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Barańska-Rybak W, Świerczewska Z, Lemiec A, Walker L. Triamcinolone Injection in the Treatment of Malar Edema. Dermatol Pract Concept 2024; 14:dpc.1402a117. [PMID: 38810029 PMCID: PMC11136127 DOI: 10.5826/dpc.1402a117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 05/31/2024] Open
Abstract
INTRODUCTION Tear-through deformities can be a detectable sign of facial aging. Over recent years, minimally invasive procedures such as hyaluronic acid filler injections have been shown to be effective in improving this area. Malar edema is the accumulation of fluid over the malar eminence persisting for 1 month or more. Given its nature, the management remains problematic. The most commonly reported treatment modality is injection with hyaluronidase. OBJECTIVES To determine the safety and efficacy of triamcinolone injection in the treatment of malar edema. METHODS A total of 15 female patients with malar edema, with a mean age of 43.77 years, were treated with triamcinolone injections. The volume injected was chosen by the investigator. Prior to the triamcinolone injection, all patients had been treated with hyaluronidase, which turned out to be ineffective in all cases. Patients were asked to note all adverse effects. RESULTS Satisfactory results were achieved after a single treatment session for 14 patients and after two treatments for one patient. Overall, injections with triamcinolone were well tolerated and no adverse reactions were reported. CONCLUSIONS Injection with triamcinolone appears to be a safe and effective option for the management of malar edema following hyaluronic acid filler injection. Nevertheless, further research with larger patient groups is compulsory.
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Affiliation(s)
- Wioletta Barańska-Rybak
- Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland
| | - Zuzanna Świerczewska
- Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland
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Karlin J, Vranis N, Dayan E, Parsa K. Post-Hyaluronic Acid Recurrent Eyelid Edema: Pathophysiologic Mechanisms and a Proposed Treatment Protocol. Aesthet Surg J Open Forum 2023; 5:ojad102. [PMID: 38828092 PMCID: PMC11140515 DOI: 10.1093/asjof/ojad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Background Hyaluronic acid (HA) filler injections for facial augmentation are commonly administered but can lead to post-hyaluronic acid recurrent eyelid edema (PHAREE). The pathophysiology of this condition has not been fully understood. Objectives To report the successful treatment of PHAREE using serial hyaluronidase and fractionated radiofrequency microneedling, with additional carbon dioxide laser skin resurfacing in selected patients. Methods Five patients with PHAREE were treated with serial hyaluronidase injections and fractionated radiofrequency microneedling, with 2 patients receiving carbon dioxide laser treatment. The patients were followed up for a minimum of 24 months. Results All patients reported a resolution of PHAREE signs/symptoms with no adverse effects or recurrence. One patient demonstrated complete resolution after a single treatment; 4 required a series of treatments. Conclusions The proposed treatment protocol may provide advantages over hyaluronidase alone for PHAREE. The impermeable malar septum, vulnerable eyelid lymphatics, and potential immunogenicity of HA fragments likely contribute to PHAREE pathophysiology. Further research on pathophysiologic mechanisms is warranted. Level of Evidence 4
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Affiliation(s)
| | | | | | - Kami Parsa
- Corresponding Author: Dr Kami Parsa, 465 N Roxbury Dr, Ste 1011, Beverly Hills, CA 90210, USA. E-mail:
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Parikh AO, Conger JR, Sibug Saber ME, Samimi D, Burnstine MA. Multiple Cases of Facial Disfigurement From Filler Use and One Injector. Ophthalmic Plast Reconstr Surg 2023; 39:366-369. [PMID: 36735327 DOI: 10.1097/iop.0000000000002323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To present a case of facial disfigurement from an injectable permanent filler and describe the consequences to patients exposed to the same injector (common source outbreak). METHODS Case report and discussion of a common source outbreak after a group of persons developed complications years after permanent filler given by one injector. RESULTS A 39-year-old transgender model underwent polymethylmethacrylate (Artefill) facial filler injections to the lips, cheeks, and chin in 2018. A year later, the patient presented to the emergency room with severe facial swelling and difficulty breathing. Treatments have included 4 surgeries to remove filler and scar tissue and chronic low-dose oral steroid therapy. Upon questioning the patient, 6 additional people suffered from similar facial swelling years after injection by the same injector. The injector cannot be located. CONCLUSIONS Care must be taken in giving all facial fillers, particularly permanent ones. When one source patient is identified, questioning the patient's knowledge of others affected is critical to help manage an epidemic problem and to report a rogue injector. Physicians have a duty to investigate and report such cases.
