Dermal fillers: pathophysiology, prevention and treatment of complications

Clinical efficacy of intradermal type I collagen injections in treating skin photoaging in patients from high-altitude areas

BACKGROUND

Photoaging, a result of chronic sun exposure, leads to skin damage and pigmentation changes. Traditional treatments may have limitations in high-altitude areas like Yunnan Province. Intradermal Col Ι injections stimulate collagen production, potentially improving skin quality. This study aims to assess the efficacy and safety of this treatment for photoaging.

AIM

To evaluate the efficacy and safety of intradermal type Ι collagen (Col Ι) injection for treating photoaging.

METHODS

This prospective, self-controlled study investigated the impact of intradermal injections of Col Ι on skin photodamage in 20 patients from the Yunnan Province. Total six treatment sessions were conducted every 4 wk ± 3 d. Before and after each treatment, facial skin characteristics were quantified using a VISIA skin detector. Skin thickness data were assessed using the ultrasound probes of the Dermalab skin detector. The Face-Q scale was used for subjective evaluation of the treatment effect by the patients.

RESULTS

The skin thickness of the right cheek consistently increased after each treatment session compared with baseline. The skin thickness of the left cheek significantly increased after the third through sixth treatment sessions compared with baseline. The skin thickness of the right zygomatic region increased after the second to sixth treatment sessions, whereas that of the left zygomatic region showed a significant increase after the fourth through sixth treatment sessions. The skin thickness of both temporal regions significantly increased after the fifth and sixth treatment sessions compared with baseline (P < 0.05). These findings were also supported by skin ultrasound images. The feature count for the red areas and wrinkle feature count decreased following the treatment (P < 0.05). VISIA assessments also revealed a decrease in the red areas after treatment. The Face-Q-Satisfaction with Facial Appearance Overall and Face-Q-Satisfaction with Skin scores significantly increased after each treatment session. The overall appearance of the patients improved after treatment.

CONCLUSION

Intradermal Col Ι injection improves photoaging, with higher patient satisfaction and fewer adverse reactions, and could be an effective treatment method for populations residing in high-altitude areas.

Photobiomodulation Therapy in the Management of Late Complications After Facial Filling

The aim of the present study is to report a clinical case of a patient diagnosed with a late adverse reaction to the injection of filler material - persistent and intermittent delayed swelling (PIDS) - in which photobiomodulation therapy (PBMT) with low-power laser was used for edema reduction. This is an observational, descriptive, and retrospective work of a case report. The female patient, aged 73 years old, had undergone dermal filler six years before and complained of increased volume in the face region (glabellar region, labiomental sulcus, and nasolabial folds) and was submitted to ultrasound and anatomopathological analysis. PBMT using a low-power laser (660 nm and 808 nm, simultaneous irradiation, in contact, 2 J/point, 100 mW) proved to be effective for the non-invasive approach of late adverse reaction to dermal filler, such as PIDS, a common complication related to the use of dermal fillers.

Combination Administration of Heparin and Nitroglycerin for the Treatment of Polycaprolactone-Induced Intravascular Embolism: A Preclinical Investigation

BACKGROUND

As a new-generation collagen stimulator, polycaprolactone (PCL) containing filler has been extensively applied in facial dermal fillers and other medical aesthetic fields. However, inadvertent intravascular injection of PCL may result in complications such as tissue edema, flap necrosis, and even blindness. To date, there is no effective treatment for PCL-induced intravascular embolism.

OBJECTIVES

The aim of this study was to identify a viable resolution for the embolism resulting from intravascular administration of PCL-containing fillers.

METHODS

Two different animal experiments were performed: (1) PCL-induced rat inferior epigastric arteries embolism, followed by gross observation, histological evaluation, and cytokines analysis from serum; and (2) PCL-induced rabbit auricular artery embolism, immediately treated with heparin and nitroglycerin. The ears were then evaluated by gross observation, Laser speckle imaging, in vivo imaging system (IVIS) imaging, and histological evaluation. Saline and hyaluronic acids (HA) were used as controls, hyaluronidase was used as a positive drug.

RESULTS

In a rat model of inferior epigastric arteries embolism, both intravascular injection of HA and PCL resulted in flap necrosis, indicating that the filler-induced intravascular embolism can lead to serious complications. In a rabbit model of auricular artery embolism, the combination treatment of heparin and nitroglycerin resulted in a relative blood reperfusion recovery of 80% in the ischemic area of the PCL group on day 7 post-operation, which was comparable to that of the HA group treated with hyaluronidase. Histological analysis revealed that the administration of heparin and nitroglycerin significantly attenuated intravascular thrombosis formation and inflammatory cell aggregation.

CONCLUSIONS

The combination of heparin and nitroglycerin effectively restores blood flow reperfusion in the intravascular embolization caused by PCL filler injection, alleviates local tissue edema and flap necrosis. These findings offer a novel approach for future clinical management of intravascular embolization with PCL-containing filler injection.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

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.

The Posthyaluronidase Syndrome: Dosing Strategies for Hyaluronidase in the Dissolving of Facial Filler and Independent Predictors of Poor Outcomes

Background

Hyaluronic acid dermal fillers are used extensively in periocular aesthetic medicine, and the incidence of filler-related complications is increasing. This study aimed to investigate the optimal dosing strategy for hyaluronidase and to identify predictors of poor outcomes.

Methods

We performed a retrospective review of 157 orbits of 90 patients treated with hyaluronidase over a 4-year period. Demographic data, indication, and details of hyaluronidase treatment and outcomes were recorded.

Results

The primary indication for dissolving filler was swelling in 52%, lumpiness in 20%, and before surgical blepharoplasty in 17%. The most frequently used hyaluronidase concentration was 150 U per mL in 66%, followed by 75 U per mL in 31%, 37.5 U per mL in 3%, and 100 U per mL in 1%. Outcomes were characterized as follows: 59% with a satisfactory result; 24% as insufficient treatment requiring further hyaluronidase; and 18% complaining of facial changes such as hollowing, indicating a post hyaluronidase syndrome. There was no statistical difference in outcomes between the 75 and 150 U per mL dosage groups (P = 0.625). A significant correlation was identified between posthyaluronidase syndrome and duration of filler in situ (P = 0.00019) and volume of filler (P = 0.000017).

