Avoiding and treating dermal filler complications

Clinical efficacy of intense pulsed light combined with low-dose intralesional corticosteroids in treating noninfectious granulomas after mesotherapy: A case series analysis

BACKGROUND

Mesotherapy is a popular cosmetic procedure for localized delivery of substances. However, due to the lack of standardized processes, there are potential risks of adverse reactions. Granulomas formation is one of the chronic reactions which impose significant physical and mental burdens on patients.

OBJECTIVES

The aim of this analysis is to evaluate the safety and feasibility of combining intense pulsed light (IPL) with intralesional corticosteroids for treating noninfectious granulomas after mesotherapy.

METHODS

This retrospective observational case series included patients who suffer from noninfectious granulomas after mesotherapy and received combination of IPL and intralesional corticosteroids treatment between October 2021 and December 2022 at Peking University Shenzhen Hospital, Shenzhen, China. The process and effect were analyzed and summarized.

RESULTS

Among the seven patients, five expressed extreme satisfaction with the efficacy, while two was slightly satisfied. The physicians believed that all patients had shown significant improvement. No adverse reactions or recurrences were observed during follow-up.

CONCLUSION

Based on this analysis, the application of the combined treatment in patients suffering from noninfectious granuloma due to mesotherapy demonstrates good clinical efficacy and safety, making it worth considering as a treatment option.

Updated Filler Emergency Kit: Next-Generation Emergency Solution

INTRODUCTION

The rising popularity of facial filler injections has corresponded with an increase in reported complications. While a filler emergency kit was previously introduced, advancements in the field have highlighted certain limitations, prompting the development of the updated filler emergency kit (UFEK).

METHODS

The authors conducted literature research up to February 2023, focusing on PubMed and open web searches for articles referred to filler emergent complications: vascular occlusion, blindness and anaphylaxis. Approximately 1200 articles were obtained from PubMed and other sources, and 45 articles were reviewed.

RESULTS

The developed UFEK protocol delineates specific interventions meticulously tailored to address diverse emergent scenarios linked to soft tissue fillers complications. This protocol emphasizes the urgent requirement for timely and personalized interventions.

CONCLUSION

The UFEK offers a standardized, comprehensive and effective approach. This work contributes to the responsible and informed progression of the field of aesthetic medicine, providing more value and safety, both for clinicians and patients. 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 .

Safety of esthetic procedures in rheumatic patients: single-center survey of patients

The popularity of esthetic medicine is growing every year, also among patients with autoimmune inflammatory rheumatic diseases (AIRD). The objective of this study was to evaluate the safety of esthetic medicine (AM) procedures in patients with AIRD. A semi-structured, anonymous questionnaire regarding rheumatic and concomitant diseases and AM procedures was distributed among adult patients hospitalized in the rheumatology department or attending outpatient clinic in the National Institute of Geriatrics, Rheumatology, and Rehabilitation, Warsaw. The main outcome was the occurrence of an adverse event. A number of 512 patients took part in the survey and 15 were excluded (AM procedure preceded the diagnosis of AIRD). The study group consisted of 497 patients, of whom 47 had undergone AM procedures. The procedures performed included: tattooing (22 patients), piercing (16 patients), hyaluronic acid (7 patients), botulinum toxin (5 patients) injections, laser procedures (6 patients), plastic surgery (4 patients), mesotherapy (3 patients) and others. The vast majority of patients had these performed during remission or low disease activity. 70.2% of patients received treatment with disease-modifying antirheumatic drugs (DMARDs) during the AM procedure, with TNF-alfa inhibitors being the most common (63.6%). Adverse events occurred in 15% of patients. All were mild and transient site reactions. Most patients would like to repeat the AM procedure in the future. The use of esthetic medicine procedures in patients with AIRD, including those treated with biologic DMARDs, was associated with a risk of mild site reactions. Most of the patients expressed satisfaction with the results of the AM procedure.