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Affiliation(s)
- Alomi O Parikh
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jordan R Conger
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California
- Eyesthetica, Los Angeles, California
| | - Maria E Sibug Saber
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California
- Department of Pathology, University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A
| | - David Samimi
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California
- Eyesthetica, Los Angeles, California
| | - Michael A Burnstine
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California
- Eyesthetica, Los Angeles, California
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Jennen DGJ, van Herwijnen M, Jetten M, Vandebriel RJ, Keizers P, Geertsma RE, de Jong WH, Kleinjans JCS. Transcriptomic Analysis in Human 3D Skin Model Injected with Resorbable Hyaluronic Acid Fillers Reveals Foreign Body Response. Int J Mol Sci 2022; 23:ijms232113046. [PMID: 36361846 PMCID: PMC9654658 DOI: 10.3390/ijms232113046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
Usage of injectable dermal fillers applied for aesthetic purposes has extensively increased over the years. As such, the number of related adverse reactions has increased, including patients showing severe complications such as product migration, topical swelling and inflammatory reactions of the skin. In order to understand the underlying molecular events of these adverse reactions we performed a genome-wide gene expression study on the multi-cell type human Phenion® Full-Thickness Skin Model exposed to five experimental hyaluronic acid (HA) preparations with increasing cross-linking degree, four commercial fillers from Perfectha®, and non-resorbable filler Bio-Alcamid®. In addition, we evaluated whether cross-linking degree or particle size of the HA-based fillers could be associated with the occurrence of adverse effects. In all cases, exposure to different HA fillers resulted in a clearly elevated gene expression of cytokines and chemokines related to acute inflammation as part of the foreign body response. Furthermore, for one experimental filler genes of OXPHOS complexes I-V were significantly down-regulated (adjusted p-value < 0.05), resulting in mitochondrial dysfunction which can be linked to over-expression of pro-inflammatory cytokines TNFα and IL-1β and chemokine CCL2. Our hypothesis that cross-linking degree or particle size of the HA-based fillers is related to the biological responses induced by these fillers could only partially be confirmed for particle size. In conclusion, our innovative approach resulted in gene expression changes from a human 3D skin model exposed to dermal fillers that mechanistically substantiate aforementioned adverse reactions, and thereby adds to the weight of evidence that these fillers may induce inflammatory and fibrotic responses.
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Affiliation(s)
- Danyel G. J. Jennen
- Department of Toxicogenomics, GROW School for Oncology and Reproduction, Maastricht University, 6200 Maastricht, The Netherlands
- Correspondence:
| | - Marcel van Herwijnen
- Department of Toxicogenomics, GROW School for Oncology and Reproduction, Maastricht University, 6200 Maastricht, The Netherlands
| | - Marlon Jetten
- Department of Toxicogenomics, GROW School for Oncology and Reproduction, Maastricht University, 6200 Maastricht, The Netherlands
| | - Rob J. Vandebriel
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), 3720 Bilthoven, The Netherlands
| | - Peter Keizers
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), 3720 Bilthoven, The Netherlands
| | - Robert E. Geertsma
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), 3720 Bilthoven, The Netherlands
| | - Wim H. de Jong
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), 3720 Bilthoven, The Netherlands
| | - Jos C. S. Kleinjans
- Department of Toxicogenomics, GROW School for Oncology and Reproduction, Maastricht University, 6200 Maastricht, The Netherlands
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Orbital post-septal hyaluronic acid: An iatrogenic etiology compounding lower eyelid steatoblepharon. JPRAS Open 2022; 34:173-177. [PMID: 36325377 PMCID: PMC9618635 DOI: 10.1016/j.jpra.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
The stark rise in the incidence of dermal filler-related adverse sequelae has given rise to a variety of cosmetic distortions related to improper filler placement that include dynamic and static contour deformities of the face. In this article, we describe two instances of post-septal hyaluronic acid filler aggravating existing steatoblepharon and outline potential causative mechanisms responsible for this condition.
