The Spectrum of Adverse Reactions After Treatment with Injectable Fillers in the Glabellar Region

Needle-Free Jet Injection of Poly-(Lactic Acid) for Atrophic Acne Scars: Literature Review and Report of Clinical Cases

Acne scars, particularly atrophic ones, present a persistent challenge in cosmetic medicine and surgery, requiring extended and multifaceted treatment approaches. Poly-(lactic acid) injectable fillers show promise in managing atrophic acne scars by stimulating collagen synthesis. However, the utilization of needle-free injectors for delivering poly-(lactic acid) into scars remains an area requiring further exploration. In this article, a summary of the latest advancements in needle-free jet injectors is provided, specifically highlighting the variations in jet-producing mechanisms. This summary emphasizes the differences in how these mechanisms operate, offering insights into the evolving technology behind needle-free injection systems. The literature review revealed documented cases focusing on treating atrophic acne scars using intralesional poly-(lactic acid) injections. The results of these clinical studies could be supported by separate in vitro and animal studies, elucidating the feasible pathways through which this treatment operates. However, there is limited information on the use of needle-free jet injectors for the intradermal delivery of poly-(lactic acid). Clinical cases of atrophic acne scar treatment are presented to explore this novel treatment concept, the needle-free delivery of poly-(lactic acid) using a jet pressure-based injector. The treatment demonstrated efficacy with minimal adverse effects, suggesting its potential for scar treatment. The clinical efficacy was supported by histological evidence obtained from cadaver skin, demonstrating an even distribution of injected particles in all layers of the dermis. In conclusion, we suggest that novel needle-free injectors offer advantages in precision and reduce patient discomfort, contributing to scar improvement and skin rejuvenation. Further comprehensive studies are warranted to substantiate these findings and ascertain the efficacy of this approach in scar treatment on a larger scale.

Needleless laser injector versus needle injection for skin enhancement and rejuvenation effect of dermal filler

BACKGROUND AND OBJECTIVES

A needleless laser-induced microjet injector is a novel transdermal drug delivery system that can rapidly inject a very small and precise drug dose into the skin with minimal pain and downtime. In this study, we aimed to compare the laser-induced microjet injection versus needle injection of polylactic acid/hyaluronic acid filler for skin enhancement and rejuvenation.

PATIENTS AND METHODS

A 24-week prospective, single-center, assessor-blinded, randomized, split-face study was conducted. The enrolled patients underwent one treatment session of dermal filler injection using a laser-induced microjet injector on one half of the face or a traditional needle injection on the other half of the face. Evaluation was conducted at baseline before treatment and at 4, 12, and 24 weeks after treatment.

RESULTS

A single treatment of filler injection with a laser-induced microjet injector resulted in similar improvements in skin hydration and elasticity as a single treatment of filler injection by using manual needle injection, with reduced pain, side effects, and decreased treatment time.

CONCLUSIONS

Laser-induced microjet injector enabled not only the application of a controlled dose and filler depth but also even distribution, improved clinical efficacy, reduced pain and side effects, and sufficient time for clinicians to perform treatment.

Soft Tissue Dermal Filler-Associated Necrosis and Impending Necrosis: A Systematic Review of the Literature

BACKGROUND

Cosmetic soft tissue fillers are a popular minimally invasive procedure. Necrosis is a rare yet devastating complication of soft tissue fillers. To date, the relationship between soft tissue fillers and necrosis has not been fully described.

OBJECTIVE

To systematically compile published cases of soft tissue fillers resulting in necrosis and collect data regarding the injection, treatment, and outcome.

METHODS AND MATERIALS

Using PRISMA protocol, a comprehensive search for soft tissue filler necrosis was performed using no time constraints, resulting in 97 articles encompassing 192 cases of soft tissue filler necrosis containing individual-level data.

RESULTS

Of the cases analyzed, 66.1% had progressed to necrosis, whereas 33.9% of patients had impending necrosis. Necrosis most commonly resulted from injection of the nasolabial fold (32.4%, n = 88). The filler material most commonly used was hyaluronic acid (71.9%, n = 138). Hyaluronidase was used most frequently as an initial treatment agent (19.1%, n = 88). Forty-three patients (22.4%) with necrosis had a prior minor procedure or surgery.

CONCLUSION

This systematic review is an extensive overview of necrosis as a complication of soft tissue fillers. It serves as a reference tool for any clinician who injects soft tissue fillers and any provider who encounters soft tissue filler necrosis.

