Resistant and Recurrent Late Reaction to Hyaluronic Acid–Based Gel

Considerations for Proper Use of Hyaluronidase in the Management of Hyaluronic Acid Fillers

Effective management of complications from hyaluronic acid (HA) fillers is crucial in aesthetic medicine. This article examined the role of hyaluronidase in addressing adverse effects associated with HA fillers, such as nodules, vascular occlusions, and excessive volume. It highlights the enzyme's ability to degrade HA, thereby resolving issues that may arise from filler treatments. The discussion includes practical aspects of using hyaluronidase, such as recommended dosing, injection techniques, and potential risks. The benefits of hyaluronidase, including its rapid action in dissolving problematic fillers and its role in improving patient outcomes, are explored. The article also addresses limitations and safety considerations to provide a comprehensive understanding of hyaluronidase in the context of filler complications. By offering insights into the application and effectiveness of hyaluronidase, this article aimed to enhance practitioners' ability to manage HA filler-related issues effectively and ensure optimal results in aesthetic procedures.

Anatomical-Based Diagnosis and Filler Injection Techniques: Lips and Philtrum

Lip augmentation has become increasingly popular in aesthetic medicine, driven by advancements in dermal filler technologies and injection techniques. This review provides a comprehensive overview of lip anatomy, age-related changes, and current best practices in lip augmentation using dermal fillers. The complex structure of the lips, including multiple layers of skin, muscle, and mucosa, contributes to their unique appearance and function. Age-related changes, such as volume loss, thinning of the vermilion border, and flattening of the philtrum, significantly impact lip aesthetics. Understanding these changes is crucial for developing effective treatment strategies. The review discusses the importance of tailoring treatments to individual patient needs, considering factors such as ethnic variations in lip structure and cultural preferences. It emphasizes the significance of proper filler selection, with hyaluronic acid-based products being the gold standard due to their biocompatibility and reversibility. Injection techniques, including needle and cannula approaches, are described in detail, with a focus on safety and optimal aesthetic outcomes. Anatomical considerations, particularly the vascular supply to the lips, are highlighted as critical for avoiding complications during filler injections. The review also addresses the evolving approach to lip augmentation, which now focuses on restoring natural contours and addressing age-related changes in the perioral region rather than simply increasing volume. Finally, the importance of managing patient expectations and the potential for future advancements in the field are discussed, including the development of more targeted filler products and refined injection techniques.

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.

Decomposition and Changes in In Vivo Post-HA Filler Injection: A Review

BACKGROUND

Hyaluronic acid (HA) fillers are widely used in aesthetic medicine, but their in vivo behavior and long-term effects are not fully understood.

AIMS

To review the decomposition and changes occurring in the body following HA filler injections, focusing on crosslinking agents, degradation processes, and tissue responses.

METHODS

This review analyzed oxidative and enzymatic degradation processes of HA fillers, evaluated the impact of 1,4-Butanediol Diglycidyl Ether (BDDE) crosslinking, and examined histological changes post-injection.

RESULTS

Uncrosslinked HA degrades rapidly due to endogenous hyaluronidase, while crosslinked HA undergoes slower degradation via free radicals and hyaluronidase. Complete cross-linking (C-MoD) showed better durability compared to partially cross-linked BDDE (P-MoD). The concept of modification efficiency (MoE) was proposed to optimize filler safety and viscoelastic properties. Histological analysis revealed collagen capsule formation and autologous tissue replacement, affecting long-term outcomes. The degree of chemical modification (MoD) influences filler durability and safety, with concerns raised about potential delayed immune reactions from accumulated pendent BDDE.

CONCLUSIONS

Clinicians should consider injection site, tissue conditions, and filler properties for safe and effective HA filler use. Emphasizing thorough BDDE removal and optimal crosslinking can enhance treatment safety and efficacy. The balance between achieving desired viscoelastic properties and minimizing potential risks is crucial. Future studies should include diverse ethnic groups to validate findings and further explore long-term tissue responses to HA fillers.

How Should We Use Hyaluronidase for Dissolving Hyaluronic Acid Fillers?

BACKGROUND

Hyaluronic acid (HA) fillers are commonly used in esthetic medicine for facial contouring and rejuvenation. However, complications such as overcorrection, vascular occlusion, and irregular filler distribution necessitate the use of hyaluronidase to dissolve the fillers. This study aimed to evaluate the efficacy of hyaluronidase in degrading different types of HA fillers and provide clinical guidelines for its use based on filler type, dosage, and application techniques.

METHODS

A series of in vitro and in vivo experiments were conducted to assess the dissolution of biphasic and monophasic HA fillers using varying concentrations of hyaluronidase. The in vivo component used animal models to determine the duration of hyaluronidase activity in biological tissues, whereas the in vitro study examined the dissolution rates of HA fillers in response to different hyaluronidase concentrations and application methods. A control study using saline was also performed to compare the natural hydration process of the fillers.

RESULTS

Hyaluronidase efficacy was found to vary based on the type of HA filler and the enzyme's concentration. Biphasic fillers dissolved more rapidly at lower concentrations of hyaluronidase compared to monophasic fillers, which required higher concentrations and longer exposure times for effective breakdown. The study also demonstrated that direct injection of hyaluronidase into the filler mass was more effective than surface application. Pharmacokinetic analysis revealed that hyaluronidase activity diminished within 30 min in biological tissues, highlighting the need for timely intervention in clinical scenarios.

CONCLUSION

Hyaluronidase is effective in dissolving HA fillers, with its efficacy dependent on the type of filler, concentration, and application technique. Biphasic fillers respond more quickly to hyaluronidase, whereas monophasic fillers require higher doses and multiple treatments. Clinical recommendations include using direct injection techniques, tailoring hyaluronidase dosage based on the filler type, and considering hypersensitivity reactions. Future research should focus on the long-term effects of hyaluronidase and refining clinical protocols for its use.

One-Year Safety Evaluation of New Hyaluronic Acid Fillers (YYS Series): A Prospective, Multicenter, Observational Study

BACKGROUND

With the continuous increasing availability of new filler products, each hyaluronic acid filler brand has distinctive pharmacokinetics, which may be associated with different complications. Therefore, the long-term safety of new generations of fillers should be evaluated.

OBJECTIVE

This prospective, multicenter, observational, postmarketing study ( ClinicalTrials.gov identifier: NCT04738019) aimed to investigate the incidence of delayed-onset nodules and adverse reactions after the injection of new hyaluronic acid fillers (YYS series) into the facial skin.