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Evaluation of Adverse Effects of Resorbable Hyaluronic Acid Fillers: Determination of Macrophage Responses. Int J Mol Sci 2022; 23:ijms23137275. [PMID: 35806280 PMCID: PMC9266407 DOI: 10.3390/ijms23137275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/26/2022] [Accepted: 06/26/2022] [Indexed: 12/01/2022] Open
Abstract
Resorbable tissue fillers for aesthetic purposes can induce severe complications including product migration, late swelling, and inflammatory reactions. The relation between product characteristics and adverse effects is not well understood. We hypothesized that the degree of cross-linking hyaluronic acid (HA) fillers was associated with the occurrence of adverse effects. Five experimental HA preparations similar to HA fillers were synthesized with an increasing degree of cross-linking. Furthermore, a series of commercial fillers (Perfectha®) was obtained that differ in degradation time based on the size of their particulate HA components. Cytotoxic responses and cytokine production by human THP-1-derived macrophages exposed to extracts of the evaluated resorbable HA fillers were absent to minimal. Gene expression analysis of the HA-exposed macrophages revealed the responses related to cell cycle control and immune reactivity. Our results could not confirm the hypothesis that the level of cross-linking in our experimental HA fillers or the particulate size of commercial HA fillers is related to the induced biological responses. However, the evaluation of cytokine induction and gene expression in macrophages after biomaterial exposure presents promising opportunities for the development of methods to identify cellular processes that may be predictive for biomaterial-induced responses in patients.
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Diaspro A, Calvisi L, Sito G. Hyaluronic Acid Gel Injection for the Treatment of Tear Trough Deformity: A Multicenter, Observational, Single-Blind Study. Aesthetic Plast Surg 2022; 46:1860-1867. [PMID: 35478038 DOI: 10.1007/s00266-022-02887-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/31/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Hyaluronic acid (HA) gel injections were first used to treat the tear trough in 2005 and since then it has been a mainstay of the approach to lower eyelid deformities. OBJECTIVE The authors present this retrospective multicentric observational study based on single-blind objective and subjective evaluation and patient satisfaction in relation to the aesthetic improvement of a large group of patients treated. METHODS AND MATERIALS Between January 2016 and December 2019, 600 patients (468 women and 132 men), were enrolled in this study, and 1200 tear trough deformities were treated with both needle and cannula techniques. RESULTS Average follow-up time was 12 ± 1 months, and the outcomes were assessed both objectively and subjectively with respect to Hirmand's classification. Statistical analysis shows an inverse correlation between age and class amelioration. CONCLUSION HA injection of the tear trough is most effective in patients between 30 and 40 years of age, while its benefits extend to up to 50 years old; afterward, it should no longer be the treatment of choice. This confirms that correction of tear trough with hyaluronic acid injections may provide an option to achieve immediate and durable results for up to one year after the injection. 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 .
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Dryden SC, Gabbard RD, Meador AG, Stoner AE, Klippenstein KA, Wesley RE. A Case of Orbital Granuloma Secondary to Dermal Filler Injection. Cureus 2021; 13:e20606. [PMID: 35103182 PMCID: PMC8781651 DOI: 10.7759/cureus.20606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/22/2022] Open
Abstract
A foreign body granulomatous reaction is a rare complication of the subcutaneous injection of fillers. We describe a 57-year-old female that presented with a six-month history of a non-painful, right lower eyelid mass. She had a dermal filler in the zygomatic region several months before the onset of her symptoms. Anterior orbitotomy and pathology revealed multinuclear giant cells consistent with a hyaluronic acid-based filler. This case describes the clinical presentation, histopathologic features, and treatment of an orbital granuloma secondary to dermal filler injection. Our case was uncommon because the zygomatic filler migrated across the orbital septum. Additionally, transconjunctival orbitotomy was used instead of a hyaluronidase injection due to the inferior location of the granuloma.