Biofilm formation is a risk factor for late and delayed complications of filler injection

Introduction

Biofilm formation is a major cause of delayed-graft complications. Similarly to implants, dermal fillers carry the risk of biofilm formation, which can lead to the development of nodules, chronic inflammatory reactions, abscesses and other complications. In this study, we investigated the late or delayed complications associated with biofilm formation on dermal fillers.

Methods

In this retrospective analysis, we analyzed all cases of complications caused by filler injections at a single center between January 2017 and December 2022, the majority of which comprised nodule formation and chronic persistent inflammatory reactions. The risk of biofilm formation with fillers was summarized and analyzed based on the results of bacterial culture and pathological examination.

Results

Sixty-one patients were enrolled, including 42 cases of nodule formation, 15 of chronic inflammatory reactions, and 4 of active infection. Bacterial culture of the tissue samples obtained from seven patients after surgical treatment were positive, and comprised four cases of Staphylococcus aureus, one case of Staphylococcus epidermidis, one case of Staphylococcus saprophyticus and one case of Mycobacterium abscessus. The corresponding histopathological results indicated extensive mononuclear lymphocyte infiltration, with a giant cell reaction in the fibrous connective tissue.

Conclusion

The results of this study suggest that biofilm formation is a significant risk factor for late and delayed complications following filler injection, and is caused by the contamination of resident bacteria and recessive infection at the injection site.

Fillers Around the Nose

OBJECTIVES

The aim of this paper is to review the fillers around the nose.

METHODS

The literature search was performed at the PubMed and Proquest Central database of the Kirikkale University Library.

RESULTS

Characteristics of an ideal dermal filling material would be low cost, high safety, not causing pain during filling, provoking few sensitivity reactions and being durable. The material should allow reproducible results that are in line with expectation and produce a natural texture, be quick to use, be operation-ready, not cause the patient to need to convalesce and rarely cause complications. Nasal contour remodeling using fillers has several advantages: there is a brief recovery period, a general anesthetic is not needed and ecchymosis does not occur. There are a lot of filler materials, such as collagen, hyaluronic acid, Polymethylmethacrylate with Bovine Collagen, Poly-L-Lactic Acid, calcium hydroxylapatite and expanded polytetrafluoroethylene.

CONCLUSION

It is absolutely essential to choose carefully appropriate material and procedure for patients to obtain optimum results.

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.

An Update on the Clinical Efficacy and Safety of Collagen Injectables for Aesthetic and Regenerative Medicine Applications

Soft tissues diseases significantly affect patients quality of life and usually require targeted, costly and sometimes constant interventions. With the average lifetime increase, a proportional increase of age-related soft tissues diseases has been witnessed. Due to this, the last two decades have seen a tremendous demand for minimally invasive one-step resolutive procedures. Intensive scientific and industrial research has led to the recognition of injectable formulations as a new advantageous approach in the management of complex diseases that are challenging to treat with conventional strategies. Among them, collagen-based products are revealed to be one of the most promising among bioactive biomaterials-based formulations. Collagen is the most abundant structural protein of vertebrate connective tissues and, because of its structural and non-structural role, is one of the most widely used multifunctional biomaterials in the health-related sectors, including medical care and cosmetics. Indeed, collagen-based formulations are historically considered as the "gold standard" and from 1981 have been paving the way for the development of a new generation of fillers. A huge number of collagen-based injectable products have been approved worldwide for clinical use and have routinely been introduced in many clinical settings for both aesthetic and regenerative surgery. In this context, this review article aims to be an update on the clinical outcomes of approved collagen-based injectables for both aesthetic and regenerative medicine of the last 20 years with an in-depth focus on their safety and effectiveness for the treatment of diseases of the integumental, gastrointestinal, musculoskeletal, and urogenital apparatus.

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

Trends of rhinoplasty research in the last decade with bibliometric analysis

Background

As rhinoplasty (RP) with different requirements is becoming more and more popular in the latest decade, this study aims to quantitatively and qualitatively explore the trends in RP research, depict research hotspots, and point out the future direction with a bibliometric analysis.