Conclusions

The posthyaluronidase syndrome may be related to previous filler volume and duration, rather than the concentration or dose of hyaluronidase used. All patients should be informed about the risks of adverse effects after hyaluronidase treatment; patients with longer histories of filler use and higher total volumes should be advised of the increased risk.

Laser Speckle Contrast Imaging Guides Needling Treatment of Vascular Complications from Dermal Fillers

BACKGROUND

Although laser Doppler imaging (LDI) accurately delineates a hypoperfused area to help target hyaluronidase treatment, laser speckle contrast imaging (LSCI) is more appropriate for assessing microvascular hemodynamics and has greater reproducibility than LDI. This study investigated the use of LSCI in the evaluation and treatment of six patients who developed vascular complications after facial dermal filler injections.

METHODS

The areas of vascular occlusion were accurately defined in real time by LSCI and were more precise than visual inspections or photographic evidence for guiding needling and hyaluronidase treatment.

RESULTS

All patients had achieved satisfactory outcomes as early as Day 2 of treatment and no procedure-related complications were reported after a median follow-up of 9.5 (7-37) days.

CONCLUSION

LSCI accurately and noninvasively delineated vascular occlusions in real time among patients experiencing complications of facial dermal filler injections. Moreover, LSCI was more accurate than visual and photographic evaluations. Clinicians can use LSCI to reliably follow-up therapeutic outcomes after salvage interventions for vascular occlusions.

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 .

Hydrogel Based on Riclin Cross-Linked with Polyethylene Glycol Diglycidyl Ether as a Soft Filler for Tissue Engineering

Hydrogels composed of natural polysaccharides have been widely used as filling materials, with a growing interest in medical cosmetology and skin care. However, conventional commercial dermal fillers still have limitations, particularly in terms of mechanical performance and durability in vivo. In this study, a novel injectable and implantable hydrogel with adjustable characteristics was prepared from succinoglycan riclin by introducing PEG diglycidyl ether as a cross-linker. FTIR spectra confirmed the cross-linking reaction. The riclin hydrogels exhibited shear-thinning behavior, excellent mechanical properties, and cytocompatibility through in vitro experiments. Furthermore, when compared with subcutaneous injection of a commercial hyaluronic acid hydrogel, the riclin hydrogels showed enhanced persistence and biocompatibility in Balb/c mice after 16 weeks. These results demonstrate the great potential of the riclin-based hydrogel as an alternative to conventional commercial soft tissue fillers.

Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations

BACKGROUND

Hyaluronidase (Hyal) can reverse complications of hyaluronic acid (HA) fillers, which has contributed substantially to the popularity of such procedures. Still, there are differing opinions regarding Hyal treatment, including dosage recommendations in filler complication management.

OBJECTIVE

We aimed to address unanswered questions regarding Hyal treatment for HA filler complications, including timing and dosage, skin pretesting, properties of various Hyals and interactions with HA gels, and pitfalls of the treatment.

METHODS

PubMed and Google Scholar databases were searched from inception for articles on Hyal therapy for filler complications. Articles were evaluated regarding their contribution to the field. The extensive literature review includes international leaders' suggestions and expert panels' recommendations.

RESULTS

There are limited controlled data but increasing clinical experience with Hyal treatment. The currently used Hyals provide good results and have an acceptable safety profile. Nonemergent complications such as the Tyndall effect, noninflamed nodules, and allergic or hypersensitivity reactions should be treated with low or moderate Hyal doses. Hyal should be considered with prior or simultaneous oral antibiotic treatment in managing inflammatory nodules. Hyal may be tried for granulomas that have not responded to intralesional steroids. Emergent complications such as vascular occlusion and blindness require immediate, high-dose Hyal treatment. Regarding blindness, the injection technique, retrobulbar versus supraorbital, remains controversial. Ultrasound guidance can increase the efficacy of the above interventions.

CONCLUSIONS

Hyal is essential in aesthetic practice because it can safely treat most HA filler complications. Immediate Hyal treatment is required for emergent complications. Aesthetic practitioners should be versed in using Hyal and effective dosage protocols.

Laser treatment for adverse reactions to injectable facial filling: a systematic review

Facial filling is widespread in society, albeit associated with inherent risks. This review analyzes clinical studies using laser therapy for filler complications to assess its safety and efficacy as an alternative treatment. A literature search was conducted up until April 2023, encompassing five different databases: PubMed, Scopus, Embase, Web of Science, and Medline, to find clinical trials addressing patients who underwent laser treatment for adverse reactions to injectable facial filling. The outcome variables were the clinical assessment of the lesion and the occurrence of post-intervention complications/sequelae. The risk of bias was assessed using the ROBINS-I tool. In total, six studies were included, all classified as having a "moderate risk" of bias. A total of 533 patients underwent laser treatment for adverse reactions to injectable facial fillers. The diode laser was the most frequently utilized equipment, with positive results reported in five studies. Among all treated patients, 96.24% achieved partial or complete resolution, 0.22% experienced some sequelae or complications, and only 0.01% showed no improvement. Laser treatment can eliminate the necessity for surgical intervention for adverse reactions to injectable facial fillers, resulting in partial or complete improvement of the condition.

Management strategies for vascular complications in hyaluronic acid filler injections: A case series analysis

BACKGROUND

As hyaluronic acid (HA) filler injections have become increasingly popular in the esthetic field, so have their side effects. Vascular complications, which can lead to skin necrosis or permanent scarring, are a particularly dangerous complication and occur when the filler is injected directly into a blood vessel or when an adjacent blood vessel is compressed by the filler material.

OBJECTIVE

To assess the clinical prognosis based on post-procedural management and clinical findings of HA filler vascular complications.

METHODS

Herein, we present a case series of vascular complications due to HA filler and evaluate their clinical prognosis based on post-procedural management and clinical findings. Clinical assessments were performed using Doppler ultrasound, thermography, and laboratory tests.