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Affiliation(s)
| | - Ryan D Gabbard
- Ophthalmology, Prisma Health/University of South Carolina, Columbia, USA
| | | | - Alison E Stoner
- Pathology and Laboratory Medicine, PathGroup, Brentwood, USA
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9
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Lessa S, Pontello J, Duarte D, Lobão D. Intralesional Tetracycline Injection, Pinch Technique, and Canthopexy for the Treatment of Severe Festoons: Preliminary Results. Aesthet Surg J Open Forum 2021; 4:ojab048. [PMID: 35156019 PMCID: PMC8830314 DOI: 10.1093/asjof/ojab048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Many techniques have been presented for the treatment of lower eyelid festoons, but no singular technique has become dominant. Objectives The authors describe the safety and efficacy of intralesional tetracycline injection, the pinch technique, and canthopexy for the treatment of severe festoons. Methods Institutional board review approval was obtained, and a retrospective chart review was performed on 15 consecutive patients who had received 2% tetracycline injections to treat lower eyelid large festoons between February 2017 and February 2020. Three months after the last injection, a series of patients underwent the surgical procedure: pinch technique and canthopexy bilaterally. Results Clinical and photographic records were reviewed, and 12 patients were included in the analysis. Three patients did not return for follow-up after the injection series. Of the 12 patients, there were 3 male patients and 9 female patients, with an average age of 66.6 years. The mean volume injected in each festoon was 0.43 mL, and the mean follow-up was 313 days. A series of injections with a 3-month time interval were performed for patients with a partial response to the initial injection. There was no evidence of complications at the site of the injection. Three months after the last injection, these 12 patients underwent complementary surgical treatment, which included pinch resection and canthopexy. Conclusions These preliminary results suggest that intralesional injections of tetracycline 2% may offer a safe option to treat lower eyelid festoons. This noninvasive procedure represents adjunct benefits to complementary surgical therapy. Level of Evidence: 4
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Affiliation(s)
- Sergio Lessa
- Division of Plastic Surgery, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - João Pontello
- Division of Plastic Surgery, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Deilton Duarte
- Division of Plastic Surgery, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Diogo Lobão
- Division of Plastic Surgery, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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10
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Novel Treatment of Inadvertent Injection of Postseptal Hyaluronic Acid Filler. Plast Reconstr Surg 2021; 148:855e-856e. [PMID: 34609999 DOI: 10.1097/prs.0000000000008465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Trinh LN, McGuigan KC, Gupta A. Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review. Facial Plast Surg 2021; 38:250-259. [PMID: 34666405 DOI: 10.1055/s-0041-1736390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Tear trough deformity is a popular target for the treatment with filler injections. The side effects are generally mild and transient. However, delayed complications may occur. We aim to perform a thorough systematic review of the published literature related to delayed complications after tear trough filler injections. A search of published literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in June 2021 and included PubMed, ScienceDirect, and Embase databases. The Medical Subject Headings (MeSH) terms used included the following terms: delayed complications, nodules, granulomas, swelling, discoloration, dermal filler, hyaluronic acid (HA), polyacrylamide, calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), eyelid, periorbital, periocular, and tear trough. Twenty-eight articles consisting of 52 individual cases were included in the final analysis. 98% (51/52) of patients were female and had an average age of 48.3 years. HA was the most reported product (71.2%, 37/52), followed by PLLA (4/52, 7.7%), and CaHA (4/52, 7.7%). The most common delayed complication with any dermal filler was swelling (42.3%, 22/52) followed by lumps or nodules (25.0%, 13/52). Xanthelasma-like reaction (17.3%, 9/52), migration (7.7%, 4/52), discoloration (3%, 3/52) also occurred. The average time of onset of any complication was 16.8 months with xanthelasma-like reaction appearing soonest (mean: 10 months) and discoloration appearing latest (mean: 52 months). Most swelling cases were caused by HA. Semi-permanent fillers such as PMMA and synthetic fillers such as PLLA were more likely to be associated with lumps and nodules than other complications. It is important that clinicians who perform tear trough augmentation with dermal fillers have a thorough understanding of the risks of the procedure to diagnose and manage them promptly as well as provide patients with accurate information regarding the potential adverse effects.