METHODS

Subjects scheduled to receive an injection YYS series filler were followed up for 52 weeks. The authors aimed to determine the incidence of a self-reported delayed-onset nodule-a visible or palpable nodule or mass at the injection site that was detected beyond the 14th day following the injection-during the 1-year follow-up period.

RESULTS

Among the 1,022 subjects who received an injection of the YYS series, the incidences of delayed-onset nodules were 0% for YYS 360, YYS 540, and YYS 720. A 0.21% incidence (1 delayed hypersensitivity reaction) of a delayed-onset adverse reaction was noted for YYS 720, although none were reported for YYS 360 and YYS 540.

CONCLUSION

In this study, a notably low frequency of adverse reactions associated with the YYS series was observed.

Review of the Adverse Effects Associated with Dermal Filler Treatments: Part I Nodules, Granuloma, and Migration

The increase in the use of filler treatments within minimally invasive cosmetic surgery has correspondingly escalated the variety and frequency of associated side effects. Initially, unregulated procedures led to primary side effects such as infections, foreign body reactions, and granuloma formation. However, severe vascular complications like skin and tissue necrosis and blindness have emerged as recognized risks. Side effects from filler treatments can range from mild to life-threatening, including edema, pain, tenderness, numbness, bleeding, bruising, hematoma, redness, erythema, pigmentation, allergic reactions, itching, pruritus, the Tyndall effect, asymmetry, irregularity, migration, skin and soft tissue infections, nodules, granulomas, and vascular compromise. These side effects are categorized into early and delayed types. Many complications, particularly those related to vascular abnormalities, are frequently linked to procedural issues, emphasizing the importance of understanding filler properties, injection techniques, and facial anatomy. Preventing side effects is ideal, but early detection and treatment are crucial. Recognizing potential side effects based on their timing and understanding appropriate preemptive treatment methods is essential. This discussion addresses non-vascular side effects, highlighting their onset, symptoms, and management strategies. The comprehensive understanding and careful management of these side effects are vital for minimizing complications and ensuring patient safety in filler treatments.

A Scoping Review of Hyaluronidase Use in Managing the Complications of Aesthetic Interventions

BACKGROUND

Hyaluronidase is used as an adjunct or main treatment to manage complications associated with cosmetic hyaluronic acid (HA) filler injections such as necrosis, blindness, hypersensitivity, delayed nodules, and poor aesthetic outcomes.

OBJECTIVE

To systematically map the available evidence and identify the gaps in knowledge on the effectiveness of hyaluronidase use in managing the aesthetic complications associated with HA injections (vascular occlusion, blindness, nodules, delayed hypersensivity, granuloma, poor aesthetic outcome).

METHODS

PubMed, Medline, Embase and Cochrane databases were used up to May 2022, to look for randomized clinical trials (RCTs), clinical trials, and retrospective case-control studies reporting on the use of hyaluronidase for managing the HA filler injection complications.

RESULTS

The database search yielded 395 studies; of those 5 RCTs (all carried out in the USA) were selected (53 subjects), indicating the effectiveness of hyaluronidase for removal of un-complicated injected HA nodules (forearm, upper arm, or back skin). The follow-ups ranged from 14 days to 4 years. The amount of HA filler injected into each site varied from 0.2 to 0.4 mL. A dose dependent response was observed for most HA fillers. No major adverse reactions were reported. Overall, for removal of every 0.1 mL of HA filler they injected 1.25-37.5 units of hyaluronidase (single injections). When 3 consecutive weekly hyaluronidase injection was used much lower doses of 0.375-2.25 unit was utilised. There was no evidence in a form of RCTs, clinical trials, and retrospective case-control studies on the removal/reversal of HA injections in the facial skin, or management of over-corrections, inflammatory nodules, or tissue ischemia/necrosis associated with HA filler injection.

CONCLUSION

Based on studies on the forearm, upper arm and back skin, hyaluronidase can be used for the reversal of uncomplicated HA filler injection nodule. However, further adequately powered studies are warranted to establish the ideal treatment protocol/dose of hyaluronidase for reversal of HA filler injections in the facial region or management of complications associated with aesthetic HA injection.

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 .

Oral Methotrexate Treatment of Delayed-Onset Inflammatory Reactions to Dermal Fillers

Background

In aesthetic practice, delayed-onset (late) inflammatory reactions (DIRs) to dermal fillers are encountered. The treatment of DIRs can be challenging, with a response to established therapies, including oral antibiotics, intralesional and oral steroids, and hyaluronidase injection, occasionally reported as unsatisfactory.

Objectives

Evaluate the efficacy of low-dose oral methotrexate (MTX) therapy in treating recalcitrant DIRs.

Methods

We retrospectively reviewed cases of recalcitrant DIRs treated with oral MTX. Data collected included individuals' gender and age, medical history, filler type, facial area(s) injected, previous treatments attempted to dissolve the DIR, MTX treatment dosage and duration, and outcome. Adverse events were monitored throughout the treatment.

Results

Thirteen females with a mean age of 52.6 years (range, 31-67 years) who developed recalcitrant DIRs to dermal filler injection are included. Eight reactions were triggered by the injection of hyaluronic acid (HA) fillers, 4 by liquid injectable silicone (LIS), and 1 by polymethylmethacrylate (PMMA). The average starting dosage of MTX was 12.1 mg/week (range, 7.5-12.5 mg/week). Patients were treated for 2 to 3 months in most cases. The average follow-up post-MTX therapy was 11.8 months (range, 2-36 months). A complete response to MTX treatment was observed in 10 patients (6 HA and 4 LIS cases), partial response in 1 (HA case), and an unsatisfactory response in 2 (HA and PMMA cases). Treatment was well tolerated.

Conclusions

A short course of low-dose oral MTX is a possible treatment for DIRs that have not responded to established therapies. The promising results of this report require validation by powered studies.

Level of Evidence 4

The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis

BACKGROUND

Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection.

METHODS

This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis.

RESULTS

This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively.

CONCLUSIONS

The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection.

LEVEL OF EVIDENCE I

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 .

Etiology of Delayed Inflammatory Reaction Induced by Hyaluronic Acid Filler

The etiology and pathophysiology of delayed inflammatory reactions caused by hyaluronic acid fillers have not yet been elucidated. Previous studies have suggested that the etiology can be attributed to the hyaluronic acid filler itself, patient's immunological status, infection, and injection technique. Hyaluronic acid fillers are composed of high-molecular weight hyaluronic acids that are chemically cross-linked using substances such as 1,4-butanediol diglycidyl ether (BDDE). The mechanism by which BDDE cross-links the two hyaluronic acid disaccharides is still unclear and it may exist as a fully reacted cross-linker, pendant cross-linker, deactivated cross-linker, and residual cross-linker. The hyaluronic acid filler also contains impurities such as silicone oil and aluminum during the manufacturing process. Impurities can induce a foreign body reaction when the hyaluronic acid filler is injected into the body. Aseptic hyaluronic acid filler injections should be performed while considering the possibility of biofilm formation or delayed inflammatory reaction. Delayed inflammatory reactions tend to occur when patients experience flu-like illnesses; thus, the patient's immunological status plays an important role in delayed inflammatory reactions. Large-bolus hyaluronic acid filler injections can induce foreign body reactions and carry a relatively high risk of granuloma formation.

