The "ART" of facial filler injections: Avoid, recognize, and treat hyaluronic acid-induced complications

Hyperbaric Oxygen Therapy in Aesthetic Medicine and Anti-Aging: A Systematic Review

INTRODUCTION

Continued interest in the optimization of recovery in aesthetics has led to the exploration of adjunctive therapies. Hyperbaric oxygen therapy (HBOT) serves as one such therapy that may have an impact in this field. HBOT is hypothesized to improve ischemia, reduce swelling, and minimize secondary hypoxic tissue damage. Its application in aesthetic procedures aims to improve healing, reduce downtime, and enhance the overall quality of outcomes.

METHODS

A systematic review was performed, searching the PubMed database. The protocol was developed following the Preferred Reporting for Items for Systematic Reviews-Protocols (PRISMA) guidelines. Included studies evaluated the use of HBOT in aesthetic surgery, medicine, and longevity and anti-aging. Selected studies matched predetermined criteria according to the employed intervention and outcomes.

RESULTS

The systematic review was performed in April 2024, with the primary search yielding 591 articles. Abstract review resulted in 53 articles of potential relevance. Comprehensive review of the articles and manual reference checks was performed, independently, by two authors. This yielded a total of 15 articles meeting inclusion criteria.

CONCLUSIONS

HBOT may serve a valuable adjunct in aesthetic surgery, medicine, and anti-aging. However, the evidence to support its use, and justify its cost, is limited. This review serves as an update, capturing the currently available literature on HBOTs use in aesthetics, and provides the first discussion of HBOTs role in anti-aging. It underscores the need for future large-scale, randomized trials with standardization of HBOT protocols being employed to allow for full assessment of HBOTs utility in this clinical space.

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 .

Vascular complications with necrotic lesions following filler injections: Literature systematic review

INTRODUCTION

Although the related risk of vascular necrosis due to filler injection is low, the outcomes can be severe when they occur. This systematic review aims to report the occurrence and treatment of vascular necrosis due to filler injection.

MATERIALS AND METHODS

The systematic review was performed according to PRISMA guidelines.

RESULTS

The results showed the most used treatment is a combination of pharmacologic therapy and hyaluronidase application, which is efficacy when applied in the first 4 h. In addition, even though management recommendations are available in literature, proper guidelines are unavailable due to the low number of complications occurrence.

CONCLUSION

Clinical and high-quality studies on treatment and management of filler injection combination are necessary to provide scientific evidence on what to do in case of vascular complication occurrence.

The role, safety, and efficacy of hyperbaric oxygen therapy in aesthetic practice-An evidence-based review

BACKGROUND

Hyperbaric oxygen therapy (HBOT) involves patients breathing 100% oxygen in a pressurized chamber, above 1 atmosphere. Many centers are now promoting the use of HBOT for skin rejuvenation. However, the current indications for HBOT do not encompass aesthetic applications.

AIM

The aim of this evidence-based review was to assess the existing literature regarding the utilization of HBOT in medical aesthetics and rejuvenation, evaluate its effectiveness and safety, and conduct a cost analysis.

MATERIALS AND METHODS

PubMed Interface, Cochrane Library, Google Scholar, and Embase searches were carried out. The Best Bets methodology was used, and the risk of bias was appraised using the Quality Assessment Tool for Quantitative Studies.

RESULTS AND MAIN FINDINGS

This review included a total of 17 human studies with a total of 766 participants. Three studies were classified as level II evidence, three studies were of level III evidence, and 11 were of level IV evidence. All the included studies were judged at high risk of bias. The most relevant findings supported by level II evidence were that HBOT decreased the shedding rate post-FUE hair transplant (27.6 ± 2.6% vs. 69.1 ± 2.4%) but this did not affect the final outcome between HBOT (96.9 ± 0.5%) and the control (93.8 ± 0.6%). Moreover, level III evidence demonstrated that following HBOT, there was a significant increase in elastic fiber length (p ≤ 0.0001, effect size = 2.71) and a significant decrease in fiber fragmentation (p = 0.012). There was also a significant increase in collagen fiber density following HBOT (p = 0.0001, effect size = 1.10). However, there was no significant effect of antioxidant vitamins A, C, and E with HBOT. The inflammatory response significantly decreased after 7 days of HBOT with a decreased expression of IL-12p40, MIP-1β, and PDGF-BB and a higher expression of IL-1Ra. Moreover, HBOT was used prophylactically prior to abdominoplasty to decrease the risk of complications. In this study, complications were decreased from 32.6% (89 patients) to 8.4% (7 patients) with a p < 0.001, and in a multivariate analysis, preoperative HBOT was an independent protective factor against postoperative complications (p < 0.001).

CONCLUSION AND RECOMMENDATIONS

There is conflicting evidence on how the method of action of HBOT can have a beneficiary effect in aesthetic and whether the treatment is justifiable. To our knowledge, this is the first comprehensive review discussing the available evidence regarding the use of HBOT in many aesthetic clinical scenarios, including preventive, medical, and surgical settings. However, randomized clinical trials with longer follow-up and better patient selection are needed to be able to generate a reliable conclusion.