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Affiliation(s)
- Lily Nguyen Trinh
- School of Medicine, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otolaryngology-Head and Neck Surgery, Mass Eye and Ear, Boston, Massachusetts
| | - Kelly C McGuigan
- School of Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Amar Gupta
- Department of Otolarynology, Private Practice-Head and Neck Surgery, Los Angeles, California
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Langsdon PR, Schroeder RJ. Recognizing, Managing, and Guiding the Patient Through Complications in Facial Plastic Surgery. Facial Plast Surg Clin North Am 2021; 28:483-491. [PMID: 33010867 DOI: 10.1016/j.fsc.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Complications in facial plastic surgery can occur in both surgical and nonsurgical procedures. Many complications can be prevented through thorough preprocedural evaluation, patient counseling, and close postoperative monitoring. Despite the best efforts complications will happen and identifying them early is critical to prevent long-term sequelae. It is important to know how to both manage the complication and guide the patient through the recovery process.
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Affiliation(s)
- Phillip R Langsdon
- The Langsdon Clinic, 7499 Poplar Pike, Germantown, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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Comparing Water Absorption of Food and Drug Administration-Approved Hyaluronic Acid Fillers. Dermatol Surg 2021; 47:1237-1242. [PMID: 34347694 DOI: 10.1097/dss.0000000000003108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To compare the water absorption of 12 FDA-approved hyaluronic acid (HA) facial fillers in vitro in conditions relevant to in vivo injection. OBJECTIVE The goal of this study was to provide long-term insight into an improved, tailored facial rejuvenation approach and to understand sequelae that could affect preoperative surgical planning. METHODS In 2 experiments, 12 FDA-approved HA fillers were loaded into test tubes with nonpreserved normal saline and then placed in a 94.5°F-96°F environment for 1 month to allow water absorption by passive diffusion. The test tubes were centrifuged so that the hydrated filler could pass to the bottom of the tube. The tubes were centrifuged for 12 minutes at 1,200 revolutions per minute in the first experiment and for 7 minutes in the second experiment. A blue dye was then instilled to demarcate the filler/saline interface. RESULTS There was variation in the water absorption of different HAs. Low absorption occurred in non-animal-stabilized hyaluronic acid. CONCLUSION The pattern of water absorption was similar in the 2 experiments. The results inform us about in vivo conditions and provide guidance for filler selection.
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Chon BH, Hwang CJ, Perry JD. Treatment Options for Lower Eyelid Festoons. Facial Plast Surg Clin North Am 2021; 29:301-309. [PMID: 33906762 DOI: 10.1016/j.fsc.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Festoons represent a combination of fluid accumulation and soft tissue laxity in the superolateral cheek. They remain a difficult entity to treat. The ideal treatment for festoons would possess minimal invasiveness and recovery time, and predictably improve the condition. No nonsurgical treatment currently meets these criteria, and surgical treatments have significant limitations. Fortunately, a variety of treatment options exist that can benefit each patient and be tailored to their specific needs. Knowledge of the underlying anatomy, clinical characteristics, and clinical evaluation will better equip the treating physician to manage festoons.