Sudden vision loss and neurological deficits after facial hyaluronic acid filler injection

BACKGROUND

The ongoing expansion of the cosmetic armamentarium of facial rejuvenation fails to uncover the inherent risks of cosmetic interventions. Informed consent to all risks of cosmetic filler injections and potential sequelae, including ocular and neurological complications, should be carefully ensured. We present two cases of complications following facial hyaluronic acid filler injections.

CASE PRESENTATIONS

Case 1: A 43-year-old woman presented with monocular vision loss of the left eye, associated ptosis, ophthalmoplegia, periocular pain and nausea, cutaneous changes of the glabella region and forehead, and sensory impairment in the left maxillary branch dermatome (V2) after receiving a hyaluronic acid (HA) filler injection into the left glabellar area. On ophthalmological examination, an ophthalmic artery occlusion (OAO) was diagnosed upon identification of a "cherry-red spot". Magnetic resonance imaging (MRI) revealed a left ischemic optic neuropathy. Supportive therapy and hyaluronidase injections were initiated. A follow-up MRI of the head performed two months after presentation corresponded to stable MRI findings. The patient had irreversible and complete vision loss of the left eye, however, the ptosis resolved. Case 2: A 29-year-old woman was admitted to hospital a few hours after a rhinoplasty and cheek augmentation with hyaluronic acid, presenting with acute monocular vision loss in the right eye, retrobulbar pain, fatigue and vomiting. In addition, the patient presented a harbinger of impending skin necrosis and a complete oculomotor nerve palsy on the right side, choroidal ischemia and vision impairment. Supportive treatment and hyaluronidase injections into the ischemic tissue were initiated. A small scar at the tip of the nose, vision impairment and an irregular pupillary margin on the right side persisted at follow-up.

CONCLUSION

These two case reports and the literature review emphasize the pathophysiological mechanisms leading to potentially devastating complications. In order to reduce the risk of vision loss secondary to cosmetic filler injections, practitioners should possess a thorough knowledge of anatomy and preventive strategies.

Efficacy of Percutaneous Intraarterial Facial/Supratrochlear Arterial Hyaluronidase Injection for Treatment of Vascular Embolism Resulting From Hyaluronic Acid Filler Cosmetic Injection

BACKGROUND

Vascular embolism is a serious complication of hyaluronic acid (HA) filler cosmetic injection, and hyaluronidase injection has been proposed as the treatment. Until now, there has been a lack of adequate clinical evidence regarding the benefits of treatment for HA filler-induced vascular embolism by percutaneous facial or supratrochlear arterial hyaluronidase injection.

OBJECTIVES

The authors sough to evaluate the efficacy of percutaneous facial or supratrochlear arterial hyaluronidase injection as a rescue treatment for HA filler-induced vascular embolism.

METHODS

We included 17 patients with vascular embolism after facial HA filler injection. Intraarterial injection of 1500 units hyaluronidase was performed via facial artery for 13 cases with skin necrosis and via supratrochlear arterial for 4 cases with severe ptosis and skin necrosis but no visual impairment. Simultaneously, general symptomatic treatment and nutritional therapy were performed.

RESULTS

After hyaluronidase injection, facial skin necrosis in all cases was restored and ptosis in the 4 cases was also significantly relieved. Patients were subsequently followed-up for 1 month to 1 year. The skin necrosis in 16 patients completely healed, and only 1 patient had small superficial scars.

CONCLUSIONS

It is effective to alleviate skin necrosis and ptosis resulting from HA filler embolism via percutaneous facial or supratrochlear arterial hyaluronidase injection.

LEVEL OF EVIDENCE: 4

The clinical spectrum of periorbital vascular complications after facial injection

BACKGROUND

Serious complications due to periorbital vascular occlusion can occur after facial injections, including skin necrosis, ophthalmoplegia, blepharoptosis, and visual loss. Visual loss after facial filler injection is particularly rare, but it is known to have a poor prognosis despite treatment.

AIMS

This study aimed to describe the prognosis and various clinical features of periorbital vascular complications after facial injection of cosmetic filler or local anesthetic.

PATIENTS/METHODS

This single-center retrospective study included 10 consecutive patients who presented with occluded periorbital vessels after facial injection.

RESULTS

Nine patients were injected with cosmetic facial fillers: seven with hyaluronic acid, one with collagen, and one with poly-Llactic acid. The other patient was injected with lidocaine mixed with epinephrine. Injection sites included the glabella (n = 5), nasal dorsum (n = 4), and temporal fossa (n = 1). Presumed arteries affected included the central (n = 2) or branch (n = 3) retinal artery, ophthalmic artery (n = 4), and angular artery (n = 1). Nine patients (90%) had purpura and blisters, and eight patients (80%) had ophthalmoplegia at presentation, but all of them recovered within 3 months. Six patients (60%) were blind at the last follow-up, and five of them had occlusion of the central retinal artery or ophthalmic artery. There was a patient with sequelae of phthisis bulbi, which was cosmetically managed with retrobulbar filler injections.