Methods

All RP literature studies in the last decade (from 2012 to 2021) were retrieved from the Web of Science Core database. Annual output, institutions, authors, journals, and most-cited literature studies were analyzed by bibliometric tools, including CiteSpace, bibliometric online platform, bibliometrix R language kit, BICOMB, and gCLUTO.

Results

A total of 2,590 RP research studies dated between 2012 and 2021 were included according to our criterion. As for the country, the United States, Turkey, and Korea maintained the top three in RP research. As for the institutions, the University of California, Irvine, Stanford University, and University of Ulsan ranked top three in RP research publications based on article counts. Professor Rhorich RJ, Most SP, and Jang YJ were the most contributed authors according to article counts and citation number. The top journals were The Plastic and Reconstructive Surgery, JAMA Facial Plastic Surgery, and Aesthetic Surgery Journal. The 10 most-cited literature studies were also listed explicitly in this study. Finally, biclustering analysis on the most frequent keywords were conducted which helped us to identify seven hotspot clusters in RP research.

Conclusions

We comprehensively summarized the publication information of RP literature studies in the past decade, highlighted the current status and trends over time, and provide guidance for in-depth research direction on RP for the future.

Treatment of bruising after injection to reduce cellulite

BACKGROUND

Cellulite 80%-98% of post-pubertal women and results in cutaneous dimples in the affected area.

AIMS

Therapies that target collagenous fibrous septae often provide successful outcomes.

MATERIALS & METHODS

Collagenase clostridium histolyticum-aaes (CCH) for injection consists of two collagenases which, under physiologic conditions, disrupt collagen structures by hydrolyzing Type I and III collagen.

RESULTS

Subcutaneous CCH was approved in the United States in 2020 for the treatment of moderate-to-severe cellulite in the buttocks of adult women. Although bruising is primarily an aesthetic concern, a conspicuous procedure-induced bruise may limit a patient's social activities and result in hesitation to undergo a similar cosmetic procedure in the future.

CONCLUSION

The purpose of this review is to describe the available techniques for hastening bruise resolution and how they apply to resolving bruises associated with a CCH injectable.

Complicated Facial Fillers: Management Algorithm

Background:

Various materials have been developed as skin fillers to correct wrinkles of the face. Dermal fillers are classified based on their biodegradability into bioresorbable versus nonbioresorbable. All dermal fillers have a potential risk of complications, which can be classified as early and late onset events. Among all the complications of filler injections, inflammatory nodules and granulomas are the most annoying and disfiguring. The purpose of the study was to provide a surgical treatment algorithm that allows us to deal with the complications of facial fillers through three surgical techniques.

Methods:

Thirty-one patients with complaints of facial contour abnormalities after filler injection, three surgical techniques were adopted according to the presenting case including face lift incision, needle aspiration and intraoral excision after preoperative preparation of the case with postoperative follow-up for 6 months.

Results:

Among our studied patients treated by these surgical techniques, dissection was difficult owing to the fibrosis and the granulomatous reaction post complicated filler injection. There were two cases of hematoma, 1 case of seroma, and 1 case of facial nerve injury that improved after 4 months, in which marked improvement of facial contour and skin quality was observed.

Conclusions:

The use of the facelift technique as a surgical treatment for post filler complication granuloma excision provides a useful and satisfactory method for patients complaining of major facial deformities following repeated complicated filler injections. Despite being more difficult than other techniques it is more satisfactory in facial rejuvenation post complicated facial fillers.

Dermal Filler Injections in Patients With Autoimmune and Inflammatory Rheumatic Diseases-The Patients' Perspective

BACKGROUND

Injecting dermal fillers in patients with autoimmune inflammatory rheumatic diseases (AIIRDs) is controversial.