RESULTS

Factors including white blood cell count, the time of treatment initiation, and time of hyaluronidase injection influenced the clinical outcomes. Early recognition and prompt hyaluronidase injection proved crucial in preventing further damage and improving prognosis.

CONCLUSION

This case series highlights the importance of early detection and appropriate management of HA filler complications. Physicians should be aware of the potential risks associated with fillers and promptly address any adverse effects to achieve optimal clinical outcomes. Further studies are warranted to confirm these findings and refine treatment strategies for the HA filler complications.

Periorbital venous stasis may be involved with filler induced malar edema-A duplex ultrasound-imaging-based case series

INTRODUCTION

Filler injections in the periocular region are regarded as a challenging and advanced maneuver in a high-risk area. Adverse events as malar edema due to filler treatment may occur. To evaluate the possible reasons, the ultrasound images, and medical data of patients that were prospectively referred with malar edema were evaluated.

MATERIALS AND METHODS

A total of 17 patients (26 eyes) with malar edema after hyaluronic acid filler treatment were included. All cases were assessed with an 18 MHz linear ultrasound device. Exact location of the filler material was noted. Relations with clinical data were analyzed using chi-square tests.

RESULTS

Onset of malar edema after treatment showed a wide range from immediate (0 days) to 3 years. Most patients had an early onset N = 13 (76%), a minority showed late onset N = 4 (24%). In 23 eyes, the filler material was found to be located inside the SMAS. In 3 cases filler material was located on the periosteum of the orbital rim. After duplex-ultrasound guided filler removal, restored venous flow could be seen in the superficial and/or deep fatty layer often accompanied by flow piercing through the SMAS. Minutes after treatment, clinical improvement of malar edema was observed.

CONCLUSION

Malar edema after by filler treatments in the periocular region may be caused by veno-lymphatic compression by filler deposits.

Personalization of Minimally-Invasive Aesthetic Procedures with the Use of Ultrasound Compared to Alternative Imaging Modalities

Ultrasonography is a well-tolerated procedure that aids in the targeted esthetic therapies of special cutaneous regions, as well as in the prevention (vascular mapping, identification of previous filler, and others) and management of potential complications (vascular occlusion, external vascular compression, product misplacement or migration, inflammatory reactions, and others). It has lately been promoted as the first-line imaging tool to address injectables. In this article, we aim to review the evolving role of ultrasonography in cosmetic filler procedures, from the fundamental ultrasound characterization of cosmetic fillers to the ultrasound-enhanced detection and management of cosmetic filler complications, including ultrasound's role in hyaluronidase-guided injections for cosmetic filler dissolution. Furthermore, the paper explores the integral role played by ultrasound in enhancing the precision, efficacy, and safety of additional minimally invasive aesthetic techniques such as mesotherapy, radiofrequency, cryolipolysis, and polydioxanone procedures.

High-resolution US of the facial vessels with new facial vein landmarks for reconstructive surgery and dermal injection

BACKGROUND

Accurate knowledge of vessel anatomy is essential in facial reconstructive surgery. The technological advances of ultrasound (US) equipment with the introduction of new high-resolution probes improved the evaluation of facial anatomical structures. Our study had these objectives: the primary objective was to identify new surgical landmarks for the facial vein and to verify their precision with US, the secondary objective was to evaluate the potential of high-resolution US examination in the study of both the facial artery and vein.

METHODS

Two radiologists examined a prospective series of adult volunteers with a 22-8 MHz hockey-stick probe. Two predictive lines of the facial artery and vein with respective measurement points were defined. The distance between the facial vein and its predictive line (named mandibular-orbital line) was determined at each measurement point. The distance from the skin and the area of the two vessels were assessed at every established measurement point.

RESULTS

Forty-one volunteers were examined. The median distance of the facial vein from its predictive line did not exceed 2 mm. The facial vein was visible at every measurement point in all volunteers on the right side, and in 40 volunteers on the left. The facial artery was visible at every measurement point in all volunteers on the right and in 37 volunteers on the left.

CONCLUSIONS

The facial vein demonstrated a constant course concerning the mandibular-orbital line, which seems a promising clinical and imaging-based method for its identification. High-resolution US is valuable in studying the facial artery and vein.

RELEVANCE STATEMENT

High-resolution US is valuable for examining facial vessels and can be a useful tool for pre-operative assessment, especially when combined with the mandibular-orbital line, a new promising imaging and clinical technique to identify the facial vein.

KEY POINTS

• High-resolution US is valuable in studying the facial artery and vein. • The facial vein demonstrated a constant course concerning its predictive mandibular-orbital line. • The clinical application of the mandibular-orbital line could help reduce facial surgical and cosmetic procedure complications.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.

Facial fillers: Relevant anatomy, injection techniques, and complications

Objective

The aim of this review article is to discuss the currently available facial fillers, their differences and indications, relevant anatomy, injection techniques, and avoidance and management of complications.

Data Sources

Clinical experience and scientific papers.

Conclusions

Reversal of facial aging via filler injection has been around since the late 1800s with the initial use of detrimental products. Today, many safe and effective products exist and can be tailored to the individual patient's desired effect. With the evolution of both products and injection techniques, the rate of complications with facial filler use is low. Nonetheless, providers offering facial filler injections should have detailed knowledge of facial anatomy, including facial planes and soft tissue compartments. Multiple injection techniques exist. Different techniques should be used, depending on the anatomic target. Providers should also know how to avoid and manage complications.

Adverse Reactions Associated with Dermal Fillers in the Oral and Maxillofacial Region: A Venezuelan Experience

BACKGROUND

Dermal facial fillers are increasingly popular. Published reports on the clinical and histopathologic characteristics related to adverse reactions to dermal fillers in the facial region have been relatively well documented. This study adds to the literature on adverse reactions to injected filler in the oral and maxillofacial region in a South American population.

METHODS

A retrospective, descriptive cross-sectional study (2019-2020) was performed. The study population was a dermatology service in Venezuela. Clinical and histopathologic features of patients with adverse effects were documented.

