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

Indirect effects of hyaluronic acid applications on the glabella and nasolabial regions: An anatomic evaluation

This study is among the first to systematically evaluate the indirect anatomical effects of hyaluronic acid injections on the glabellar and nasolabial regions. It focuses on changes in wrinkle severity and anatomical parameters to enhance safety and efficacy. In this study, we analyzed pre- and post-treatment photographs of 31 women with a mean age of 45.97 ± 7.10, who received hyaluronic acid treatment. The study was designed retrospectively. Photographs taken before the procedure and one month after treatment were obtained from the clinical archive. Digital anatomical measurements were performed on these images. The anatomical measurements focused on the glabella (including facial convexity, total facial convexity, and facial concavity) and the nasolabial regions (including nasolabial and nasolabial fold angles on both the right and left sides). Wrinkle Severity Rating Scale (WSRS) evaluations were also conducted for both the glabella and nasolabial folds. Evaluations were performed by analyzing photographs taken before, 4 weeks after, and 12 weeks after hyaluronic acid filler application. In the glabellar region, hyaluronic acid injections into the temporal and zygomatic areas significantly reduced wrinkles, especially 12 weeks post-treatment (P = .004), indicating an indirect improvement in glabellar wrinkles. A positive correlation between age and wrinkle improvement was found (r = 0.601, P = .000), suggesting more pronounced effects in older individuals. In the nasolabial region, significant reductions were observed in both the right (P < .001) and left (P < .001) nasolabial folds post-treatment, with age also correlating with improvement (right: r = 0.693, P = .000; left: r = 0.496, P = .005). The S300 and S500 formulations reduced wrinkles, with the S500 showing greater efficacy than the S300. The findings of our study suggest that hyaluronic acid fillers can indirectly reduce the depth of nasolabial folds, and this effect can be achieved particularly when applied using techniques that are suitable for anatomical and vascular structures. This approach may be considered a viable alternative in aesthetic procedures, as it has the potential to enhance treatment safety by reducing the risk of complications associated with direct interventions.

Dangerous and Under-Recognized Arteries of the Glabella-An Ultrasound Study of Central and Paracentral Arteries and Risk During Filler Injection

BACKGROUND

Injecting fillers in the glabella is dangerous due to the presence of the central and paracentral arteries. These superficial arteries can connect to the ophthalmic artery putting patients at risk for blindness and stroke.

OBJECTIVE

Determine the prevalence of the central and paracentral arteries (PCA) utilizing a portable ultrasound device.

MATERIALS AND METHODS

A retrospective review of ultrasound data to determine the incidence and location of glabellar arteries at the level of the medial eyebrow in 29 Iranian subjects.

RESULTS

The central and PCA were found on ultrasound in 26 and 36 of the 58 sides, respectively. The average distance from midline to the central and PCA was 4.1 mm (range 1.8-6.7 mm) and 8.2 mm (6.8-10.1 mm), respectively. The average depth from the skin to the central and PCA was 2.7 mm (2.2-3.2) and 3.0 mm (2.6-3.4 mm), respectively. Almost all patients (26/29) had at least 1 artery in the subcutaneous plane underlying the glabella. Increased body mass index resulted in increased arterial depth.

CONCLUSION

Portable ultrasound was able to detect the central and paracentral arteries in most patients. Knowledge of the existence of these arteries and their subdermal location may be important to develop strategies to increase the safety of glabellar filler injections.

Update on Blindness From Filler: Review of Prognostic Factors, Management Approaches, and a Century of Published Cases

Vision loss secondary to aesthetic filler treatment is a rare but disastrous complication. The aim of this review was to update the published cases of blindness after filler injection that have occurred since our group published reviews of 98 cases in 2015 and an additional 48 cases in 2019. A literature review was performed to identify all cases of visual complications caused by filler injection published between September 2018 and March 2023. The cases were analyzed independently and in combination with previously reviewed cases. Analyses were based on the number of cases with data available. A total of 365 new cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nose (40.6%), forehead (27.7%), and glabella (19.0%). The filler injected was hyaluronic acid in 79.6% of cases. The most common associated signs were ptosis (56.2%), ophthalmoplegia (44.1%), pain (31.2%), and skin changes (73.2%). Strokelike features were seen in 19.2% of cases. Of the cases reporting visual outcomes (318), 6.0% experienced complete vision recovery, 25.8% had partial improvement in visual acuity, and 68.2% had no vision recovery. Partially preserved visual acuity at onset was a significant predictor of visual improvement (P < .001). The 3 most common treatments were subcutaneous hyaluronidase at or near the filler site (70.1%), systemic steroids (57.3%), and intraarterial thrombolytic therapy (56.0%). No treatments were significantly associated with visual improvement (P > .05). Although blindness and stroke from fillers is a rare complication, practitioners who inject filler should have a thorough knowledge of prevention and management strategies.