CONCLUSION

Facial injections can cause periorbital arterial occlusion, and the clinical features are diverse according to the site and extent of vascular occlusion and injection materials. Visual prognosis was associated with the site of vascular occlusion and initial visual acuity. Other common complications, such as skin lesions, blepharoptosis, and limited extraocular movement, can fully resolve only with supportive treatments in most cases.

A new three-point filler technique to maximize safety for the correction of glabellar rhytids: Evaluation of 50 patients

BACKGROUND

Hyaluronic acid (HA) fillers have been widely used for reversing the signs of the aging face. Injectable fillers are particularly effective in treating vertical glabellar wrinkles.

AIMS

The aim of this study was to share our own safe glabella filling technique and to evaluate our results in 50 patients with facial rejuvenation.

METHODS

A total of 50 patients consisting of women and men with moderate to severe glabellar rhytids were enrolled in the study. Patients were evaluated before the injection procedure and 2 weeks after the procedure by using the Rao-Goldman scale. We have described a new three-point filler technique.

RESULTS

Of 50 patients, 39 were females and 11 males, and the mean age was 39.82 ± 6.44 years. The mean volume of HA that was injected into the glabellar wrinkles was 0.61 ± 0.12 mL. Eight patients had experienced mild complications related to the procedure. None of the patients had experienced skin necrosis and visual impairment.

CONCLUSION

Our technique is a simple and safe procedure to correct glabellar rhytids. Practitioners should be aware of the safe injection techniques, potential complications, and management of these complications for a good clinical practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE IV

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

The Role of Anastomotic Vessels in Controlling Tissue Viability and Defining Tissue Necrosis with Special Reference to Complications following Injection of Hyaluronic Acid Fillers

BACKGROUND

Most target areas for facial volumization procedures relate to the anatomical location of the facial or ophthalmic artery. Occasionally, inadvertent injection of hyaluronic acid filler into the arterial circulation occurs and, unrecognized, is irreparably associated with disastrous vascular complications. Of note, the site of complications, irrespective of the injection site, is similar, and falls into only five areas of the face, all within the functional angiosome of the facial or ophthalmic artery.

METHODS

Retrospective and prospective studies were performed to assess the site and behavior of anastomotic vessels connecting the angiosomes of the face and their possible involvement in the pathogenesis of tissue necrosis. In vivo studies of pig and rabbit, and archival human total body and prospective selective lead oxide injections of the head and neck, were analyzed. Results were compared with documented patterns of necrosis following inadvertent hyaluronic acid intraarterial or intravenous injection.

RESULTS

Studies showed that the location of true and choke anastomoses connecting the facial artery with neighboring angiosomes predicted the tissue at risk of necrosis following inadvertent intraarterial hyaluronic acid injection.

CONCLUSION

Complications related to hyaluronic acid injections are intimately associated with (1) the anatomical distribution of true and choke anastomoses connecting the facial artery to neighboring ophthalmic and maxillary angiosomes where choke vessels define the boundary of necrosis of an involved artery but true anastomoses allow free passage to a remote site; or possibly (2) retrograde perfusion of hyaluronic acid into avalvular facial veins, especially in the periorbital region, and thereby the ophthalmic vein, cavernous sinus, and brain.

Adverse effects of fillers

Filler injections belong to the most frequently performed noninvasive beautifying procedures. When done correctly they are generally well tolerated. However, a number of factors, such as poor filler quality, and particularly host as well as user dependent filler reactions may lead to unwanted effects. These may be early, late, or delayed events with characteristics for each of them. Temporary fillers almost invariably cause temporary side effects whereas those of permanent fillers may last forever. Some fillers are notorious for their poor safety profile; for example, silicone is banned in the European Union and the United States but nevertheless used by many practitioners and beauticians. Many fillers can be identified in histopathologic sections allowing specific measures to be instituted.

Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations

Background

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

Methods

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

Results

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

Conclusions

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

Level of Evidence V

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

Forehead reconstruction using modified double-opposing rotation-advancement flaps for severe skin necrosis after filler injection

Varying degrees of complications can occur after hyaluronic acid filler injections. Tissue necrosis due to interruption of the vascular supply is an early complication that can be severe. If the site of tissue necrosis due to the filler injection is the forehead, successfully reconstructing the region without distorting the key landmarks is challenging. We describe the case of a 50-year-old man who experienced widespread forehead skin necrosis after hyaluronic acid filler injection in the glabellar area. We successfully covered the forehead area with a 3×4-cm² midline necrotic tissue using the modified double-opposing rotation-advancement flap method. Although modified double-opposing rotation-advancement flap closure has the disadvantage of leaving a longer scar compared to conventional double-opposing rotation-advancement flap closure, the additional incision line made along the superior border of the eyebrow aids in camouflaging the scar and decreases eyebrow distortion. Therefore, it is believed that the modified double-opposing rotation-advancement flap technique is an excellent tool for providing adequate soft tissue coverage and minimal free margin distortion when reconstructing widespread skin necrosis in the central mid-lower forehead that can occur after filler injection in the glabellar area.

Skin Necrosis with Oculomotor Nerve Palsy Due to a Hyaluronic Acid Filler Injection

Performing rhinoplasty using filler injections, which improve facial wrinkles or soft tissues, is relatively inexpensive. However, intravascular filler injections can cause severe complications, such as skin necrosis and visual loss. We describe a case of blepharoptosis and skin necrosis caused by augmentation rhinoplasty and we discuss the patient's clinical progress. We describe the case of a 25-year-old female patient who experienced severe pain, blepharoptosis, and decreased visual acuity immediately after receiving a filler injection. Our case suggests that surgeons should be aware of nasal vascularity before performing an operation, and that they should avoid injecting fillers at a high pressure and/or in excessive amounts. Additionally, filler injections should be stopped if the patient complains of severe pain, and appropriate measures should be taken to prevent complications caused by intravascular filler injections.

Nonsurgical Rejuvenation of the Eyelids with Hyaluronic Acid Gel Injections

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

[Fillers and associated side effects]

BACKGROUND

A variety of fillers is commonly used for tissue augmentation as well as skin rejuvenation, and consist of a large heterogeneous group of biomaterials. The objective was to provide an overview and classification of the most commonly injected filler materials and filler-related complications including therapy.

METHOD

A summary of the current literature and common associated side effects is provided from a personal clinical perspective.

RESULTS

According to degradability, filler materials can be classified as temporary (degradable), semi-permanent, and permanent (nondegradable). Temporary fillers such as hyaluronic acid and collagen are completely degraded by the surrounding tissue within several months. Semi-permanent fillers are degradable, but may induce longer-lasting secondary effects. Permanent fillers such as silicone and mineral oil derivatives are not biodegradable and have been increasingly abandoned because of severe and irreversible side effects. The most common filler-related adverse events include pigmentation changes, edema and post-injection deformations. Visible or palpable nodules can be due to filler accumulation, formation of granuloma, or infection.

CONCLUSIONS

Substantial knowledge of the chemical and clinical features of the injected materials is indispensable for safe and efficient application. Early recognition of filler-related adverse effects is important to avoid severe complications and to achieve optimal results.

Managing Complications of Fillers: Rare and Not-So-Rare

Fillers belong to the most frequently used beautifying products. They are generally well tolerated, but any one of them may occasionally produce adverse side effects. Adverse effects usually last as long as the filler is in the skin, which means that short-lived fillers have short-term side effects and permanent fillers may induce life-long adverse effects. The main goal is to prevent them, however, this is not always possible. Utmost care has to be given to the prevention of infections and the injection technique has to be perfect. Treatment of adverse effects is often with hyaluronidase or steroid injections and in some cases together with 5-fluorouracil plus allopurinol orally. Histological examination of biopsy specimens often helps to identify the responsible filler allowing a specific treatment to be adapted.

Common Dermatologic Procedures

Dermatologists perform a wide variety of procedures on a daily basis. The skin biopsy is a fundamental technique that can be performed by all physicians who manage cutaneous conditions. Specimens should always be sent for pathologic evaluation, regardless of whether the sampled lesion appears benign. Postoperative care and education are critical for minimizing complications.

Dermal fillers: facts and controversies

Dermal fillers have been used for decades in soft tissue augmentation. Currently, filler implementation is among the most common minimally invasive procedures for rejuvenation and body sculpturing. There is a broad variety of filler materials and products. Despite immense experience, a number of controversies in this topic exist. Some of these controversies are addressed in this review, for example, who should perform filler injections, the difference between permanent and nonpermanent fillers, the off-label use of liquid silicone, and the role of pain reduction. Implementation of guidelines and restriction of filler use by trained physicians can improve safety for patients.

