Ocular and cerebral infarction from periocular filler injection

Causes and management of sight threatening complications of dermal filler injections: A review

Injectable dermal fillers continue to increase in popularity in aesthetic medicine. Although rare, vision loss secondary to filler injections is a devastating complication associated with a poor visual prognosis. The mechanism for vision loss is thought to be related to retrograde embolization of the dermal filler from peripheral vessels in the face into the ophthalmic arterial system. Early recognition and prompt management are essential if vision is to be salvaged. The use of retrobulbar hyaluronidase is still contentious, however when administered by a specialist, this treatment gives the best chance at visual recovery and should be considered for all cases.

The Safety of Injections in the Infraorbital Region

BACKGROUND

 Infraorbital filler injection is a commonly used minimally invasive cosmetic procedure on the face, which can cause vascular complications.

OBJECTIVE

 In this study, we aimed to explore the anatomical structure of the infraorbital vasculature and to establish an accurate protocol for infraorbital filler injection.

METHODS

 The vascular structure of the infraorbital region was evaluated in 84 hemifacial specimens using computed tomography. Four segments (P1-P4) and five sections (C1-C5) were considered. We recorded the number of identified arteries in each slice and at each location and the number of deep arteries. Furthermore, we also measured the infraorbital artery (IOA) distribution.

RESULTS

 At P1-P4, the lowest number of arteries was detected in segment P4, with a 317/1727 (18.4%) and 65/338 (2.3%) probability of total and deep arterial identification, respectively. The probabilities of encountering an identified artery at the five designated locations (C1-C5) were 277/1727 (16%), 318/1727 (18.4%), 410/1727 (23.7%), 397/1727 (23%), and 325/1727 (18.8%), respectively. The probability of an IOA being identified at C2 was 68/84 (81%).

CONCLUSION

 We described an effective filler injection technique in the infraorbital region to minimize the associated risks.

LEVEL OF EVIDENCE IV

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Disastrous cerebral and ocular vascular complications after cosmetic facial filler injections: a retrospective case series study

Soft tissue filler injections are among the most popular facial rejuvenation methods. Cerebral infarction and ophthalmic artery occlusion are rare and catastrophic complications, especially when facial cosmetic fillers are injected by inexperienced doctors. Radiologists and plastic surgeons need to increase their awareness of the complications associated with fillers, which allows early diagnosis and intervention to improve patient prognosis. Regarding the mechanism by which vascular occlusion occurs after facial filler injections, a retrograde embolic mechanism is currently the predominant theory. Numerous case reports have been presented regarding complications associated with injections of facial aesthetics. However, the small sample sizes of these studies did not allow for an adequate assessment of the clinical and imaging manifestations based on the location of the occlusion and the type of filler, and detailed elaboration of multiple cerebral infarctions is also lacking. Therefore, this study aimed to investigate the clinical and radiological features of severe cerebral and ocular complications caused by cosmetic facial filler injections. In addition, we discuss the pathogenesis, treatment, and prognosis of these patients. The clinical, computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) findings were described and analysed. Radiological examinations are crucial for demonstrating severe complications, and brain MRI is especially strongly suggested for patients with cosmetic filler-induced vision loss to identify asymptomatic cerebral infarctions. Extreme caution and care should be taken during facial injections by plastic surgeons.

Ocular Complications Post-Cosmetic Periocular Hyaluronic Acid Injections: A Systematic Review

BACKGROUND

With the global rise in the use of hyaluronic acid (HA) fillers as a minimally invasive cosmetic procedure, significant adverse effects such as vascular compromise and blindness have become common. Hence, we present the first systematic review aimed to investigate ocular complications secondary to a facial HA injection and to understand the presentation, cause, management, and outcome of these complications.

METHODS

The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to report this review. A systematic search was performed in July 2021 for published literature using the PubMed, MEDLINE, and Cochrane databases. The following terms were used: facial fillers, facial injections, hyaluronic acid, blindness, ophthalmoplegia, diplopia, ptosis, ophthalmic artery occlusion, posterior ciliary artery occlusion, and ocular ischemic syndrome.