OBJECTIVE

To evaluate the attitudes of patients with AIIRDs regarding the use of dermal fillers and the side effects of those who underwent them.

METHODS

Patients with AIIRDs who attended a rheumatology outpatient clinic between 2016 and 2018 filled in a questionnaire about their attitudes toward dermal filler injections. The questionnaire evaluated information received from professionals and the factors that influenced their decision of whether or not to undergo the procedures.

RESULTS

Overall, 194 patients with AIIRDs (mean age 56.5 ± 14.0, 99% women) responded. Forty-two of them had previously undergone the injections and intended to repeat them (Group A), 37 had not received filler injections but intended to do so (Group B), and 114 who had never undergone them did not intend to undergo them. The major motivation for undergoing filler injections was social. Patients treated with dermal fillers refrained from informing their rheumatologist about their injections. They were, however, highly satisfied with the procedure and reported negligible side effects.

CONCLUSION

The use of dermal fillers was apparently safe and well received by patients with AIIRDs. Physicians' recommendations to refrain from injecting them with dermal fillers should be reconsidered and evaluated in clinical studies.

A Case of Orbital Granuloma Secondary to Dermal Filler Injection

A foreign body granulomatous reaction is a rare complication of the subcutaneous injection of fillers. We describe a 57-year-old female that presented with a six-month history of a non-painful, right lower eyelid mass. She had a dermal filler in the zygomatic region several months before the onset of her symptoms. Anterior orbitotomy and pathology revealed multinuclear giant cells consistent with a hyaluronic acid-based filler. This case describes the clinical presentation, histopathologic features, and treatment of an orbital granuloma secondary to dermal filler injection. Our case was uncommon because the zygomatic filler migrated across the orbital septum. Additionally, transconjunctival orbitotomy was used instead of a hyaluronidase injection due to the inferior location of the granuloma.

The Aetiopathogenesis of Late Inflammatory Reactions (LIRs) After Soft Tissue Filler Use: A Systematic Review of the Literature

Background

Late inflammatory reactions (LIRs) are the most challenging complications after filler use. The immune system plays a prominent role in its etiology, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for LIRs. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of LIRs.

Methods

We undertook a systematic literature review focused on immunological factors and microbiota in relation to LIRs after filler use. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE and the Cochrane databases were searched from inception up to August 2019. Included studies were assessed for the following variables: subject characteristics, number of patients, primary indication for filler injection, implant type/amount and injection site, type of complication, follow-up or injection duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors.

Results

Data on immunological factors and bacterial contamination were retrieved from 21 included studies. Notably, the presence of histocytes, giant cells and Staphylococcus epidermidis within biopsies were often associated with LIRs.

Conclusion

This review provides a clear overview of the immunological factors associated with LIRs and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with LIRs has been provided. Follow-up research may result in clinical recommendations to prevent LIRs.

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..

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02306-3.

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.

Filler Migration to the Orbit

BACKGROUND

Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications.

OBJECTIVES

We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed.

METHODS

A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections.

RESULTS

Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively.

CONCLUSIONS

Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

LEVEL OF EVIDENCE: 4

Upper eyelid blepharoplasty following hyaluronic acid injection with improved facial aesthetics and eye symptoms: a case report

BACKGROUND

Dermatochalasis of the upper eyelids (blepharochalasis) is a typical age-related change in the upper third of the face and a major concern for facial aesthetics. Nowadays both surgical and nonsurgical interventions are available for patients complaining of upper eyelid dermatochalasis. Although nonsurgical treatments are often easier to perform, if they are not performed correctly, complications may ensue and worsen the condition.