RESULTS

A total of 35 cases of adverse reactions associated with cosmetic filler procedures were diagnosed during the analyzed period; of these, six cases (17.1%) involved the oral and maxillofacial region. All cases occurred in women. The mean age at diagnosis was 59.3 years (58-73). In three cases, dermal fillers were used in different locations on the face, while three involved the lips. Five patients exhibited adverse reactions to lip filler. All six cases were histopathologically diagnosed as foreign body reactions to injected material. Four and two cases revealed microscopic features compatible with hyaluronic acid and polymethylmethacrylate, respectively.

CONCLUSION

Reflecting the dramatic increase in cosmetic procedures with soft tissue fillers, this study contributed by reporting six cases of foreign body reaction involving the oral and maxillofacial region, confirmed with biopsy and histopathology.

Clinical Manifestations and Prognosis of Embolism Caused by Filler Injection in Different Facial Regions

Background

Embolism is a serious complication after facial filling, with a usually poor prognosis of the symptoms after embolism. The authors systematically reviewed reported cases of facial vascular embolism, explored the relationship between the location and material used for facial filling and occurrence of vascular embolism, and assessed the prognosis of complications after vascular embolism.

Methods

This study provides a systematic review of published cases of vascular embolism after facial filling. A summary of the filling materials and filling sites for each case, the adverse reactions and embolized blood vessels, a recording of the time when each patient experienced adverse reactions and started treatment, and a presentation of their prognosis are provided.

Results

The frontal, eyebrow, and nose are common filling sites causing facial embolism. The main clinical manifestations after embolism were visual impairment, skin necrosis, and ptosis. The prognosis of visual impairment after embolization was poor, whereas skin necrosis and ptosis generally improved after treatment.

Conclusions

This article aimed to review the clinical manifestations, therapies, and prognosis of embolism after facial filling. A better understanding of these complications can help clinicians to detect the occurrence of complications as early as possible and give patients timely treatment.

A pilot study comparing the efficacy of autologous cultured fibroblast injections with hyaluronic acid fillers for treating nasolabial folds

Autologous cultured fibroblast injections for soft tissue augmentation are a potential alternative to other filler materials. No studies have compared autologous fibroblast injections and hyaluronic acid (HA) fillers for treating nasolabial folds (NLFs). To compare the efficacies and safeties of autologous cultured fibroblast injections and HA fillers for treating NLFs. This prospective, evaluator-blinded, pilot study enrolled 60 Thai female adult patients diagnosed with moderate to severe NLFs. They were randomized to receive either 3 treatments of autologous fibroblasts at 2-week intervals or 1 treatment with HA fillers. The primary outcome was the clinical improvement of the NLFs graded by 2 blinded dermatologists immediately after injection and at 1-, 3-, 6-, and 12-month follow-ups. Objective measurement of the NLF volume was evaluated. Patient self-assessment scores, pain scores, and adverse reactions were recorded. Of the 60 patients, 55 (91.7%) completed the study protocol. The NLF volumes improved significantly in the autologous fibroblast group at all follow-ups relative to baseline (P = 0.000, 0.004, 0.000, 0.000, and 0.003). The patients in the autologous fibroblast group rated more noticeable NLF improvements than those in the HA filler group (3-month follow-up, 58.41% vs. 54.67%; 6-month follow-up, 52.50% vs. 46%; 12-month follow-up, 44.55% vs. 31.33%). No serious adverse reactions were recorded. Autologous fibroblast injections are safe and effective for treating NLFs. These injections also promise sustained growth of living cells, possibly leading to a greater persistence than shown by other fillers.

Radiesse Rescue: A Preliminary Study for a Simple and Effective Technique for the Removal of Calcium Hydroxyapatite-Based Fillers

BACKGROUND

Radiesse, or calcium hydroxyapatite (CaHA), is a semipermanent, biodegradable injectable filler that provides immediate aesthetic improvement, while also stimulating neocollagenesis for biological effects. The physical properties of CaHA make it difficult, if not impossible, to remove. Unlike some hyaluronic acid-based fillers, CaHA cannot be easily dissolved.

OBJECTIVES

The aim of this study was to present a simple and reliable technique for debulking and removing excess CaHA in the event of nodule formation, vascular compression, or overcorrection.

METHODS

An 18-gauge needle was used to make an incision near the filler excess. A 1-mm-diameter grater-type microliposuction cannula (Lipocube, Inc.; London, UK) was attached to a 5- to 10-mL syringe under negative pressure. The cannula under syringe suction was used in a back-and-forth reaming motion beginning in the base of the material and gradually moving toward the surface until the desired effect was achieved. Identification of the CaHA can be established and removal confirmed with ultrasound (Clarius, Inc.; Vancouver, BC, Canada) if available.

RESULTS

Although nodules, excess material and vascular compression secondary to CaHA are very rare occurrences, 4 patients were treated with excess material and/or nodules. In 1 patient, the prominent cheek filler was reduced and a 1-cm nodule that was palpable in the buccal region was eliminated. In the other 3 other patients, the palpable excess material was easily removed, in 2 at the time of injection and in the third, 6 months later. No patient required repeat treatment or replacement.

CONCLUSIONS

This removal technique has been shown to adequately remove excess CaHA filler but is not applicable to inadvertent intravascular injection.

Infections in patients with adverse reactions to the use of unknown modeling substances for soft tissue enhancement in Cali, Colombia

The infiltration of foreign materials not approved for medical purposes or of modeling substances used in soft tissue to modify the anatomical appearance for aesthetic purposes represents a serious health problem. These procedures lead to the development of delayed complications, including infections. The objective of this study was to characterize infections in patients with adverse reactions to the use of modeling substances in Cali, Colombia. A cross-sectional and descriptive study was used to determine the frequency of bacterial and fungal infections associated with complications from and adverse reactions to the use of modeling substances in 113 patients. We identified microorganisms in 22 patients and a frequency of 68.1% monomicrobial infections and 31.8% polymicrobial infections. The microorganisms identified in our study included Bacillus cereus, Mycobacterium fortuitum, and Pseudomonas stutzeri, among other microorganisms. The presence of adverse effects derived from the use of illegal modeling substances has been demonstrated; among these effects, infections occur with high frequency and place the health of the patient at risk and increase problems in health care.