LEVEL OF EVIDENCE: 3

Identifying Levels of Competency in Aesthetic Medicine: A Questionnaire-based Study

BACKGROUND

In 2022, the US experienced a significant increase in demand for minimally invasive aesthetic procedures, underscoring its rising acceptance amid an unregulated educational environment for practitioners. The absence of standardized educational pathways and quality control in aesthetic medicine, primarily provided by nonacademic institutions, highlights a critical need for establishing educational standards to ensure practitioner competence and patient safety.

OBJECTIVES

The aim of this study was to identify levels of competency for the aesthetic practitioner and necessary achievement milestones during the educational path from novice to expert injector.

METHODS

A total of n = 386 international study participants responded to an online questionnaire regarding their experience in aesthetic medicine practice. The questionnaire comprised 58 questions focusing on professional data, the perceived difficulty of injection, and risk for the occurrence of adverse events for specific facial regions in soft tissue filler and toxin injections.

RESULTS

Regardless of medical specialty and experience level, averages of 3.85 (1.8) years, 786.4 (2628) filler injections and 549.9 (1543) toxin injections were estimated to progress from novice to advanced injector, while averages of 6.10 (3.7) years, 1842.2 (4793) filler injections, and 1308.5 (3363) toxin injections were estimated to advance from advanced to expert injector. The nose and the perioral region have been ranked as the facial regions where it is most difficult to achieve a perfect aesthetic outcome and with the greatest risk for the occurrence of adverse events for filler and toxin injections, respectively.

CONCLUSIONS

In this study we establish an educational framework in aesthetic medicine by defining the progression from novice to competent and expert injector levels, suggesting 4 years of practice and over 790 filler and 550 neuromodulator injections for competence, and at least 6 years with 1840 filler and 1310 neuromodulator injections for expertise. We also identify critical facial regions for targeted treatments by different expertise levels.

LEVEL OF EVIDENCE: 4

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications

INTRODUCTION

The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment.

METHODS

A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes.

RESULTS

The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant.

CONCLUSION

The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers.

LEVEL OF EVIDENCE III

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

Embolization of Ophthalmic Artery Induced By Ear Hyaluronic Acid Injection

Ear filling injection of hyaluronic acid (HA) is emerging as a new application of HA filling in clinical practice. However, its risks and complications have not been sufficiently investigated. Herein, we report a case of 25-year-old female with embolization of ophthalmic artery, a severe complication caused by ear filling of HA. Injection of HA at the triangular fossa immediately induced amaurosis and dizziness, and complete loss of light sensation in the right eye 10 min after injection. These symptoms did not resolve after emergency treatment, and she was sent to our hospital for treatment. A diagnosis of central retinal arterial occlusion (CRAO) was made, for which the patient received intravascular interventional therapy as an emergency treatment. Following surgery, the patient received a multifaceted treatment approach to promote nerve health, improve blood circulation, reduce edema, and enhance oxygen delivery through hyperbaric oxygen therapy. This treatment regimen restored light perception and resolved mottled skin discoloration. This case report expands our understanding of the potential mechanisms and anatomical factors involved in embolization associated with ear filler injections. Furthermore, it highlights the importance of prompt intervention, providing valuable insights for reducing the complication rate and improving patient outcomes following such procedures.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 .

Delayed Diagnosis of Septal Ulcer after Hyaluronic Acid Nasal Filler Injection

The utilization of fillers, notably hyaluronic acid, has increased due to their proven effectiveness, versatility, and generally favorable safety profile. In the field of rhinoplasty, hyaluronic acid dermal fillers have been employed for the correction of nasal deformities and surface irregularities. Nevertheless, the intricate vascular network of the nasal region, involving anastomoses between the external and internal carotid arteries, predisposes it to serious vascular complications. We report a case of a severe septal ulcer secondary to local ischemia following an injection of a hyaluronic acid nasal filler. The patient presented with immediate pain and nasal discomfort; however, there was an unfortunate delay in diagnosis and treatment. This report discusses the intricacies of the case and imparts crucial insights gleaned from the incident.

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

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

Dermal Filler Hypersensitivity Post-COVID-19 Illness: Case Series and Literature Review

OBJECTIVE

To report two cases of dermal filler hypersensitivity post-COVID-19 illness and review the literature.

METHODS

A literature review was performed. Data were extracted from the articles: the author, year of publication, age and sex of the patient, filler substance, injection site, symptoms and signs, onset time, diagnostic results, treatment, and prognosis.

RESULTS

Six cases from six literatures were included in the review. All of them were female and were confirmed infected with COVID-19. Five of them received hyaluronic acid injection and one patient received polyacrylamide. Time after injection ranged from 8 months to 9 years. Onset of symptoms ranged from two to four weeks post-infection. The clinical manifestations included swelling, edema, induration, erythema, and tenderness. The site where the symptoms appeared was the injection site, and symptoms appeared at each injection site at the same time, including cheeks, periocular area, and lips.