CASE PRESENTATION

We describe the case of a Caucasian patient presenting with bilateral upper eyelid dermatochalasis, previously treated with multiple injections of hyaluronic acid filler. Following these procedures, the patient reported nonspecific eye symptoms (such as a sense of heaviness and asthenopia) and cosmetic concerns. We decided to perform an upper eyelid blepharoplasty. During the procedure we found a ribbon of hard, fibrous material, which was carefully removed. The patient reported resolution of functional eye symptoms owing to the reduction of upper lid heaviness, which also resulted in subjective improvement of the visual field. Patient satisfaction was assessed preoperatively and 3 months postoperatively using the Blepharoplasty Outcomes Evaluation (BOE), which showed an overall satisfaction rate of 95.8 %.

CONCLUSIONS

Blepharoplasty not only treated the patient's blepharochalasis but also allowed us to correct the previous nonsurgical intervention by removing the excessive amount of injected hyaluronic acid. Both aesthetic and functional results were successfully achieved.

Hyperbaric oxygen therapy acts as an alternative method in treating injection-induced nodules

BACKGROUND

Cosmetic injection-induced nodules are tricky to handle in the clinic.

AIMS

We reported a case of injection-induced nodule receiving the experimental treatment of hyperbaric oxygen therapy (HOT).

PATIENT

A woman presented with multiple red solid nodules on the neck after receiving mesotherapy conducted by syringe. Ultrasound examination showed multiple thickened inflammatory skin tissues on the neck. Pathological biopsy results showed epithelioid granulomas in the dermis, within which there were degenerative necrosis and foreign bodies in the center and multinucleated giant cells around. The bacteria tests remained negative. Diagnosed with foreign body granuloma, the patient rejected the resection or steroids, but willingly took the experimental treatment of HOT instead. After one month, the patient's ultrasound examination showed that the lesion's local hardness got significantly reduced, and the local blood flow increased, indicating the condition improved.

RESULTS

Although the patient's nodule has not been eliminated, some improvements have been achieved. So far there has no case report on HOT treating injection-induced nodules in the literature.

CONCLUSION

HOT may be considered as a potential alternative when other treatment options cannot be implemented. More research is needed in this field.

Orbital infarction syndrome following hyaluronic acid filler rhinoplasty

Purpose

Over the last decade, injectable soft tissue fillers have become an essential part of facial plastic surgery practice. We report here a tragic complication of hyaluronic acid filler injection in a young healthy woman, management offered, and the outcome.

Observations

A 32-year-old woman developed unilateral acute blindness, orbital pain, total ophthalmoplegia, and anterior and posterior segment ischemia immediately following hyaluronic acid injection. Urgent measures were taken including hyaluronidase enzyme injection, vigorous messaging, and systemic steroids. Eight weeks later, the extraocular motility has fully recovered; however, the consequences of ischemia on the anterior and posterior ocular segments persisted.

Conclusions and Importance

Describing a major refractory complication following injecting hyaluronic acid dermal filler. Prompt intervention including the use retro or peribulbar injection of hyaluronidase has a little impact when it comes to reversing ocular sequalae. Therefore, injectors should be aware of facial danger zones that could potentially lead to this devastating outcome.

Actinomyces Infection after Permanent Fillers Lip Augmentation: Diagnosis and Treatment

Background:

Although dermal filler injections are a widespread and secure practice, early or late complications may nonetheless occur.

Objective:

In this paper, the authors report an unusual asymptomatic late filler infection caused by Actinomycetes in a patient having received liquid silicone and acrylate filler injections for lip enhancement, seeking treatment for upper lip macrocheilia.

Methods:

The case report is about a patient who complained of recurrent lip region edema and denied any infective episodes. Preoperative analysis was in the normal range. Sonographic exam showed two fillers in the upper lip, suggestive of silicone and polyacrylamide gel. A conservative macrocheilia reduction was performed; healing was uneventful.

Results:

Histology report confirmed the preoperative sonographic diagnosis, together with an actinomycetes infection, clinically unsuspected. Many microorganisms have been reported to cause abscesses or granuloma after dermal filler treatments, sterile abscesses were reported as well, suggesting a biofilm infection as causative granuloma origin.