Evaluation of the Safety of Neauvia Stimulate Injectable Product in Patients with Autoimmune Thyroid Diseases Based on Histopathological Examinations and Retrospective Analysis of Medical Records

The aim of this study was to test the effect of hyaluronic acid cross-linked with polyethylene glycol containing micronized portions of calcium hydroxyapatite (Neauvia Stimulate) on both local tissue and systemic consequences, which are crucial from the perspective of long-term safety, in patients suffering from Hashimoto's disease. This most common autoimmune disease is a frequently mentioned contraindication to the use of fillers based on hyaluronic acid as well as biostimulants based on calcium hydroxyapatite. Broad-spectrum aspects of histopathology were analyzed to identify key features of inflammatory infiltration before the procedure and 5, 21, and 150 days after the procedure. A statistically significant effect on the reduction of the intensity of the inflammatory infiltration in the tissue in relation to the state before the procedure was demonstrated, combined with a reduction in the occurrence of both antigen-recognizing (CD4) and cytotoxic (CD8) T lymphocytes. With complete statistical certainty, it was demonstrated that the treatment with Neauvia Stimulate had no effect on the levels of these antibodies. All this corresponds with the risk analysis that showed no alarming symptoms during the time of observation. The choice of hyaluronic acid fillers cross-linked with polyethylene glycol should be considered justified and safe in the case of patients suffering from Hashimoto's disease.

Side effects after hyaluronic acid facial injection in adults during COVID-19 pandemic

BACKGROUND

Different causes may be responsible for delayed inflammatory reactions after hyaluronic acid injections, among them several mechanisms of SARS-CoV-2.

AIMS

The study's objective was to assess the percentage of adverse reactions after hyaluronic acid injections in a cohort of adult patients with a test for SARS-CoV-2 or vaccinated during the COVID-19 pandemic.

PATIENTS/METHODS

An observational, retrospective, comparative, multi-center, non-interventional in a real-life setting study was carried out with patients treated with facial injections of hyaluronic acid from May to September 2021, with a test to discard SARS-COV 2 or that had been vaccinated.

RESULTS

Sixty-three patients were included. Seven (11.1%) were vaccinated patients without a test for SaRS-CoV-2 and 56 (88.9%) with antigenic or PCR screening tests (18 [32.1%] negative and 39 [69.6%] positives for COVID-19). The mean age was 51.3 (SD 12.71; range 23-70), and 57 (90.5%) were female. Twenty-three patients (36.5%) had a history of adverse events with hyaluronic acid injections. During the study, 15 adverse events were reported; 11 patients (73.3%) had a history (p = 0.0018); two patients (13.3%) had been vaccinated; 13 (86.7%) had performed a SARS-CoV2 test (six [46.2%] negatives, and seven [53.8%] with a positive result; p = 0.5969). All adverse study events were resolved, and none had sequelae.

CONCLUSION

Adverse events after hyaluronic acid facial injections were higher among patients with a history but not among those diagnosed with COVID-19. The new scenario related to COVID-19 infections or vaccinations would require readapting criteria for applying hyaluronic acid injections.

Potential Effects of Repetitive Panfacial Filler Injections on Facelift Surgery and Surgical Outcomes: Survey Results of the Members of The Aesthetic Society

Background

Facial soft-tissue filler injections are being performed in the United States with increasing popularity.f.

Objectives

This study aimed to characterize the observations of The Aesthetic Society members regarding the potential impact of repetitive panfacial fillers on the outcomes of subsequent facelift surgery.

Methods

A survey containing closed and open-ended questions was sent to The Aesthetic Society members through email.

Results

The response rate was 3.7%. The majority of the respondents (80.8%) believed that less than 60% of their facelift patients had previous repetitive panfacial filler injections. One half (51.9%) reported that a history of panfacial filler injections increased the difficulty of performing facelifts. A large subset (39.7%) of respondents believed that a history of panfacial fillers increased postoperative complication rates, while the remaining either disagreed (28.9%) or were unsure (31.4%). The most common complications following the facelift surgery included undesirable palpability or visibility of filler (32.7%), compromised flap vascularity (15.4%), and decreased longevity of the lifting effect (9.6%).

Conclusions

This study identified a potential association with repetitive panfacial filler injections and outcomes following facelift surgery, although the exact effect on postoperative outcomes remains unclear. Large prospectively designed studies are needed to capture objective data comparing facelift patients with a history of repetitive panfacial fillers with those facelift patients who have never had injectables. Given the results of The Aesthetic Society members' survey, the authors encourage careful history-taking to elicit an accurate filler injection record including complications after filler injections, as well as engaging patients in a thorough preoperative discussion regarding the potential of panfacial fillers on the facelift procedure and postoperative outcomes.

Level of Evidence 5

No association found between late-onset inflammatory adverse events after soft tissue filler injections and the adaptive immune system

BACKGROUND

To date, it is unknown why some individuals develop late-onset inflammatory adverse events after treatment with fillers. These events may result from various factors, including an immunological response of the adaptive immune system.

OBJECTIVE

In a pilot study, we looked for evidence that is there a relation between late-onset inflammatory adverse events and the presence of immune cells surrounding the injected filler.

METHODS AND MATERIALS

We included 47 patients, of whom 20 experienced late-onset inflammatory adverse events to different fillers (inflammatory group) and 27 who did not (reference group). A biopsy was taken from the area of the adverse event. Hematoxylin-eosin staining and immunohistochemistry analysis with CD3 (T-cells) and CD68 (macrophages) on paraffin tissue sections was used to assess the biopsies.

RESULTS

Immune cells were found in biopsies obtained from 18 of 47 patients: Nine biopsies from the inflammation group and nine from the reference group. All these 18 cases showed CD68-positive immune cells. Virtually no CD3-positive immune cells were found.

CONCLUSION

Our results indicate that there is no T-cell activity in biopsies from areas with late-onset adverse events after filler injections. The macrophages found in the biopsies are probably not responsible for the inflammatory response.

Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers

BACKGROUND

Hyaluronic acid fillers are known for a reliable safety profile, but complications do occur, even serious vascular adverse events.

OBJECTIVE

To improve the treatment outcome after a vascular adverse event with use of hyaluronic acid filler treatments.

METHODS

Duplex ultrasonography is used to detect the hyaluronic acid filler causing the intra-arterial obstruction.

RESULTS

If treated in time, 1 single treatment of ultrasonographically guided injections of hyaluronidase into the filler deposit will prevent skin necrosis.

CONCLUSION

Because the use of duplex ultrasonography adds extra essential information, its use may become an integral part of the prevention and treatment of injection adverse events.

NOT SO "HAPPY BUMP": A complication due to hyaluronic acid

INTRODUCTION

The use of hyaluronic acid (HA) as a dermal filler is considered safe. However, as new brands come to the market, reports of adverse events are becoming more and more common.

OBJECTIVE

To describe a particular type of adverse effect that, unlike the erythematous, indurated, and painful nodules described in the literature as "angry red bumps," is characterized by noninflammatory, stony-like nodules that appear in sites previously treated with HA.

METHODS

The report of four patients who presented this complication, and the occurrence of two HA syringes from the same batch that had hardened the product inside at the time of filling.

CONCLUSION

The authors propose the nomenclature "happy bump" to group adverse reactions to HA that translate into noninflammatory nodules, with a stony consistency, appearing up to 4 weeks (recent) or after one month (late) in sites previously treated with AH.

COVID-19 vaccines and filler reactions: Should it be considered as a concern?

BACKGROUND

Any implant or external material used in the body tissues can potentially be followed by autoimmune or inflammatory reactions. With the global vaccination program against COVID-19, the reports of tissue filler reactions would be increasingly demonstrated.

AIM

To summarize the data regarding COVID vaccination and filler reactions.

METHOD

We reviewed the existing data in this regard through searching on PubMed, Google Scholar and Scopus. All of the relevant papers published until March 2022, which we could access to their fulltexts were included.

RESULTS

Here, we summarized the data regarding COVID-19 vaccination and filler reactions and discussed its etiopathogenesis, management, and importance.

CONCLUSION

Although the end of pandemic was announced, the necessity of continuing COVI-D19 vaccination in future mandates gathering data regarding safety of vaccines.

Association between BNT162b2 vaccination and the development of delayed inflammatory reactions to hyaluronic acid-based dermal fillers - A nationwide survey

Background

Delayed inflammatory reactions (DIRs) to hyaluronic acid (HA)‐based dermal fillers following COVID‐19 vaccination has been reported in a few anecdotal reports and small series of cases.

Aim

To evaluate the clinical characteristics, incidence and management options relevant to BNT162b2 vaccination‐associated DIR – A nationwide survey was conducted.

Methods

An online self‐administered survey was sent to physicians who actively practice tissue filler injections. The data acquired included demographic and clinical characteristics of relevant DIR cases.

Results

Out of 262 responders, 20 cases with DIR following the vaccination were reported. 35% and 65% occurred shortly after the first and second vaccination dose, respectively. Overall, 65% of the DIRs appeared ≤5 days after vaccine administration and most DIRs resolved within 21 days. The filler's volume (P = .016) was associated with higher DIR severity, and the same tendency was noted among some filler types and locations of injection. Medical intervention was provided in 12 (60%) cases.

Conclusion

DIR associated with BNT162b2 vaccination is rare and tends to resolve spontaneously or with short‐term medical intervention.

Review of Delayed Reactions to 15 Hyaluronic Acid Fillers

BACKGROUND

Delayed-onset reactions are increasingly relevant given the growing use of hyaluronic acid dermal fillers. There is poor understanding of the phenomenon's etiology and incidence.

OBJECTIVE

To highlight differences between the dermal filler products with an emphasis on delayed-onset reaction incidence, pathogenesis, prevention, and treatment.

METHODS

A literature review was performed for delayed-onset reactions following hyaluronic acid dermal filler injection using PubMeb and Embase. Articles were included based on relevance, quality, and the predetermined definition of "delayed-onset reaction" (>30 days post injection). A total of 28 studies were included in the data analysis.

RESULTS

A total of 13,136 subjects from 28 studies treated with 15 filler types were included in the analysis. VYC-15L dermal filler injections carried the highest risk of delayed reaction with a mean incidence of 3.83% ( n = 46/1,202), followed by VYC-20L (0.92%) and VYC-17.5L (0.88%). The mean incidence of delayed reactions among all filler types was 1.13%.

CONCLUSION

Incidence of delayed reaction to hyaluronic fillers ranges from 0% to 3.83% (mean = 1.13%) and varies by filler type. The exact etiology of these delayed reactions remains disputed. Future studies should report reaction description, precise timeline, and posttreatment immunologic history to better delineate the incidence of delayed-onset hypersensitivity reactions.

Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results

Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.

Treatment of Delayed-onset Inflammatory Reactions to Hyaluronic Acid Filler: An Algorithmic Approach

Hyaluronic acid fillers are one of the most widely used and versatile fillers worldwide. Although traditionally regarded as immunologically inert, many currently available products have been substantially modified to improve longevity and to optimize properties for specific indications. Such modifications, either alone or in combination with other factors (such as the immune status of the patient, immune-triggering events, and bacterial contamination), may lead to the development of late-onset inflammatory nodules in some patients. This article discusses the clinical presentation of late-onset adverse inflammatory reactions to hyaluronic acid injections, describes their likely triggers, and presents the author's treatment algorithm for successful resolution.

Hyaluronic Acid Gel Injection for the Treatment of Tear Trough Deformity: A Multicenter, Observational, Single-Blind Study

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 .

Incidence and Treatment of Delayed-onset Nodules After VYC Filler Injections to 2139 Patients at a Single Canadian Clinic

Background

Data suggest that hyaluronic acid (HA) fillers using VYC technology have a higher incidence of delayed‐onset nodule development at facial injection sites than earlier HA products.

Objective

To assess the incidence of delayed‐onset nodules with VYC products based on a single experienced injector.

Methods and Materials

Patients with delayed‐onset nodules after injections with VYC‐20L, VYC‐17.5L, and VYC‐15L were identified by retrospective chart review.