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

Early warm compress treatment can promote recanalization of vascular embolisms and reduce tissue necrosis after polymethyl methacrylate injection

Injection of fillers for soft tissue augmentation can lead to a variety of complications, among which vascular occlusion caused by intravascular injection of filler will induce severe or permanent damage. The treatment strategies for intravascular embolization caused by injection include warm compress application, but the exact beneficial effects of this therapy have not been confirmed. The purpose of this study is to construct an intravascular injection embolism model and observe the effectiveness of warm and cold compress through a randomized, controlled trial. Thirty rabbit's sixty ears were randomly divided into warm compress group, cold compress group, and control group. Polymethyl methacrylate (PMMA) was slowly injected into the central ear artery (CEA) to cause vascular embolism. Warm compress and cold compress treatment were performed respectively. The vascular recanalization and other related indexes were observed at 30 min, 1 day, and 7 days after injection, and the tissue necrosis was analyzed at 7 days. In the early stage of vascular embolization, warm compress can immediately promote vascular dilatation, blood circulation and partial blood flow recovery. One day after intravascular injection, warm compress can reduce intravascular embolization and reduce the incidence of tissue necrosis. At 7 days after intravascular injection, the vessels in the cold compress and control groups were still embolized while the percentage of recanalization in the warm compress group was 47.4% (P < 0.000). Early-stage warm compress after intravascular PMMA injection is conducive to recanalization of vascular embolization and reducing tissue necrosis.

Standards for aseptic techniques in medical aesthetic practices in the Benelux: Consensus recommendations

INTRODUCTION

While the demand for aesthetic procedures is rising, complications are rising alongside. Infection is a frequent complication, there is therefore an increased need for strict aseptic technique, particularly in procedures breaching the skin. The level of training of practitioners carrying out these procedures varies and there are no comprehensive guidelines on aseptic aesthetic practice in the Benelux region.

OBJECTIVE

Developing a step-by-step procedure for achieving and maintaining a high standard of aseptic conditions in a standard aesthetic practice in the Benelux region.

METHODS

A consensus group of 10 aesthetic medical practitioners (dermatologists, plastic surgeons, and cosmetic physicians) representing the Benelux region convened to discuss best practice for aseptic techniques in medical aesthetics. Step-by-step procedures were recommended to achieve optimal aseptic practice in private facilities and define important considerations for reducing infection risk. Recommendations were based on current evidence and extensive clinical experience.

RESULTS

Recommendations were made to achieve and maintain a high standard of asepsis and infection control. Guidance included maintaining high standard aseptic conditions of the injecting room, the injecting area on the patient, the injection procedure, the materials, and procedures commonly used to achieve aseptic conditions.

CONCLUSIONS

This expert consensus summary publication recommends aseptic procedures, setting a standard with the goal of minimizing rates of complications in aesthetic clinical practice in the Benelux region.

Complications Following Facial Injection of Growth Factor Solution

OBJECTIVE

Topical injection of growth factor (GF) for facial rejuvenation is unauthorized, but it is commonly performed in China, leading to emerging and challenging complications. The purpose of this study is to investigate the clinical, imaging, and histopathologic characteristics of complications caused by facial GF injection, as well as their treatments and outcomes.

METHODS

We performed a retrospective single-centered case series study on consecutive patients who were treated for complications following facial injection of GF. The primary outcome was the recurrence over follow-up period. The secondary outcomes were the subjective evaluations of the facial aesthetic, symptomatic, and psychological improvements using the Global Aesthetic Improvement Scale (GAIS) and a patient-reported outcome measurement (PROM). Kaplan-Meier analysis and log-rank test were performed to investigate the recurrence.

RESULTS

A total of 32 females with an average age of 42.6 ± 9.4 years were included. Most patients received GF injections in non-medical institutes such as beauty spas and presented with uncontrollable soft tissue hyperplasia, diffuse subcutaneous swelling, and skin redness. Ultrasonography showed heterogeneous hypoechoic or echogenic areas in a thickened and disorganized subcutaneous tissue hierarchy. MRI showed flaky isointensive or hypointensive signals on T1WI and hyperintensive signals on T2WI. 37.5% patient underwent triamcinolone acetonide injection, whereas 62.5% patients underwent surgical interventions. Lipoma-like hyperplastic tissue was found during surgery. HE staining confirmed intramuscular lipoma and fibrolipomatous tissue hyperplasia. Recurrence was found in 37.5% patients over a median follow-up of 6 months. KM curves and log-rank test demonstrated no significant difference in the recurrence between patients who underwent nonsurgical or surgical interventions (p = 0.77). GAIS and PROM scores indicated substantial aesthetic, symptomatic, and psychological improvements in 70%, 91.7%, and 75% patients, respectively.

CONCLUSIONS

Both surgical and nonsurgical interventions are feasible and effective treatment options for GF-induced complications. Although recurrence rate was relatively high, aesthetic, symptomatic, and psychological improvements were achieved in most patients. We developed a workflow that might help diagnose and treat complications following unknown dermal filler injections.

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 .

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.

An overview of surgical techniques and non-surgical treatments in lifting the eyebrow including current treatments available

The eyebrow is a complex structure of the human face, which has both functional (communication) and aesthetic aspects and contributes to a persons’ individual appearance. Ptosis of the eyebrow is a common condition, especially among the elderly and smokers. Facial appearance is disrupted by eyebrow ptosis, and in many cases, correction and treatment are needed. No specific type of browlift has been shown to be superior to another, and since there is a wide variation in treatment preference between patients, it requires an individual approach to each specific patient. This review provides an overview of the history of the browlift, non-surgical treatment and current surgical techniques available.

Level of evidence: Not ratable.