Hyaluronic acid filler-induced vascular occlusion-Three case reports and overview of prevention and treatment

BACKGROUND

Vascular occlusion induced by hyaluronic acid injections is rare, but can lead to severe adverse events, including necrosis, blindness, and cerebral infarction.

OBJECTIVE

This study aims to explore methods of reducing the risk of complications such as embolism induced by hyaluronic acid injection, and to study the impact of comprehensive systematic treatment on the prognosis of patients with hyaluronic acid embolism.

METHODS

The clinical data of three female patients with vascular occlusion due to hyaluronic acid injection was analyzed. Their median age was 26 years, with symptoms presenting 1-6 h postinjection. Hospital stays averaged 6 days. Two patients had ptosis, diplopia, and severe pain after injection of eyebrows. The other, who had a nose enhancement, experienced facial skin color changes and intense pain.

RESULTS

Two patients received comprehensive, systematic treatment based on injectable hyaluronidase. One patient self-discharged after receiving injectable hyaluronidase, antispasmodic, and vasodilator treatment on the night of embolism and returned to the hospital 3 days later with worsening embolism symptoms and received symptomatic treatment again. Two patients who received comprehensive, systematic treatment based on injectable hyaluronidase showed significant improvement, while the patient who did not undergo systematic treatment left scars on the face.

CONCLUSION

Vascular occlusion caused by hyaluronic acid facial filling is a severe adverse event, and timely, comprehensive, systematic treatment can effectively improve irreversible damage caused by thrombosis, and even cure it.

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.

Patterns of Filler-Induced Facial Skin Ischemia: A Systematic Review of 243 Cases and Introduction of the FOEM Scoring System and Grading Scale

BACKGROUND

The incidence of facial skin necrosis has increased considerably because of the growth in the popularity of dermal fillers. This study describes the patterns and severity of facial skin ischemia, along with associated neuro-ophthalmologic injuries, in the published literature through the introduction of the facial artery, ophthalmic artery, distal external carotid artery, internal maxillary artery (FOEM) facial angiosome scoring system and grading scale.

METHODS

A systematic review of all photographic cases of facial skin ischemia attributable to vascular occlusion with dermal fillers and injectable materials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 243 cases were identified, with 738 digital clinical photographs retrieved. The facial artery (58% of cases) and ophthalmic artery (48% of cases) angiosomes were most commonly affected. The frontonasal and angulonasal territories were the most common facial skin segments injured by filler-induced vascular occlusion. Cutaneous involvement of the ophthalmic angiosome was significantly associated with neuro-ophthalmologic complications [vision loss, 39% versus 0.8% ( P = 0.00001); stroke, 8% versus 0.8% ( P = 0.0085)]. Injuries with greater cutaneous surface area or cross-angiosome involvement were associated with a higher incidence of severe visual deficits and bilateral stroke.

CONCLUSIONS

Facial skin necrosis attributable to vascular occlusion is a rapidly growing problem that has remained poorly characterized in the literature. This study provides the largest descriptive analysis of published photographic reports of skin ischemia to date and proposes a novel scoring system and grading classification to aid in future reporting.

Use of the high-dose pulsed hyaluronidase protocol in the management of impending skin necrosis associated with hyaluronic acid fillers: a systematic review

Impending skin necrosis resulting from inadvertent intravascular injection of hyaluronic acid (HA) fillers can lead to tissue loss and significant scarring. In recent years, management trends have shifted from multimodal approaches to the sole use of high doses of hyaluronidase. The aim of this systematic review was to evaluate the effectiveness of the high-dose pulsed hyaluronidase management protocol in preventing skin necrosis and possible subsequent scarring. An online search of the bibliographic databases PubMed and Embase yielded 3039 articles. A total of 72 studies reporting 186 cases were found to be eligible for inclusion. The selection and evaluation process was done according to the PRISMA criteria. Included studies were assessed using the JBI and STROBE critical appraisal tools. The analysis of treatment outcomes was done according to the timing of treatment initiation and the type of intervention used. This review found that an immediate intervention using the high-dose pulsed hyaluronidase management protocol provided predictable and satisfactory outcomes. Initiating the protocol within 24 h of filler injection halted the progression of necrosis and prevented permanent sequelae. The conclusions are limited by the lack of a high level of evidence, since the only available sources of data are case reports and case series.

Hyperbaric oxygen therapy for treatment of a late presenting ischaemic complication from hyaluronic acid cosmetic filler injection

Vascular compromise and resulting ischaemic injury are known rare complications of cosmetic filler injections. Most hyaluronic acid vascular compromises present early and can be treated effectively by hyaluronidase. Here we present a case of ischaemic wound and mucosal necrosis after cosmetic facial hyaluronic acid injection that appeared within hours of injection but was not diagnosed and treated for 5 days. At day 5, the patient was treated with hyaluronidase injection immediately followed by 14 sessions of daily hyperbaric oxygen therapy (HBOT). Despite the delayed treatment, the patient had essentially complete recovery and the hyperbaric therapy was overall well-tolerated. Our case report suggests that hyaluronidase injection with concurrent daily HBOT sessions may be effective to allow recovery from late-presenting filler ischaemic complication. Furthermore, given the safety profile of HBOT, we suggest a more deliberate approach to this modality as a therapeutic adjunct by cosmetic practitioners when similar complications arise.