Results

Since 2010, 2139 patients received injections from the same physician with combinations of VYC‐20L (57.6% of patients; 2.4 syringes/patient), VYC‐17.5L (23.9%; 1.5), or VYC‐15L (18.5%; 1.5). Seven female patients (mean age, 62 years) developed delayed‐onset nodules for an overall incidence of 0.33%. A potential inflammatory trigger (reported by 6 patients) occurred 1–168 days prior to nodule development. Nodule biopsy in 1 patient confirmed a foreign‐body granuloma. The most effective treatment incorporated prednisone with or without hyaluronidase, and in 2 patients, nodules resolved spontaneously. The incidence of delayed‐onset nodules was not associated with injection technique or amount of product used.

Conclusion

VYC‐associated incidence of delayed‐onset nodules (0.33%) was lower than earlier estimates from previous studies. In the current analysis, VYC‐15L had a rate of delayed reactions comparable with non‐VYC products.

Juvéderm Volift (VYC-17.5L), a Hyaluronic Acid Filler with Lidocaine, is Safe and Effective for Correcting Nasolabial Folds in Chinese Subjects

PURPOSE

Hyaluronic acid injectable gels are commonly used to treat nasolabial folds (NLFs). We evaluated the safety and effectiveness of VYC-17.5L for correcting NLFs in Chinese subjects.

PATIENTS AND METHODS

This prospective, multicenter, double-blind, within-subject‒controlled study randomized adults with moderate-to-severe NLFs to VYC-17.5L treatment (initial and touch-up) in 1 NLF and control (without lidocaine) in the contralateral NLF. Effectiveness endpoints at 6 months included noninferiority of VYC-17.5L to control in NLF Severity Scale response rate (primary endpoint), subject-reported procedural pain (11-point scale), and investigator and subject assessments using the Global Aesthetic Improvement Scale (GAIS).

RESULTS

A total of 175 subjects were included. The primary endpoint was met, with response rates of 84.2% for VYC-17.5L and 82.5% for control. Mean pain scores after initial and touch-up treatments were 2.4 for VYC-17.5L versus 5.2 for control (P < 0.001) and 2.0 versus 3.3 (P < 0.001), respectively. Investigator-rated GAIS scores were 86.5% for VYC-17.5L versus 86.0% for control. There were no between-group differences in subject-rated GAIS scores. Safety profiles were comparable for VYC-17.5L and control.

CONCLUSION

VYC-17.5L was noninferior to control without lidocaine for correcting moderate-to-severe NLFs in Chinese subjects and was superior to control in reducing procedural pain.

Postmarket Safety Surveillance of Delayed Complications for Recent FDA-Approved Hyaluronic Acid Dermal Fillers

OBJECTIVE

To review postmarketing data for delayed (≥14 days post-treatment) adverse events (AEs) of interest (inflammatory and noninflammatory nodules, hypersensitivity, granulomas) for newer hyaluronic acid (HA) fillers FDA-approved within the last 5 years (2016-2020).

METHODS

Reports from the Manufacturer and User Facility Device Experience (MAUDE) database were extracted for HAREF, HADEF, HAKYS, HAVER, HAVLR, HAVOB, HARH2, HARH3, and HARH4 from January 2016 to January 2021. Keywords from event narratives were used to identify and categorize AEs and then verified through inclusion/exclusion criteria. Percentages are based on the total combined events of interest to provide an overall perspective of the events reported during the search period.

RESULTS

Of 585 MAUDE reports, there were 195 (33.3%) delayed AEs of interest. Of those, 71.8% were nodules (42.1% inflammatory and 29.7% noninflammatory), 21.5% hypersensitivity, and 6.7% granulomas. The combined total events of interest, ordered by frequency reported, were HAVLR (74.4%), HAVOB (12.3%), HADEF (5.1%), HARH4 (3.6%), HAREF (2.6%), and HARH2 (2.1%), with no reports for HARH3, HAVER, and HAKYS.

CONCLUSION

Although delayed nodules and inflammatory events are rare, reports for these events were extracted from the MAUDE database from 2016 to 2020 for HAVLR, HAVOB, HADEF, HARH4, HAREF, and HARH2 (most to least frequent).

Adverse Events Following COVID-19 Vaccine in Patients Previously Injected with Facial Filler: Scoping Review and Case Report

The “Vaccines and Related Biological Products Advisory Committee 17 December 2020 Meeting Briefing Document”, formulated by the FDA, reported three cases of swelling in areas previously injected with HA filler, introducing the possible relationship between a COVID-19 vaccine and adverse events in areas previously injected with HA fillers. The aim of this research is to report a case of an adverse event following a COVID-19 vaccine in a patient previously injected with facial filler. Furthermore, a scoping review on the same topic was performed. The research was carried out on the electronic databases PubMed, Cochrane Library, Web of Science, Google Scholar and Scopus. The selection process identified four articles as eligible for inclusion in the review. Nineteen patients, including the described case report, who experienced an adverse event following a COVID-19 vaccine in areas previously injected with facial filler were identified. Adverse events following a COVID-19 vaccine in patients previously injected with facial filler appear to be rare. A high BDDE cross-linking rate and/or a low-molecular-weight hyaluronic acid filler may have a higher tardive adverse event rate when triggered.

Evaluating safety in hyaluronic acid lip injections

INTRODUCTION

Soft tissue filler augmentation has become increasingly popular due to its perceived ease and impressive results. Unfortunately, although the results are impressive, so are the reported complications. This article describes complications specific to peri-oral soft tissue filler injection and then discusses evidence-based, anatomic prevention and treatment guidelines.

AREAS COVERED

The authors aimed at providing an overview of the complications associated with peri-oral soft tissue filler. Hyaluronic Acid (H.A) fillers may have devastating complications which are oft undisclosed or published. This narrative review aims to describe the various complications and provide preventative strategies.

EXPERT OPINION

Given the paucity of prospective, randomized clinical trials on the subject and in light of complication underreporting, the authors believe that efficacy and safety literature on the subject is lacking. Injectors must rely on the one strength which exists in the lip literature to date, that is anatomy. The basis of all successful injections is a mandatory understanding of normal as well as variations of vital structures in an area, combined with meticulous injection techniques, deposition of small aliquots of product and the ability to recognize unwanted adverse events early enough to act on them.