Immune reconstitution inflammatory syndrome induced by gluteal silicones in a transgender woman living with HIV

We report a case of an immune reconstitution inflammatory syndrome induced by gluteal silicones in a transgender woman living with HIV following the start of antiretroviral therapy. This case resembles the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) syndrome that has been described as a complication of insertions of materials such as injected or implanted silicones. The potential of developing an inflammatory response in patient with injected or implanted silicones/foreign substances should be considered in patients who have recently started antiretroviral therapy.

Facial Arterial Variations in Asians: A Study on Computed Tomographic Angiography

BACKGROUND

A consensus on facial artery anatomy has not been established due to the discrepancies in previous studies.

OBJECTIVES

The authors sought to assess the branches, course, and location of the facial artery in Asians by utilizing computed tomographic angiography.

METHODS

The computed tomographic angiography images of 300 facial arteries from 150 Asian patients were evaluated. The FA was classified as follows: type 1, facial artery terminates superior labial or inferior labial artery; type 2, facial artery terminates lateral nasal or inferior alar artery; type 3, facial artery terminates medial canthal artery; or type 4, facial artery is divided into duplex branches with dominant medial canthal artery laterally. The relationship between nasolabial fold and FA was evaluated, and the distances from anatomical landmarks to FA were measured to position the course.

RESULTS

Seventy (23.3%), 163 (54.3%), 49 (16.3%), and the other 18 arteries (6.0%) were classified as type 1, 2, 3, and 4, respectively. A total 72.3% of facial arteries were located medially to the nasolabial fold, and only 14.7% of arteries were lateral to the nasolabial fold. The vertical distance between the facial artery and the inner canthus or the midpoint of the inferior orbital rim decreased from type 1 to type 4 facial artery (P < 0.0001). The 4 types did not significantly differ in distance between the mandibular angle (P = 0.1226) or oral commissure (P = 0.1030) and the facial artery at inferior of mandible.

CONCLUSIONS

Detailed findings of the facial artery will provide a valuable reference for filler injection in cosmetic procedures and flap design in reconstructive surgery.

Hybrid Nasal Filler: Combining Agarose Gel and Hyaluronic Acid for Nonsurgical Rhinoplasty

Given its structural properties, it would be a mistake to assume that a single type of filler fits perfectly to each anatomical region of the nose in nonsurgical rhinoplasty procedures. Therefore, we aimed to develop a hybrid treatment model by applying two different structural types of fillers. Hyaluronic acid (HA), a hydrophilic material, and agarose gel (AG), a nonhydrophilic and high G-prime material, were used in the study according to their advantages and disadvantages.

Methods

Patients who presented to the office desiring filler treatment for nonsurgical correction of the nose in a 2-year period were enrolled in the study. HA was used intradermally 0.1 ml per each point in the tip defining points and supratip. Injections of 0.4-0.7 and 0.4-0.6 ml AG were used supraperiosteally in the radix and nasal spine, respectively. Clinical improvement was evaluated two weeks later using the Global Aesthetic Improvement Scale from 1 to 5 (1: exceptional improvement; 5: worsened patient). Patient satisfaction was evaluated on a scale from 0 to 10 (0: not satisfied; 10: very satisfied).

Results

A total of 32 patients (mean age: 27 years) were enrolled in the study. Mean score of patient satisfaction was 9.09 of 10 after injection and 9 of 10 after 2 weeks. Clinical evaluation scores after injection were 1.72 of 5 and 1.69 of 5 on the Global Aesthetic Improvement Scale. No major complication was observed.

Conclusion

The HA and AG filler hybrid concept applied in different anatomical locations represents a safe and convenient option for nonsurgical rhinoplasty procedures.

The Facial Vein on Computed Tomographic Angiography: Implications for Plastic Surgery and Filler Injection

BACKGROUND

Knowledge of the anatomy of the facial vein is essential for plastic surgery and filler injection.

OBJECTIVES

The authors sought to investigate the variation and 3-dimensional (3D) course of the facial vein utilizing computed tomographic angiography.

METHODS

The computed tomographic angiography images of 300 facial veins from 150 Asian patients were included in this study. The distance between each anatomical landmark and the facial vein was measured to position the course. The depth of the facial vein beneath the skin and the height of the facial vein above the periosteum were measured at 5 anatomical planes.

RESULTS

The facial vein showed a relatively constant course with a frequency of 7.0% variation. The vertical distance between the medial canthus, midpoint of inferior orbital rim, or external canthus and the facial vein was 10.28 ± 2.17 mm, 6.86 ± 2.02 mm, or 48.82 ± 7.26 mm, respectively. The horizontal distance between medial canthus, nasal alar, or oral commissure and the facial vein was 6.04 ± 1.44 mm, 22.34 ± 3.79 mm, or 32.21 ± 4.84 mm, respectively. The distance between the mandibular angle or oral commissure and the facial vein at the inferior of mandible was 24.99 ± 6.23 mm or 53.04 ± 6.56 mm. The depth of the facial vein beneath the skin and the height of the facial vein above the periosteum varied from the plane of the medial canthus to the plane of the mandible.

CONCLUSIONS

This study revealed the 3D course of the facial vein with reference to anatomical landmarks. Detailed findings of the facial vein will provide a valuable reference for plastic surgery and filler injection.

Clinical Management of Complications Following Filler Injection

AIM

Dermal fillers have been progressively used for cosmetic procedures. Concurrently, the rates of filler complications have also increased. The aim of this study is to describe the clinical management and treatment we performed in patients with complications occurred after filler injection.

METHODS

From March 2000 to February 2020, 197 patients have been evaluated for complications due to filler injection. For each patient type of material, symptoms and signs were recorded. Ultrasound evaluation was used to obtain information about the type, amount and location of the injected material. Magnetic Resonance Imaging was performed in those patients who were candidate for surgery. Based on the clinical manifestations, we performed a targeted therapy.

RESULTS

The local and systemic medical therapy allowed us a complete remission of the clinical signs and symptoms in all patients presented with edema and erythema. We obtained optimal results with surgery, where a complete removal of the injected material was possible. In all the cases in which the complete removal of the infiltrated area could have led to functional impairments, we performed partial removal with poor outcomes.