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Affiliation(s)
- Brian H Chon
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Catherine J Hwang
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Julian D Perry
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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The use of periocular fillers in aesthetic medicine. J Plast Reconstr Aesthet Surg 2021; 74:1602-1609. [PMID: 33546985 DOI: 10.1016/j.bjps.2020.12.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 12/08/2020] [Accepted: 12/20/2020] [Indexed: 11/22/2022]
Abstract
The periocular area is the first to display signs of ageing. Dermal fillers are an increasingly popular, minimally invasive method for facial rejuvenation. The eye is anatomically delicate and complex. Therefore, special consideration must be taken if dermal fillers are employed. This article examines the literature to assess the efficacy and safety of dermal fillers around the eye as well as the management of complications secondary to dermal filler use, such as oedema, granuloma formation, filler migration, xanthelasma, skin necrosis and visual loss. Hyaluronic acid (HA) is the most popular and commonly employed dermal filler for periocular use. It is effective, with good observer improvement and patient satisfaction (p<0.0001). Ninety percent of adverse events are mild in nature and self-resolve within 1 month. Malar oedema is a delayed complication unique to the periocular area, occurring in 11% of patients. This can be managed with use of hyaluronidase if a HA filler has been employed. Other complications, such as granuloma formation, filler migration and xanthelasma, have also been reported with variable management outcomes. Vascular adverse events include skin necrosis and visual loss. No Level 1 evidence exists for the management of visual loss. Two cases of visual restoration have been identified in the literature; however, this is rare.
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Akoglu G, Ozge G, Eşme P, Erbil H. A case report of episcleral artery embolism caused by hyaluronic acid injection into the malar area. J Cosmet Dermatol 2020; 19:3420-3422. [DOI: 10.1111/jocd.13663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/29/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Gulsen Akoglu
- Department of Dermatology and Venereology Gulhane School of Medicine University of Health Sciences Ankara Turkey
| | - Gokhan Ozge
- Department of Ophthalmology Gulhane School of Medicine University of Health Sciences Ankara Turkey
| | - Pelin Eşme
- Department of Dermatology and Venereology Gulhane School of Medicine University of Health Sciences Ankara Turkey
| | - Hakan Erbil
- Department of Dermatology Private Dermatology Clinic Ankara Turkey
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Kim JH, Kwon TR, Lee SE, Jang YN, Han HS, Mun SK, Kim BJ. Comparative Evaluation of the Effectiveness of Novel Hyaluronic Acid-Polynucleotide Complex Dermal Filler. Sci Rep 2020; 10:5127. [PMID: 32198443 PMCID: PMC7083941 DOI: 10.1038/s41598-020-61952-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/18/2020] [Indexed: 11/08/2022] Open
Abstract
HA (Hyaluronic acid) filler, the most commonly used dermal filler, causes several side effects. HA-PN (Hyaluronic acid-Polynucleotide), a new composite filler, has excellent biocompatibility and induces tissue regeneration. In this study, we compare the efficacies and safety profiles of these fillers. The characteristics of HA and HA-PN fillers were compared using scanning electron microscopy and rheometry. No morphological difference was noted between the fillers. However, the latter had higher viscosity and elasticity values. The HA-PN filler induced higher cell migration than the HA filler in a wound healing assay. It was also found to stimulate better collagen synthesis in human and mouse fibroblasts. The HA and HA-PN fillers were injected into SKH1 hairless mice to determine changes in their volume for up to 24 weeks. Increased cell migration and collagen synthesis were observed in mice injected with the HA-PN complex filler. Although the safety and durability of the HA and HA-PN fillers were similar, the latter induced a lower transient receptor potential vanilloid 4 expression and caused less stimulation upon injection. In conclusion, HA-PN complex fillers can stimulate fibroblast growth and facilitate volume growth and skin regeneration.
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Affiliation(s)
- Jong Hwan Kim
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Tae-Rin Kwon
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sung Eun Lee
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
| | - Yoo Na Jang
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
| | - Hye Sung Han
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
| | - Seog Kyun Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Beom Joon Kim
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea.
- Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea.