Non-Surgical Touch-Up with Hyaluronic Acid Fillers Following Facial Reconstructive Surgery

The use of hyaluronic acid (HA) injectable fillers has become increasingly widespread in facial recontouring and rejuvenation. We report our experiences to emphasize the role of HA fillers as tools beyond aesthetic treatments in cases of post-surgical facial sequelae. HA fillers are generally used for aesthetic rejuvenation, but one potential new horizon could be their application in trauma, reconstructive, and craniofacial surgery. This study was conducted retrospectively, evaluating medical reports of patients treated at the Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, Naples, for lip incompetence, trauma, oncological, reconstructive, and craniosynostosis surgery sequelae. Visual analog scale (VAS) evaluation was performed to assess patient satisfaction. No major complications (i.e., impending necrosis or visual loss) were reported. Bruising and swelling was reported for 48 h after lip injection. At the immediate VAS evaluation, 67% of the patients were “extremely satisfied” and 33% “satisfied”. In those 33%, VAS scores changed to “extremely satisfied” at 6–9 weeks and 3–6 months of VAS evaluation (contextually to improvement in tissue flexibility, elasticity, and aesthetic appearance). Results indicate that this minimally invasive approach achieves a high level of aesthetic enhancement, improving patient satisfaction. The concept of HA filler applications could be a frontier that may be applicable to other areas of reconstructive facial plastic surgery.

Hyaluronic Acid Is an Effective Dermal Filler for Lip Augmentation: A Meta-Analysis

Introduction: The lips and the mouth play an indispensable role in vocalization, mastication and face aesthetics. Various noxious factors may alter and destruct the original structure, and appearance of the lips and the anatomical area surrounding the mouth. The application of hyaluronic acid (HA) may serve as a safe method for lip regeneration. Although a number of studies exist for HA effectiveness and safety, its beneficial effect is not well-established. Aim: The present meta-analysis and systematic review was performed to investigate the effectiveness of HA on lip augmentation. We also investigated the types and nature of adverse effects (AEs) of HA application. Methods: We reported our meta-analysis in accordance with the PRISMA Statement. PROSPERO protocol registration: CRD42018102899. We performed the systematic literature search in CENTRAL, Embase, and MEDLINE. Randomized controlled trials, cohort studies, case series and case reports were included. The untransformed proportion (random-effects, DerSimonian-Laird method) of responder rate to HA injection was calculated. For treatment related AEs descriptive statistics were used. Results: The systematic literature search yielded 32 eligible records for descriptive statistics and 10 records for quantitative synthesis. The results indicated that the overall estimate of responders (percentage of subjects with increased lip fullness by one point or higher) was 91% (ES = 0.91, 95% CI:0.85-0.96) 2 months after injection. The rate of responders was 74% (ES = 0.74, 95% CI:0.66-0.82) and 46% (ES = 0.46, 95% CI:0.28-0.65) after 6 and 12 months, respectively. We included 1,496 participants for estimating the event rates of AEs. The most frequent treatment-related AEs were tenderness (88.8%), injection site swelling (74.3%) and bruising (39.5%). Rare AEs included foreign body granulomas (0.6%), herpes labialis (0.6%) and angioedema (0.3%). Conclusion: Our meta-analysis revealed that lip augmentation with injectable HA is an efficient method for increasing lip fullness for at least up to 6 months after augmentation. Moreover, we found that most AEs of HA treatment were mild or moderate, but a small number of serious adverse effects were also found. In conclusion, further well-designed RCTs are still needed to make the presently available evidence stronger.

The Immunogenicity of Hyaluronic Fillers and Its Consequences

Hyaluronic acid (HA) is a glycosaminoglycan, a natural component of the extracellular matrix. The identical structure of the molecule in all living organisms is its main advantage, as it translates into the minimal probability of immunogenicity. Therefore, it is the closest to the ideal preparation used as a filler, due to its biocompatibility and stability at the site of implantation. This paper includes the discussion of the potential mechanisms of adverse immune reactions to HA along with the mechanisms of reaction following vaccinations against SARS-CoV-2. Based on the literature, we tried to systematize adverse immune reactions with systemic manifestations to HA. The occurrence of unpredictable reactions to hyaluronic acid indicates that they may not be treated as neutral or non-allergenic. The modifications of the chemical structure of HA, additives and individual tendencies in a patient may be the cause of unpredictable reactions, leading to serious health consequences. Preparations of unknown origin, poorly purified, or including bacterial DNA are particularly dangerous. Therefore, long-lasting follow-up of the patient and the selection of a preparation approved by the FDA or EMA are of high importance. Patients are often unaware of the consequences of cheaper procedures performed by persons without suitable knowledge with the use of unregistered products, so the public should be educated and legal regulations should be introduced.

Hyaluronic acid soft tissue filler delayed inflammatory reaction following COVID-19 vaccination - A case report

Background

The use of hyaluronic acid soft tissue fillers in aesthetic medicine exploded in recent years for many reasons, including being relatively safe. Incidence of delayed inflammatory reactions (DIRs) to hyaluronic acid soft tissue fillers range between 0.3% and 4.25%. These reactions are mediated by T‐lymphocytes and can be triggered by flu‐like illnesses, including SARS‐CoV‐2 infection. Vaccination may also induce hypersensitivity.

Aim

In this case report, we present two cases of delayed reaction after hyaluronic acid soft tissue filler treatment of the tear trough area and following mRNA vaccination against SARS‐Cov‐2, also known as COVID‐19, months later.

Patients

A 39‐year old female who previously had her tear trough area treated with hyaluronic acid soft tissue filler developed swelling days after getting the mRNA Pfizer‐BioNTech COVID‐19 vaccine. Another patient, a 61‐year‐olf female, developed intermittent facial swelling in areas previously treated with hyaluronic acid soft tissue fillers days after receiving her first dose of the mRNA Pfizer‐BioNTech COVID‐19 vaccine.

Results

As demonstrated in our case report, vaccination against COVID‐19 may induce DIRs in patients who previously had hyaluronic soft tissue fillers.

Conclusion

Delayed inflammatory reactions to hyaluronic acid soft tissue fillers are uncommon and usually self‐limited, with frequent spontaneous resolution. However, considering the ongoing pandemic and the worldwide demand for vaccines against COVID‐19, the aesthetic providers should be conscious of the risks posed by the interaction of such vaccines in patients who previously had or seeking hyaluronic acid soft tissue filler injections.

Immediate nor Delayed Type Hypersensitivity Plays a Role in Late Inflammatory Reactions After Hyaluronic Acid Filler Injections

Purpose

The exact etiology of late inflammatory reactions (LIRs) to hyaluronic acid (HA) fillers is currently unknown. Some argue that these result from a hypersensitivity reaction, although evidence to support this is very scarce. Most reports on such reactions are not substantiated by positive skin tests. The purpose of our study was to determine whether immediate or delayed type hypersensitivity reaction follows hyaluronic acid (HA) filler injections.

Patients and Methods

Twelve patients were referred for general allergic screening (patch tests), as well as specific intradermal testing (injection of 0.1cc boluses) on the medial upper arm with a selection of several currently available hyaluronic acid (HA) fillers on the market. A positive allergic reaction was defined as erythema, firmness or swelling.