CONCLUSION

We observed complex clinical manifestations in the patients subjected to permanent fillers. An accurate knowledge upon the effects of the materials on tissues, a specific instrumental evaluation and a targeted therapy are crucial. We suggest the use of absorbable fillers. Patient should be subjected to filler implant in authorized structures by an expert specialist with experience in filler injection and with a thorough knowledge of the anatomical structures.

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 Quality of Online Information on Cosmetic Injectable Fillers: Current Status

Web-based health information plays an increasingly vital role in spreading health information. Many patients interested in aesthetic surgery study the procedure on the Internet. This study aims to evaluate the quality of online health information on injectable fillers using the modified "Ensuring Quality Information for Patients" (EQIP) tool. Nine different search terms, including "fillers," "fuller cheeks," "wrinkle removal," and "antiwrinkle treatment" were identified and queried on Google. Unique links from the first three pages of each search term were identified and evaluated if the contents were in English language and were for general non-medical public use. A total of 172 websites were analyzed, with a median EQIP score of 20. In total 129 websites belonged to aesthetic practitioners, of which 81 were operated by medical doctors. Eighty-three percent of websites disclosed some forms of postoperative complications, most commonly edema (74%) and bruising (73%). Blindness and tissue necrosis were only mentioned by 12 and 10% of the websites, respectively. The current health information available on injectable fillers is of poor quality. While many do provide some information on risks, the majority of websites fail to disclose severe complications and quantifying risks. This poses a barrier against informed decision-making and may lead to unrealistic expectations. Patient satisfaction and expectations may be improved by developing better online education resources on fillers.

Complications of Nonpermanent Facial Fillers: A Systematic Review

Background:

A variety of complications after injection of nonpermanent fillers for facial rejuvenation have been reported so far. However, to date, the overall complication rate is still a matter of debate. The aim of this study was to perform a systematic review of literature to assess the type and severity of associated complications following injections in different anatomical regions of the face.

Methods:

The entire PubMed/Medline database was screened to identify case reports and clinical studies describing complications that have occurred after injection of nonpermanent fillers in the face. These complications have been reviewed and analyzed according to their occurrence in different anatomical regions of the face.

Results:

Forty-six articles including a total of 164 patients reported on a total of 436 complications during the time period between January 2003 and February 2020. The majority of the complications were reported after injections to the nose and the nasolabial fold (n = 230), the forehead and the eyebrows (n = 53), and the glabellar region (n = 36). Out of 436 complications, 163 have been classified as severe or permanent including skin necrosis (n = 46), loss of vision (n = 35), or encephalitis (n = 1), whereas 273 complications were classified as mild or transient, such as local edema (n = 74), skin erythema (n = 69), and filler migration (n = 2). The most severe complications were observed in treatments of nose, glabella, and forehead.

Conclusions:

Nonpermanent facial fillers are associated with rare but potentially severe complications. Severity and impact of complications depend on the anatomical region of the face and eventually require profound knowledge of facial anatomy.

Radiographic Features of Facial Cosmetic Material: Report of Two Cases

Recently, the use of noninvasive facial cosmetic procedures has been widely disseminated. In the face, cosmetic fillers, threads, and implants are used to reduce or delay the effects of aging or adjust facial defects caused by trauma or disease. The dentist or dental specialist may encounter these materials in the radiographic images of their patients. There are few reports in the dental literature describing the radiographic appearance of some materials along with the diseases they mimic. As the procedures and materials advance and evolve, dentists and dental specialists must be aware of their radiographic appearance to avoid errors in diagnosis. This is a report of two cases that include panoramic radiography and CBCT scan. Among these cases, there is an unusual appearance of a cosmetic filler due to a subperiosteal injection method. Moreover, it will discuss common types of cosmetic materials used in the face and their imaginological appearance. This is the key to dentists and dental specialists due to increasing use of facial cosmetic materials and a parallel increase in the use of cone beam CT and chances to encounter such findings.

Laser Doppler Imaging for Treating Vascular Complications from Procedures Involving Dermal Fillers: Case Series and Literature Review

Vascular occlusion is a rare but severe complication of dermal filler injections. Early treatment of this complication produces better outcomes. Current diagnostic methods for vascular occlusion in the skin are subjective and imprecise; these include capillary refill time, skin color, and reports of pain. This study aimed to assess the use of laser Doppler imaging (LDI) in the evaluation and treatment of vascular complications caused by dermal filler injections. This retrospective study used laser Doppler imaging (LDI) in 13 patients who developed vascular occlusion after facial dermal filler injections, with subsequent follow-up. The precise areas of perfusion observed on LDI were compared with the findings of clinical and photographic evaluation. The results showed that LDI accurately identified areas of vascular occlusion and improved treatment precision among these thirteen patients. The procedure was more precise than visual inspection or photographic evidence. Satisfactory outcomes were achieved for all patients, and no procedure-related complications were reported. Collectively, LDI provides fast, noninvasive, and accurate delineation of areas of vascular occlusion caused by complications of dermal filler injections and avoids several subjective shortcomings of visual and photographic evaluations. Thus, LDI effectively tracks treatment outcomes. However, large-scale studies are required to confirm the present findings.

5-Fluorouracil in Dermatology: The Diverse Uses Beyond Malignant and Premalignant Skin Disease

BACKGROUND

5-fluorouracil (5-FU) is widely used for treatment of malignant and premalignant skin cancers; however, its use in other common cutaneous conditions has been less widely reported.

OBJECTIVE

We investigated the off-label uses of 5-FU beyond malignant and premalignant skin disease.

METHODS

We conducted a literature review searching multiple databases to evaluate the evidence for the off-label uses of 5-FU. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first using the Oxford Centre of Evidence-Based Medicine 2011 guidance.

RESULTS

We found underlying evidence to support the use of 5-FU for a wide range of noncancerous cutaneous indications including scarring (keloid, hypertrophic), pigmentary disorders (vitiligo, idiopathic guttate hypomelanosis), cutaneous infections (viral warts, molluscum contagiosum), inflammatory dermatoses (Darier's disease, Hailey-Hailey disease and sarcoidosis), and cosmetic indications (photoaging, treatment of filler nodules and granulomas).