CONCLUSION

Dermal filler hypersensitivity may occur post-COVID-19 illness. A detailed history and clinical examination can help confirm the diagnosis.

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 .

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.

Research hotspots and trends of oculomotor nerve palsy from 2001 to 2021 based on web of science: A bibliometric analysis

Background

Oculomotor nerve palsy (ONP) is a clinically occurring neurological disorder. Due to the complex anatomy and long travel distances of the oculomotor nerve, the causes of ONP vary and manifest in various ways. With continued interest in this area, it has become necessary to conduct a bibliometric study in ONP. This work aims to synthesize and visually identify current research themes and future trends in ONP through a literature-based analysis.

Method

Articles and reviews on ONP published from 2002 to 2021 were derived from the Web of Science Core Collection (WoSCC) database. We generated visual images and performed quantitative and qualitative analysis through an online bibliometric tool, Citespace and VOSviewer software.

Results

A total of 1,205 published articles were included in this analysis. The annual number of this area's publications is showing an overall upward trend, with the number of citations increasing every year, reaching 2,698 by 2021. The United States (367) and Japan (116) dominated the list with the most numerous articles published. The University of California Los Angeles in the USA is the institution that published the highest number of articles (47). Engle EC (23) and the JOURNAL OF NEUROSURGERY (46) are the most influential authors and journals in this field. The co-occurrence network analysis divided the keywords into five main research themes, which mainly include clinical manifestations of ONP, aneurysms, cerebral neurological symptoms, diseases with ONP as a complication, and other neurological disorders.

Conclusion

This study is the first comprehensive and systematic bibliometric analysis of the current state of global ONP research over the past 20 years. We organized current hotspots and expected trends and provided key information for exploring potential research frontiers in ONP.

Clinical Characteristics of Methanol-Induced Optic Neuropathy: Correlation between Aetiology and Clinical Findings

PURPOSE

To show the clinical characteristics, identify the magnetic resonance imaging (MRI) and optical coherence tomography (OCT) features, and observe the visual outcome of methanol-induced optic neuropathy.

METHODS

Clinical data were retrospectively collected from in-patients diagnosed with methanol-induced optic neuropathy in the Neuro-Ophthalmology Department of the Chinese People's Liberation Army General Hospital from January 2016 to January 2021.

RESULTS

Eight patients were included in this study. The exposure time was 6-34 h for ingestion, 3-4 months for inhalation, and more than ten years for skin absorption. All patients demonstrated bilateral acute visual impairment. Seven of eight patients had other accompanying systemic symptoms. Seven of eight patients demonstrated optic nerve lesions in MRI, and five presented with a hyperintense T2 signal in a "central" type. OCT showed the macular ganglion cell layer and inner plexiform layer (mGCL-IPL) thinning before the peripapillary retinal nerve fiber layer (pRNFL) thinning. The visual improvement was achieved transiently for seven of eight patients after treatment. One patient with a mitochondrial DNA mutation maintained a bilateral no-light perception (NLP) from the onset to the last visit. All patients had poor visual prognoses, with either light perception or NLP.

CONCLUSIONS

Methanol-induced optic neuropathy is a rare bilateral optic neuropathy with a poor visual outcome. A centrally hyperintense T2 signal of the optic nerve is common in methanol-induced optic neuropathy. The thinning of the mGCL-IPL is more sensitive than that of the pRNFL for early diagnosis. A mitochondrial genetic defect may be a predisposing factor for methanol-induced optic neuropathy.

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)-Implications for Therapeutic Interventions

Biocompatible hyaluronic acid (HA, hyaluronan) gel implants have altered the therapeutic landscape of surgery and medicine, fostering an array of innovative products that include viscosurgical aids, synovial supplements, and drug-eluting nanomaterials. However, it is perhaps the explosive growth in the cosmetic applications of injectable dermal fillers that has captured the brightest spotlight, emerging as the dominant modality in plastic surgery and aesthetic medicine. The popularity surge with which injectable HA fillers have risen to in vogue status has also brought a concomitant increase in the incidence of once-rare iatrogenic vaso-occlusive injuries ranging from disfiguring facial skin necrosis to disabling neuro-ophthalmological sequelae. As our understanding of the pathophysiology of these injuries has evolved, supplemented by more than a century of astute observations, the formulation of novel therapeutic and preventative strategies has permitted the amelioration of this burdensome complication. In this special issue article, we review the relevant mechanisms underlying HA filler-induced vascular occlusion (FIVO), with particular emphasis on the rheo-mechanical aspects of vascular blockade; the thromboembolic potential of HA mixtures; and the tissue-specific ischemic susceptibility of microvascular networks, which leads to underperfusion, hypoxia, and ultimate injury. In addition, recent therapeutic advances and novel considerations on the prevention and management of muco-cutaneous and neuro-ophthalmological complications are examined.