Results

During the 4 month follow-up, no reactions to any of the tested HA fillers were reported. No correlation was found between results from the general allergic screening and a history with LIRs to HA fillers.

Conclusion

The results suggest that neither type I nor type IV hypersensitivity plays a role in late inflammatory reactions (LIRs) to hyaluronic acid (HA) fillers.

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A case of delayed inflammatory filler reaction following vaccination with succesful response to colchicine

Delayed inflammatory reactions (DIRs) associated with hyaluronic acid injections are not rare and can be seen in up to 4.25% of patients. Although the exact mechanism is not clear, several triggering factors, including infections, trauma, and dental procedures, were reported in the literature. A 43-year-old female patient treated with HA fillers developed an inflammatory reaction following vaccination in all areas of injection, including temples, lips, and lower eyelids. Systemic steroid and ciprofloxacin were used as a first-line treatment without response. Colchicine 1 mg/day along with hyaluronidase in lower eyelids improved all lesions successfully.

"New classification of late and delayed complications after dermal filler: Localized or Generalized?"

Background: As filler injections have become very common procedures worldwide, the number of complications has increased. However, there is a lack of systematized studies and precise classification of late and delayed complications. This study aimed to suggest new and reliable classifications and to characterize the clinical manifestations of late and delayed complications after filler injections.Methods: This retrospective study analyzed patients and suggested a new classification of delayed adverse effects related to filler injection. Several demographic and clinical findings were analyzed. Patients were classified into two types according to their clinical presentation: Type I (Localized) or Type II (Generalized).Results: Twenty-five patients were evaluated during a clinically active adverse event suspected to be related to fillers. The most common injected filler substance was hyaluronic acid (HA, 68.8%). 76% of the patients were classified with Localized complications. In the Generalized complications group, systemic symptoms were more common (p=0.002), the treatment response was poor (p=0.010), and fewer patients showed complete remission (p=0.007) than in the Localized complications group.Conclusions: We propose a simple new classification method for late and delayed complications after dermal filler: Localized and Generalized. We expect that this new classification could help provide appropriate treatment and predict patient prognosis.

Hypersensitivity reaction to Hyaluronic Acid Dermal filler following novel Coronavirus infection - a case report

The incidence of hypersensitivity reactions to hyaluronic acid dermal fillers is between 0.3 and 4.25%, mediated by T-lymphocytes. Flu-like illness can trigger immunogenic reactions at the site of filler placement. Cases of SARS-CoV-2 are significant and pose a possible risk of inducing hypersensitivity. This case report is of a delayed-type hypersensitivity after hyaluronic acid dermal filler treatment of the nose and subsequent infection with SARS-CoV-2. Risk factors for the development of such symptoms were identified as the presence of hyaluronic acid combined with flu-like illness and repeated treatment of one area. The case resolved without intervention. Clinicians should be mindful of the risk posed by the interaction of hyaluronic acid dermal filler with SARS-CoV-2 in light of the pandemic.

"COVID-19/SARS-CoV-2 virus spike protein-related delayed inflammatory reaction to hyaluronic acid dermal fillers: a challenging clinical conundrum in diagnosis and treatment"

We present the first reported cases of delayed inflammatory reactions (DIR) to hyaluronic acid (HA) dermal fillers after exposure to the COVID-19 spike protein. DIR to HA is reported to occur in the different scenarios including: secondary to poor injection technique, following dental cleaning procedures, following bacterial/viral illness, and after vaccination. In this report of 4 cases with distinct clinical histories and presentations: one case occured following a community acquired COVID-19 infection, one case occured in a study subject in the mRNA-1273 clinical phase III trial, one case occurred following the first dose of publically available mRNA-1273 vaccine (Moderna, Cambridge MA), and the last case occurred after the second dose of BNT162b2 vaccine (Pfizer, New York, NY). Injectable HA dermal fillers are prevalent in aesthetic medicine for facial rejuvenation. Structural modifications in the crosslinking of HA fillers have enhanced the products’ resistance to enzymatic breakdown and thus increased injected product longevity, however, have also led to a rise in DIR. Previous, DIR to HA dermal fillers can present clinically as edema with symptomatic and inflammatory erythematous papules and nodules. The mechanism of action for the delayed reaction to HA fillers is unknown and is likely to be multifactorial in nature. A potential mechanism of DIR to HA fillers in COVID-19 related cases is binding and blockade of angiotensin 2 converting enzyme receptors (ACE2), which are targeted by the SARS-CoV-2 virus spike protein to gain entry into the cell. Spike protein interaction with dermal ACE2 receptors favors a pro-inflammatory, loco-regional TH1 cascade, promoting a CD8+T cell mediated reaction to incipient granulomas, which previously formed around residual HA particles. Management to suppress the inflammatory response in the native COVID-19 case required high-dose corticosteroids (CS) to suppress inflammatory pathways, with concurrent ACE2 upregulation, along with high-dose intralesional hyaluronidase to dissolve the inciting HA filler. With regards to the two vaccine related cases; in the mRNA-1273 case, a low dose angiotensin converting enzyme inhibitor (ACE-I) was utilized for treatment, to reduce pro-inflammatory Angiotensin II. Whereas, in the BNT162b2 case the filler reaction was suppressed with oral corticosteroids. Regarding final disposition of the cases; the vaccine-related cases returned to baseline appearance within 3 days, whereas the native COVID-19 case continued to have migratory, evanescent, periorbital edema for weeks which ultimately subsided.

The use of periocular fillers in aesthetic medicine

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.

Hypersensitivity Caused by Cosmetic Injection: Systematic Review and Case Report

OBJECTIVE

Botulinum toxin injection, micro-needling injection, and filler injection are the most widely used non-surgical facial cosmetic treatments. Hypersensitivity reactions associated with injections have not received sufficient attention due to their low incidence rates. The authors tried to summarize the characteristics of the hypersensitivity caused by cosmetic injections and helped to improve the diagnosis and treatment.

METHODS

A comprehensive search of the PubMed database to September 2019 was performed. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, injection information (injected material, trade name, location of injection, symptoms of allergy, time of onset), diagnostic examination, treatment, and prognosis.

RESULTS

A total of 14 articles (57 patients) were included. There were 3 patients receiving botulinum toxin injection, 3 patients receiving micro-needling injection, and 46 patients receiving hyaluronic acid injection. Five patients were injected with collagen, polyacrylamide, paraffin, alkyl-imide or hyaluronidase, separately. The symptoms were redness, swelling, itching or induration at the injection site. The diagnosis and treatment methods vary greatly depending on the injection fillers. Removing the injected filler is the primary treatment.