RESULTS

A total of 2496 publications were searched, and 34 articles published between January 2000 and July 2021 were included. Twenty-seven case reports and seven case series were evaluated. The nose was the most common site of injection (n = 25; 40.67%). Ocular pain was the most common initial symptom of ocular complications (n = 13, 22.41 %). The most common complication was vision loss (n = 17, 50%). The majority of patients received hyaluronidase, aspirin, and steroids. Regarding the outcome, 15 (45.45%) of the published studies showed no improvement in complications even after management.

CONCLUSION

HA is gaining popularity in cosmetic applications. Post-HA ocular complications nearly always have an immediate onset. Proper knowledge of potential adverse events is crucial for clinicians to attempt to decrease complications and improve outcomes.

LEVEL OF EVIDENCE III

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.

Cerebral Embolism as a Result of Facial Filler Injections: A Literature Review

Background

With the growth in the popularity of facial filler injections, increased numbers of severe adverse events, such as cerebral embolism, have been reported.

Objectives

The aim of this article was to summarize the clinical manifestations and proposed mechanisms of filler-induced cerebral embolism (FICE).

Methods

A literature review was performed with the search keywords “filler injection,” “hyaluronic acid,” “fat graft,” “cerebral infarction,” “cerebral embolism,” “stroke,” “cerebrovascular infarction,” “disorders of consciousness,” and “hemiplegia.”

Results

Among the 43 cases of FICE enrolled from 35 articles, 37 patients were female, and 6 were male. Twenty-nine of these patients had received fat grafting, and 12 hyaluronic acid injection. Most FICE patients had been injected in the glabella, followed by the temporal, forehead, and nasal areas. Among 30 patients injected under local anesthesia, 43.33% presented with neurologic symptoms during the procedure. The main symptoms were consciousness disorders and hemiplegia. Most of the embolization sites were in the middle cerebral artery, followed by frontal lobe infarction and anterior cerebral artery infarction. Three patients developed cerebral hemorrhage after embolism. Twenty-six patients presented with newly acquired vision loss. The management for FICE cases included embolectomy, thrombolysis, decompressive craniectomy, antiplatelet/anticoagulant therapy, and symptomatic and nutritional treatment. Nearly half of the patients recovered or exhibited improved neurologic manifestations but not visual loss. Five patients died.

Conclusions

FICE is a severe complication following facial filler injection. Careful prevention, timely identification, and treatment are crucial to decreasing the morbidity and mortality of FICE.

Level of Evidence: 4

Superior Ophthalmic Vein Embolism Following Forehead Augmentation with Autologous Fat Injection

Background

Facial rejuvenation and reconstruction with autologous fat injection are a common and effective procedure used worldwide. Most surgeons and patients are satisfied with the favorable outcomes. However, catastrophic complications from arterial and venous occlusion resulting in visual loss and stroke may occur.

Case presentation

We herein report a case of isolated venous occlusion from fat embolism. The patient developed acute painful proptosis and blurred vision of her right eye while undergoing an esthetic autologous fat injection into her forehead. Based on her clinical manifestations and radiologic findings, the patient was diagnosed with superior ophthalmic vein occlusion. Symptomatic and supportive treatments were given. Spontaneous clinical improvement occurred without secondary complications. Therefore, the initially planned endovascular therapy with transfemoral transvenous embolectomy of the right superior ophthalmic vein was canceled.

Conclusions

Facial augmentation with autologous fat injection can cause superior ophthalmic vein embolism. Surgeons should therefore perform this procedure very cautiously. Prompt ophthalmological evaluation and proper management are important for improving clinical outcomes.

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.

Long-term Outcomes of Ophthalmic and Retinal Artery Occlusion After Cosmetic Facial Filler Injection

BACKGROUND

Ophthalmic artery occlusion (OAO) and retinal artery occlusion (RAO) after facial filler injection have become increasingly significant due to the growth in cosmetic injection procedures for aesthetic purposes.