CONCLUSION

In selected patients, 5-FU can be as effective as more established treatments, with fewer side-effects.

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.

An Anatomical Guide to the Terminal Facial Artery: Lumen Diameter and Associated Anatomy Relevant to Dermatologic Procedures

BACKGROUND

Dermal filler injection in the vicinity of the terminal facial artery (FA) can lead to vascular compromise with devastating consequences, including tissue necrosis, blindness, and stroke.

OBJECTIVE

The purpose of this study was to examine lumen diameter and other anatomical features of the terminal FA relevant to dermal filler injection.

MATERIALS AND METHODS

Eighteen embalmed adult cadavers were dissected along the distribution of the terminal FA. Gross and microscopic measurements were taken at predetermined points in its course.

RESULTS

Mean lumen diameter was largest at the midpoint between the oral commissure and the lateral supra-alar crease (0.81 ± 0.36 mm; point P1) and smallest at the midpoint between the lateral supra-alar crease and the medial canthus (0.43 ± 0.23 mm; point P3). Mean cutaneous depth was deepest at the lateral supra-alar crease (5.06 ± 1.84 mm; point P2) and most superficial at the midpoint between the lateral supra-alar crease and the medial canthus (3.13 ± 2.07 mm; point P3).

CONCLUSION

The large-caliber lumen diameter of the terminal FA creates the potential for intra-arterial injection with commonly used filler needles and blunt-tipped cannulas at all points in its course in the nasolabial fold and midface.

Covalently Crosslinked Hydrogels via Step-Growth Reactions: Crosslinking Chemistries, Polymers, and Clinical Impact

Hydrogels are an important class of biomaterials with the unique property of high-water content in a crosslinked polymer network. In particular, chemically crosslinked hydrogels have made a great clinical impact in past years because of their desirable mechanical properties and tunability of structural and chemical properties. Various polymers and step-growth crosslinking chemistries are harnessed for fabricating such covalently crosslinked hydrogels for translational research. However, selecting appropriate crosslinking chemistries and polymers for the intended clinical application is time-consuming and challenging. It requires the integration of polymer chemistry knowledge with thoughtful crosslinking reaction design. This task becomes even more challenging when other factors such as the biological mechanisms of the pathology, practical administration routes, and regulatory requirements add additional constraints. In this review, key features of crosslinking chemistries and polymers commonly used for preparing translatable hydrogels are outlined and their performance in biological systems is summarized. The examples of effective polymer/crosslinking chemistry combinations that have yielded clinically approved hydrogel products are specifically highlighted. These hydrogel design parameters in the context of the regulatory process and clinical translation barriers, providing a guideline for the rational selection of polymer/crosslinking chemistry combinations to construct hydrogels with high translational potential are further considered.

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.

A study of the microbiological profile of filler-induced skin necrosis

Skin necrosis is one of the most severe complications following filler injections, and can result in permanent aesthetic defects. Although an increasing number of studies have addressed the management of dermal filler complications, no study has described the spectrum of microbial pathogens. The aim of this study was to delineate the bacterial profile and prognostic factors of filler-related skin necrosis by reviewing the clinical and microbiological features of these patients. A retrospective medical record review of patients undergoing treatment for skin necrosis induced by fillers was conducted. In total, 10 cases were identified, with injection sites being the nasolabial fold (70%; n = 7), nasal dorsum (20%; n = 2) and nasal tip (10%; n = 1). Reviewing the culture results, the true culture-positive rate was found to be 50% after cases of contamination were excluded. To avoid permanent sequelae, all physicians should be aware of possible secondary infections when treating filler-induced skin necrosis.

Delayed migration of soft tissue fillers in the periocular area masquerading as eyelid and orbital pathology

Soft tissue fillers used for facial rejuvenation can cause complications. We present two cases of late migration of injected fillers mimicking other pathology in the periocular area. Case 1 is a 52-year-old woman referred with chronic bilateral upper lid swelling, mimicking blepharochalasis syndrome, 5¹/₂ years after undergoing injection of hyaluronic acid filler in both brows. Extensive blood investigations were normal. Bilateral, sequential upper lid biopsy revealed migrated hyaluronic acid filler, which was successfully treated with hyaluronidase. Case 2 is a 62-year-old woman who presented with a right lower lid mass 8 years after undergoing injection of polyalkylimide gel into both cheeks. CT scanning confirmed an intermediate density soft tissue mass overlying the inferior orbital rim. Histology from surgical excision reported chronic granulomatous inflammation due to migrated polyalkylimide gel. An awareness of late migration of fillers causing eyelid swelling and masses in the periocular area will prevent unnecessary investigations and facilitate prompt management.

Specific complications associated with non-surgical rhinoplasty

Non-surgical rhinoplasty is becoming an increasingly common procedure to alter the appearance and cosmesis of the nose. Although rare, complications with this procedure do exist, some of which can be devastating. Major complications include infection, vascular compromise, skin necrosis, and blindness. Here we discuss the nasal anatomy, complications associated with non-surgical rhinoplasty, and techniques to prevent these complications.

Unilateral Vision Loss After Hyaluronic Acid Injection: A Case Report

ABSTRACT

Vascular occlusion causing vision loss is a rare yet one of the most devastating complications of facial esthetic fillers. In this article, we present a case of unilateral blindness and superficial skin necrosis in a 31-year-old woman after the injection of hyaluronic acid for esthetic purposes. The delicate ocular fundal findings of ophthalmic artery occlusion were demonstrated by ophthalmoscopy, optical coherence tomography, and fluorescein angiography. Magnetic resonance imaging also showed subsequent ischemic changes in the optic nerve and posterior scleral wall after ophthalmic artery occlusion. Despite management including intraocular pressure-lowering agents, globe massage, and anticoagulation with acetylsalicylic acid and hyperbaric oxygen therapy, her final vision was not restored. Given the lack of effective treatments, this report depicts the comprehensive ocular fundal findings of an ophthalmic artery occlusion after esthetic hyaluronic acid filler injection, and highlights the importance of a preventive approach to avoid such catastrophic complications.