Ischemic oculomotor nerve palsy and skin necrosis caused by vascular embolization after hyaluronic acid filler injection: a case report

Hyaluronic acid filler injection is widely used for soft tissue augmentation. However, there can be disastrous complications by direct vascular embolization. We present a case of ischemic oculomotor nerve palsy and skin necrosis after hyaluronic acid filler injection on glabellar.blepharoptosis, exotropia and diplopia developed suddenly after the injection, and skin necrosis gradually occurred. Symptoms and signs of oculomotor nerve palsy continuously improved with steroid therapy. Skin defects healed with minimal scars through intensive wound care.Percutaneous filler injection of periorbital areas should be performed carefully by experienced surgeons, and the possibility of embolization should be considered promptly if symptoms develop.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Clinical data on injectable tissue fillers: a review

Treatment with injectable tissue fillers for aesthetic purposes is increasingly popular. In parallel with this success, questions related to the safety of these treatments and the products involved are being raised more prominently. To gain insight in the safety aspects of injectable tissue fillers, we performed a literature review to collect studies reporting clinical data of injectable tissue fillers. We found several case reports where serious complications after more than three years are described. However, there are only a limited number of well-defined prospective clinical studies available with follow-up periods longer than three years. Furthermore, causes of complications, that is, treatment or product related, are often not specified in literature. Considering the intended functional period of fillers in combination with the known occurrence of long-term complications, there is a need for well-defined prospective clinical studies. In order to be able to discriminate between product failure (a product safety issue) or application methodology (a physician expertise or training issue), better identification of observed complications and whether they are product or treatment related, is needed. For the safe use of the fillers it is important that treatment with injectable tissue fillers is performed by a trained physician, who knows the product specifications and its applications.

Complications following injection of soft-tissue fillers

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complications of injectable fillers, part I

Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.

[Side effects in aesthetic medicine. Spectrum, management and avoidance]

Aesthetic medicine has become increasingly popular in the last two decades. The same trend has occurred in dermatology. Aesthetic dermatology prefers minimally invasive procedures. Nevertheless, even these procedures are not free of possible adverse effects. The spectrum of possible adverse effects, their management and prevention are discussed for four popular procedures in aesthetic dermatology, i.e. chemical peels, mesotherapy, botulinum toxin, and dermal fillers. Aesthetic procedures should only be performed by well-educated, well-trained medical doctors with an excellent medical background, never by lay persons.

[Injectable fillers: adverse reactions and their management]

Injectable fillers are one of the corner stones of aesthetic medicine. In general they are safe to use. However, adverse reactions may occur. These reactions may be acute, subacute or delayed, e.g. after decades. It is important to know these reactions and to be prepared so that they can be adequately treated, in view of the clinical symptoms, the injected material and if applicable other diseases/treatments that might trigger these reactions. Last but not least, all reactions should be reported either to specialized registries or regulatory agencies. Only then we are able to learn more about these reactions and their best possible treatment.

Hyaluronic acid dermal fillers: can adjunctive lidocaine improve patient satisfaction without decreasing efficacy or duration?

Hyaluronic acid (HA) dermal fillers are the most widely used injectables to augment facial volume without surgery. HA dermal fillers are popular because of their ease of administration, predictable effectiveness, good safety profile, and quick patient recovery. The most common patient complaint is pain. Our goal is to review the current literature on HA fillers and compare outcomes with and without lidocaine. We found adjunctive lidocaine significantly decreases pain during injection and postinjection with corresponding increased patient satisfaction. The efficacy and safety profile appears unchanged. Rare complications with HA fillers and those associated with constituents of the product, contaminants, and lidocaine are reviewed. The corrective effects of HA fillers are temporary; repeat treatment is required to maintain results. Minimizing pain is crucial to optimize patient satisfaction.

[A five years experience of subcutaneous chemical lipolysis with phosphatidylcholine injections]

Instead the fact that chemical lipolysis through phosphatidylcholin injections really works, this procedure eliminating limited fat deposits remains confidential in France. Inconstant results, necessity to repeat injections, unclear legacy may explain that this very basic procedure remains unsuccessful. We have proceeded to lipolysis injections for five years on a very limited number of patients: in our hands, it may be efficient on puffy cheeks, double chin, superficial cellulitis, liposuction and lipofilling sequellaes. Eyelid bags may also be considered but not recommended. On the other hand, chemical lipolysis cannot compete with liposuction. We have not noticed any drawbacks or complications which confirm the lipolysis network practitioners' opinion in more than 1000 users.