OBJECTIVES

The aim of this study was to analyze the long-term visual outcomes and complications of cosmetic facial filler-related OAO and RAO.

METHODS

This single-center, retrospective case series included 17 eyes of 16 filler-related OAO or RAO patients with a follow-up period of 1 year or longer. Main outcome measures were best-corrected visual acuity (BCVA) and long-term complications.

RESULTS

The mean [standard deviation] age at diagnosis was 31.7 [9.7] years; all the patients were female. The mean follow-up period was 5.4 [2.4] years. The mean BCVA was 2.34 and 2.41 logMAR at the initial and final visits, respectively, which indicates sustained long-term visual impairment. Ocular complications included retinal atrophy and degeneration (100.0%), optic atrophy and blindess (no light perception) (82.4%), strabismus (80.0%), retinal fibrous membrane (68.8%), posterior synechiae (35.3%), neovascularization (29.4%), iris atrophy and cataract (23.5%), corneal opacity and phthisis bulbi (17.6%), visual field defect and iris defect (11.8%), ophthalmoplegia (7.7%), and pupillary block (5.9%). Extraocular complications of brain infarction and depression were found in 25.0%, whereas skin necrosis was found in 13.3% of patients.

CONCLUSIONS

Facial filler-related OAO or RAO resulted in long-term poor visual outcome, and most of the patients experienced irreversible visual impairment with no light perception despite various treatments. Various long-term ocular and extraocular complications were observed, which should be monitored for a long-term follow-up period. Our findings suggest that prevention should be emphasized more than treatment.

LEVEL OF EVIDENCE: 4

Ocular Perfusion Following Orbital Apex Exenteration

A 68-year-old man with a history of type 2 diabetes mellitus and kidney transplantation on chronic immunosuppression presented with right-sided proptosis and vision loss. He was hospitalized 4 months prior for invasive sinus aspergillosis. MRI revealed abnormal enhancement in the right orbital apex, inferior medial right orbit, anterior cranial fossa floor, and anterior aspect of the falx cerebri. The patient was successfully managed with extensive sinus surgery, bifrontal craniotomy with resection of dura, cribriform plate resection, and a right orbital apex exenteration. The globe and anterior orbital structures were preserved to cover the large surgical sinodural-orbital defect and avoid complex reconstructive surgery. Orbital perfusion was maintained by exploiting the robust anastomoses between branches of external carotid and ophthalmic artery.

Complications and Adverse Effects of Periocular Aesthetic Treatments

The popularity and variety of temporary and permanent periocular aesthetic treatments has increased over the past decade. Patients frequently present to eye clinics with ocular complications and side effects following these treatments, their severity ranging from ocular irritation from dry eyes to visual loss from vascular occlusion. A careful, thorough history is essential, as many patients may not associate aesthetic procedures with ocular complications, and some may be embarrassed to disclose this information. All ophthalmologists should understand the potential ocular sequelae of these treatments and be able to initiate treatment in sight-threatening cases. Wesummarises the current literature on ophthalmic complications of the most common periocular aesthetic treatments.

Skin Necrosis and Vision Loss or Impairment After Facial Filler Injection

Purpose of the present study is to objectively evaluate the number of severe vascular complications, represented by skin necrosis and vision loss or impairment, following facial filler injection. The investigators implemented a review of the literature including articles published on PubMed database without limitation about year of publication, including all reports concerning skin necrosis and vision loss or impairment related to the injection of fillers for cosmetic uses. The search highlighted 45 articles and a total of 164 cases of skin necrosis and vision loss or impairment after injection of different substances. The injection site most frequently associated with complications was the nose (44.5%), followed by glabella (21%), nasolabial fold (15%), and forehead (10%). Results of the present study suggest that injectable filler can cause severe complications even in expertized hands. Treatments in the new defined "Dangerous triangle" must be carefully carried out. Despite our expectations, the highest rates of sever adverse events have been associated with autologous fat transfer practice.