CONCLUSION

Although hypersensitivity reaction is a relatively uncommon adverse event, more practice guidelines and research on diagnosis and treatment are demanded to help improve the 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 .

Histopathologic reaction patterns to differentially cross-linked hyaluronic acid fillers: A retrospective case series

BACKGROUND

Hyaluronic acid filler reactions have been increasingly observed in recent years. Our study investigates whether the increased number of filler reactions observed since 2014 is associated with a specific histopathologic inflammatory pattern and type of filler.

METHODS

The institution's dermatopathology electronic database was retrospectively searched for histopathologic reactions to hyaluronic acid from January 2014 to December 2019. The age, sex, type of filler, procedure, location, and histopathologic patterns were recorded.

RESULTS

From 2014 to 2019, there were 15 cases of granulomatous reactions to hyaluronic acid filler. In 10 of these cases, there was a characteristic inflammatory pattern characterized by tightly cuffed palisades of histiocytes with varying numbers of eosinophils. Of the 11 cases in which the type of filler was known, all used Vycross technology, a novel manufacturing process in the production of hyaluronic acid filler.

CONCLUSION

A characteristic histopathologic pattern of discrete foci of tightly cuffed palisaded granulomas with eosinophils is associated with fillers manufactured using Vycross technology.

Establishing a Standardized Facial Cosmetic Preinjection Safety Tool: The ACIST

In the past 20 years, the American population has seen an increased demand for nonsurgical minimally invasive facial rejuvenation solutions for the aging process. This widespread and increased demand for cosmetic injections brings a greater propensity for complications and adverse events. Choosing suitable patients for dermal filler is essential, as is concrete knowledge of the factors related to adverse events; however, there was no standardized tool to facilitate this process. The Joint Commission's Universal Safety checklist tools have been integrated into hospital surgical operating rooms and ambulatory outpatient settings across America and internationally and have successfully reduced errors in patient safety and outcomes. This article establishes the importance of integrating the Assessment Cosmetic Injection Safety Tool (ACIST), a standardized preinjection safety tool, into the cosmetic practice to decrease the incidence of adverse events associated with dermal filler and to achieve optimal patient satisfaction and outcomes. The ACIST was designed from the scientific literature, piloted at an urban cosmetic practice in the southern United States, finalized on the basis of feedback from participating staff members at the pilot study center, and disseminated to cosmetic nurse injectors.

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

Mandibular osteomyelitis after hyaluronic acid injection

BACKGROUND

Mandibular osteomyelitis after filler injection is extremely rare.

AIMS

We reported a case of mandibular osteomyelitis after hyaluronic acid injection.

PATIENTS

A 33-year-old woman received 1 mL hyaluronic acid injection on her chin 1 year ago, after which her chin kept swelling and painful, and gradually ulcerated with pus flowing out. She received antibiotics, debridement procedures, negative pressure wound therapy, and hyperbaric oxygen therapy without symptoms improved. Cone-beam computed tomography scan showed local bone destruction, sequestrum formation, and tissue calcification on the right mandible body. The patient was diagnosed with mandibular osteomyelitis and received local curettage for the removal of necrotized bone.

RESULTS

Literature search found no case reports on mandibular osteomyelitis after filler injection so far.

CONCLUSION

Minimizing the risk of contamination and infection is strictly required during the filler injection process. Once the patient shows signs of incurable mandibular infection postoperation, clinicians should consider the possibility of osteomyelitis.

Herpes reactivation after the injection of hyaluronic acid dermal filler: A case report and review of literature

INTRODUCTION

Hyaluronic acid injections is relatively safe with little risk of complications. Although herpes reactivation after the injection of hyaluronic acid is rare, it produces quite a huge pressure and panic on patients. Quite a lot cosmetic practitioners have no awareness of preventing, diagnosing, and giving correct treatment in time due to lack of experience.

PATIENT CONCERNS

A 24-year-old woman presented with erythema, crusted papules, pain and swelling on the nose after receiving the injection of hyaluronic acid. A swab of the discharge fluid was obtained for bacterial and viral culture, showing positive for herpes simplex virus.

DIAGNOSIS

The patient was diagnosed as herpes reactivation after the injection of hyaluronic acid.

INTERVENTIONS

The patient underwent antiviral therapy with acyclovir 400 mg, 3 times daily for seven days.

OUTCOMES

After a week of antiviral treatment, the clinical signs improved.

CONCLUSION

Herpes reactivation after the injection of hyaluronic acid is quite rare but needed sufficient attention of cosmetic practitioners to make the proper diagnosis, prevention and treatment.

Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm

Background and Objectives

There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose.

Materials and Methods

A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists.

Results

Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3-6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement.

Conclusion

A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.

Management Patterns of Delayed Inflammatory Reactions to Hyaluronic Acid Dermal Fillers: An Online Survey in Israel

BACKGROUND

Over the past few decades, soft tissue augmentation is ever-increasing, specifically hyaluronic acid (HA)-based filler injections. As the number of these procedures have risen, so have the adverse reactions. Delayed-type inflammatory reactions (DIRs) secondary to tissue fillers are typically classified according to the time of appearance post-procedure and have various presentations including nodules, abscesses, edema, and discoloration. Currently, the treatment of these complications varies among physicians.

OBJECTIVE

The aim of this study was to assess the knowledge and experience of practitioners in Israel who inject HA-based tissue fillers with respect to the management of late-onset procedural complications.

MATERIALS AND METHODS

A survey regarding management and treatment of late-onset inflammatory reactions was sent to 1120 physicians and dentists in Israel who practice tissue filler injections.

RESULTS

Three hundred thirty-four out of the 1120 practitioners replied to the questionnaire. The majority of respondents were dentists (group A) comprising 31% of all respondents. Group B accounted for 31% of injectors and consisted of dermatologists (19%) and plastic surgeons (12%), and group C (38%) accounted for all other practitioners; 48.2% of all injectors indicated that they have not previously encountered a DIR, whereas 11.4% responded that they have encountered more than 5 DIRs. In order to assess treatment management, we presented the injectors with a simulatory case of a woman with a late-onset complication. Most injectors referred the patient to the emergency department. When asked to establish a treatment plan, the majority of practitioners prescribed short-term oral steroids, ie, prednisone (35.3%). A limited number of patients were treated with intra-lesional hyaluronidase (31.4%) injection as only 34% of injectors kept hyaluronidase at their clinic.

CONCLUSION

The varied approach regarding the management of delayed type reactions to HA-based filler injections, reflected in our study, illustrates the existing ambivalence in the current literature regarding the management and therapy of late-onset complications.