is a rare complication caused by hyaluronic acid (HA) injection. However, it is one of the most serious complications. Once it happens, the complication would have a great and long-term impact on patients. Intra-arterial recanalization has been reported for recovering the visual acuity in patients with visual loss caused by hyaluronic acid. There is little report about the benefits of superselective intra-arterial recanalization therapy for skin wounds caused by hyaluronic acid vascular embolization.

METHODS

Eight patients who had received the superselective intra-arterial recanalization therapy were retrospectively reviewed. Hyaluronidase was injected into the facial artery by superselective intra-arterial recanalization therapy, followed by symptomatic treatment. The facial artery recanalization was successfully performed and no interventional procedure-related adverse events happened.

RESULTS

Arterial embolization accompanies by the interruption or reduction of blood supply, followed by ochrodermia, pain, numbness, swelling, yellowish white secreta and even necrosis on skin wound area. Early detection of skin blood supply disorders and early recovery of blood supply are very critical to treat facial artery embolization caused by HA. After superselective intra-arterial recanalization therapy, the blood supply to facial skin was restored and skin wounds recovered in all patients. Only 1 patient was left with small and superficial scars.

CONCLUSION

Superselective intra-arterial recanalization therapy is an effective and safe method that can alleviate skin wounds caused by HA vascular embolization.

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 .

Consensus statement on prevention and management of adverse effects following rejuvenation procedures with hyaluronic acid-based fillers

Facial fillers play an important role in the correction of facial changes associated with ageing. They offer quick treatments in the outpatient setting with minimal subsequent downtime that provide predictable, natural-looking, long-lasting results. Adverse reactions after hyaluronic acid injections tend to be mild or moderate and rather temporary. However, as with all injected or implanted biomaterials, severe adverse events can occur and patients must be fully informed of potential risks prior to undergoing treatment. A panel of experts from Germany (D), Austria (A) and Switzerland (CH) developed recommendations, and this study provides the 'DACH Consensus Recommendations' from this group specifically on the use of hyaluronic acid fillers. The aim is to help clinicians recognize potential risks and to provide guidance on how best to treat adverse events if they arise. Contraindications to hyaluronic acid fillers are also detailed, and ways to prevent adverse events occurring are discussed. Hyaluronic acid-based products are claimed to be very close to an ideal tissue augmentation agent; nevertheless, profound medical, anatomical and product knowledge are of paramount importance to minimize the occurrence of adverse reactions.

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.

[Efficacy and tolerability of highly crosslinked hyaluronic acid injections in the management of the enophthalmous orbit]

OBJECTIVE

Evaluation of the efficacy and tolerability of highly crosslinked hyaluronic acid injections in treating the enophthalmous orbit.

METHODS

Retrospective study of 11 enophthalmic patients who received an intraorbital injection of Juvederm(®) Voluma between June 2007 and October 2008. The mean follow-up was 19 months (range 12-25 months).

RESULTS

Twelve orbits of 11 patients were treated, including nine with post-enucleation socket syndrome (PESS). Volume loss was corrected in 66.67% of cases (eight orbits) with only one intraorbital injection. Two patients requested an additional injection, achieving a final success rate of 83.33%. A rate of 16.67% (two orbits) developed some bruising, mild swelling and hypersensivity at the injection site within 24 hours of administration of the filler, representing minor, temporary side-effects of which the patients had been forewarned. Persistent edema was noted in 16.67% of cases, likely due to an overcorrection of ptosis, and ptosis was exacerbated in 16.67% of cases (two orbits). One ptosis was corrected after several months, with no particular difficulties related to the hyaluronic acid. No additional complications were identified.

CONCLUSION

Juvederm(®) Voluma appears to be an effective filler for reduction of enophthalmos with a single intraorbital injection. In our experience, this product seems to have a longer duration of action than reported by the manufacturer and appears to perform like a semi-permanent or even permanent filler.

Review of long-term adverse effects associated with the use of chemically-modified animal and nonanimal source hyaluronic acid dermal fillers

Although only recently introduced, chemically-modified hyaluronic acid dermal fillers have gained widespread acceptance as "redefining" dermal fillers in the fields of dermatology and cosmetic facial surgery. Although hyaluronic acid-based dermal fillers have a low overall incidence of long-term side effects, occasional adverse outcomes, ranging from chronic lymphoplasmacytic inflammatory reactions to classic foreign body-type granulomatous reactions have been documented. These long-term adverse events are reviewed.

Combination therapy with BOTOXtm and fillers: the new rejuvnation paradigm

Until relatively recently, restoration of appearance by replacement of lost facial volume and muscular relaxation has been an illusory goal. With advances in the commercial availability of newer filling agents and a better understanding of the clinical esthetic effects of botulinum toxin A, remarkably sophisticated and refined results can now be achieved by using these noninvasive techniques. The combined use of BTX-A and filling agents, such as collagen and hyaluronic acid, can restore facial appearance by the dual mechanisms of reflation and relaxation. In addition, their combined use appears to increase the longevity of tissue dwell time of the filling agent. Current practices now strive to correct wrinkles by restoring volume and also relaxing the pull of muscles that create negative facial expressions such as glabellar folds, mouth frown, crow's feet, horizontal forehead lines, and perioral and cervical rhytides. As with any of the new technological innovations currently available, understanding of the differing properties of the agents used and education in optimal technique is essential to clinical and esthetic success.

The histological aspects of fillers complications

The histological aspects of resorbable heterologous fillers (bovine collagen, acid hyaluronique), autologous fillers (lipofilling, dermis-fat graft), biodegradable fillers (New-Fill), and permanent fillers (silicone, Artecoll, Evolution, Aquamid, DermaLive, DermaDeep, Bioplastique, Paraffin) are described. This article relates the morphological aspect of these materials, the normal tissue reaction after injection, and its chronological evolution as the morphological aspects from the different side effects, more frequently observed for the permanent fillers. They mainly consist of granulomatous reactions which may appear long after injection.