Factors influencing pre-injection aspiration for hyaluronic acid fillers: A systematic literature review and meta-analysis

Pre-injection aspiration of hyaluronic acid filler is a well-recognized yet controversial safety technique. Many consider aspiration to be an important safety measure to prevent inadvertent intravascular filler injection. To assess factors influencing pre-injection aspiration by understanding the relationship between aspiration time and a range of product, needle, and procedural characteristics. We conducted a systematic review and meta-analysis of data, adopting the preferred reporting items for systematic reviews and metaanalyses guidelines. Our literature search identified four articles presenting data on variables associated with aspiration time for different HA filler brands. Statistical models pooling data from the four articles suggest a robust association between aspiration time and a filler's elastic modulus (G'), drop weight (cohesivity), and cross-sectional area of the needle lumen. However, there is insufficient evidence to confirm a robust association between aspiration time and HA concentration, viscous modulus (G″), needle length, and pullback volume. A deeper understanding of the relationship between product, needle, and procedural characteristics, and aspiration time can provide a sound base for discussing the role of pre-injection negative aspiration as a safety measure. The understanding of the effect of various factors on preinjection aspiration would further benefit from studies under clinical conditions.

The Effect of Hyaluronidase on Depth of Necrosis in Hyaluronic Acid Filling-Related Skin Complications

AIM

In this clinical study, 16 female patients with vascular compression and occlusion-related ischemia and skin necrosis after hyaluronic acid filling injection were analyzed retrospectively. Dose, timing, and efficacy of hyaluronidase use in skin necrosis are discussed.

PATIENTS AND METHODS

In a total of 841 cases, aged between 18 and 60 years, hyaluronic acid filling injections were performed. All patients were followed up for 3-24 months. Filling injected areas include nasolabial (391 cases), lip (225 cases), glabella-forehead (90 cases), infraorbital (46 cases), malar region (25 cases), chin (24 cases), and nose (40 cases). Skin complications occurred in four cases during the application and in 12 cases 6-24 h after the procedure. Only palliative treatment was performed in six cases, while hyaluronidase was used in 10 cases in addition to palliative treatment. Hyaluronidase injection was performed 30 s after filling injection in four cases and 6-24 h after the injection in the remaining six cases. A total of 1500 units of hyaluronidase was applied to each case in average.

RESULTS

Recovery period of the patients who received palliative treatment only lasted 40-60 days. The area of necrosis was limited in these patients who did heal well only with some change of pigmentation and no obvious scar. In the patient group who received hyaluronidase in addition to palliative treatment, a large necrosis area was observed at the same time in four patients. Despite the hyaluronidase treatment in this group, recovery period was 20-90 days. The affected and necrosis areas were large. The cause of ischemia depended both on occlusion and on compression. While four patients healed with a scar, the remaining 12 patients healed without any significant scar.

CONCLUSIONS

Hyaluronidase injection provides earlier recovery of limited skin necrosis. Immediate hyaluronidase injection allows small damage to heal in a short time; however, it does not completely eliminate large necrosis, although it limits the necrotic area.

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 .

Fatal Cerebral Infarction and Ophthalmic Artery Occlusion After Nasal Augmentation with Hyaluronic Acid-A Case Report and Review of Literature

BACKGROUND

Cerebral infarction is a rare complication of hyaluronic acid (HA) filler injection, usually presenting with sudden increase in intracranial pressure and loss of vision.

METHODS

A 40-year-old Asian woman in a coma was transferred to the emergency intensive care unit of Xijing Hospital, China, 48 h after nasal augmentation with HA. Magnetic resonance imaging indicated cerebral infarction and left optic nerve edema and ischemia. Magnetic resonance angiography did not reveal vessel embolism.

RESULTS

The patient developed gastric ulceration, pulmonary infection, respiratory failure, and cerebral herniation, and died 6 days after the HA filler injection.

CONCLUSION

Facial cosmetic HA filler injection can cause devastating and even fatal complications.

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.