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Skippen B, Baldelli I, Hartstein M, Casabona G, Montes JR, Bernardini F. Rehabilitation of the Dysmorphic Lower Eyelid From Hyaluronic Acid Filler: What to Do After a Good Periocular Treatment Goes Bad. Aesthet Surg J 2020; 40:197-205. [PMID: 30877762 DOI: 10.1093/asj/sjz078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic, long-lasting edema accompanied by the Tyndall effect as a delayed reaction to hyaluronic acid (HA) filler injection seems to occur exclusively in the eyelids. OBJECTIVES The authors sought to present a treatment algorithm for management of patients with chronic lower eyelid edema as a delayed complication of HA filler injection. METHODS Retrospective study including 61 patients with delayed-onset chronic periocular edema following uneventful HA filler injection in the lower eyelids or cheeks. All patients underwent hyaluronidase enzyme dissolution followed by secondary treatment. Three retreatment options were presented: (1) observation, (2) secondary treatment with HA filler, and (3) lower eyelid blepharoplasty. RESULTS All patients underwent filler dissolution using hyaluronidase. The mean age was 48 years and 97% of the patients were female. Single treatment was effective in 92% of patients with 8% requiring another hyaluronidase injection to completely eradicate residual edema. Six patients (10%) were satisfied after hyaluronidase only and 6 patients (10%) underwent lower eyelid blepharoplasty. Secondary treatment with HA filler was performed in 48 patients (80%). All were satisfied with final results without further edema in the follow-up period. CONCLUSIONS Delayed-onset chronic lower eyelid edema is a frequent HA-related complication and cause of concern when considering periocular HA treatment. Previous treatment has been limited to either hyaluronidase only or blepharoplasty as a secondary solution after hyaluronidase, with only a minority of patients satisfied. Hyaluronidase, shortly followed by HA filler retreatment, is a safe and effective solution. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Brent Skippen
- Oculoplastic surgeon in private practice in Wagga Wagga, Australia
| | - Ilaria Baldelli
- Department of Plastic Surgery, University of Genova, San Martino Hospital, Genova, Italy
| | - Morris Hartstein
- Oculoplastic Surgeon, Assaf Harofeh Medical Center, Tel Aviv University-Sackler School of Medicine, Israel
| | - Gabriela Casabona
- Dermatologist in private practice in Higienópolis, São Paulo, Brazil
| | - Jose Raul Montes
- Oculoplastic surgeon in private practice in San Juan, Puerto Rico
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Doxycycline Injection for Sclerotherapy of Lower Eyelid Festoons and Malar Edema: Preliminary Results. Ophthalmic Plast Reconstr Surg 2019; 35:474-477. [DOI: 10.1097/iop.0000000000001332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
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.
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Zoumalan CI. Managing Periocular Filler-Related Syndrome Prior to Lower Blepharoplasty. Aesthetic Plast Surg 2019; 43:115-122. [PMID: 30298348 DOI: 10.1007/s00266-018-1250-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/22/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hyaluronic acid (HA) fillers are extensively used in periocular volume augmentation. Although they have an excellent safety profile, filler-related issues such as visibility/palpability, contour abnormalities, malar edema, and blue-gray dyschromia can occur. Recognition and management of filler-related issues are critical prior to subsequent procedures. The clinical course of patients who had periocular HA filler-related issues and subsequently underwent lower eyelid blepharoplasty is described. METHODS HA filler was dissolved with hyaluronidase (15-30 U/cm2) treatment. Visible lower eyelid fat prolapse after filler removal was corrected with transconjunctival blepharoplasty with fat repositioning and skin resurfacing. Complications and outcome were assessed and recorded. RESULTS Twenty-three patients (46 eyelids) were treated. All presented with contour abnormalities, 19 with contour abnormalities and malar edema, and seven with blue-gray dyschromia. In 15 patients, one session of hyaluronidase completely dissolved the filler, and in eight patients, two sessions were required. Of these eight patients, edema resolved after the second hyaluronidase injection in four; in the remaining four, mild edema persisted despite absence of visible/palpable filler. Postblepharoplasty, 19 patients had an acceptable outcome with no complications (82.6%). Four patients had prolonged edema postoperatively; three had a resolution by 6 months. In 23 patients who had skin resurfacing procedures, there was no incidence of postinflammatory hyperpigmentation. CONCLUSIONS HA filler-related issues need to be identified and managed prior to further intervention. Hyaluronidase treatment effectively dissolves the filler, but mild malar edema can persist. Outcomes are acceptable after subsequent blepharoplasty, but adequate patient counseling is necessary about expectations and limitations. 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 .
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Affiliation(s)
- Christopher I Zoumalan
- Keck School of Medicine, University of Southern California, 9401 Wilshire Blvd, Suite 1105, Beverly Hills, CA, 90212, USA.
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