Conclusion:

This study differs from previous filler complication reports because of the occasional finding of a silent actinomyces infection, a commensal of the oral cavity but responsible for suppurative diseases in the soft tissues. This occasional finding seems to support the biofilm origin of dermal filler granuloma.

Granulomas and nongranulomatous nodules after filler injection: Different complications require different treatments

Dermal fillers are widely used for facial rejuvenation and reconstruction and present fewer risks than surgical approaches. Nevertheless, several complications may occur, including nodule formation. A nodule is a clinical sign corresponding to different etiologies, such as overcorrection, infection, allergic reaction, or granuloma. However, their treatment represents a diagnostic challenge. We present a retrospective review of 26 consecutive patients who underwent a biopsy for facial nodule formation more than 3 months after filler injections, to determine the diagnosis of the nodule and type of filler used. All patients were women (mean age, 57.8 years). Some patients suffered from different localizations: lip, 14 cases; nasolabial folds, 6; cheeks, 5; infraorbital region, 5; the glabella, 2; the temporal region, 1; and chin, 1 case. Only 5 (19.2%) patients knew the type of filler used, and in another 4 cases, the injector was able to provide some information. In 65.4% of cases, the filler type was unknown. Histopathological analysis revealed a "granulomatous" nodule in 30 sites and a "non-granulomatous" nodule in 4 cases. Concerning the type of filler, 5 different histopathological patterns were found. Our results demonstrate that a clinical history and histopathological analysis whether to confirm or not to confirm the diagnosis of granuloma and to identify the type of filler are essential tools to achieve an accurate diagnosis of the problem-oriented treatment of nodules after dermal filler injections. We propose an algorithm for the management of nodules after filler injection.

Recombinant Silk Hydrogel as a Novel Dermal Filler Component: Preclinical Safety and Efficacy Studies of a New Class of Tissue Fillers

BACKGROUND

Hyaluronic acid-based tissue fillers are commonly utilized in reconstructive surgery as well as for aesthetic augmentation. A new type of recombinant silk-based tissue filler might pose a beneficial alternative for surgeons and patients.

OBJECTIVES

The aim of this study was to compare injectability, reshaping, tolerability, and postimplantation behavior of dermal filler preparations containing recombinant silk hydrogel with a commercially available hyaluronic acid filler in 2 different animal models.

METHODS

Recombinant silk hydrogel as standalone preparation or as a mixture with commercial stabilized hyaluronic acid was tested in rodent and porcine animal models. The preparations were analyzed in detail and administered subdermally followed by clinical, volumetric, and histological monitoring of the subdermal depots over several months.

RESULTS

Applicability, dosing, and tissue distribution of the filler preparations were facilitated in the presence of silk hydrogel. No clinical complications attributable to tissue filler application were recorded. State-of-the art methods, such as high-performance magnetic resonance imaging, were applied successfully to monitor the volumetric development of the filler depots in live animals.

CONCLUSIONS

The preclinical data demonstrate the basic suitability of recombinant silk hydrogel as safe and convenient tissue filler ingredient. Due to its shear thinning properties, recombinant silk hydrogel has the potential for less painful application, comfortable aesthetic reshaping immediately after administration, and negligible postoperative discomfort.

The Nonsurgical Rhinoplasty: A Retrospective Review of 5000 Treatments

BACKGROUND

Nonsurgical rhinoplasty with injectable dermal fillers has become an increasingly popular alternative to surgical procedures, in view of its relative low cost, convenience and rapid recovery, and low risk profile. The safety and efficacy of nonsurgical rhinoplasty remains a relatively contentious and ambiguous matter, given that there are few large-scale series reporting results or complications. This study reports the experience of a single clinician performing nonsurgical rhinoplasty in the largest cohort to date.

METHODS

Patient demographics, indications, treatment details, and outcomes of patients treated between March of 2016 and January of 2019 were reviewed. The nonsurgical rhinoplasty technique described previously by Harb was used using hyaluronic acid dermal filler.

RESULTS

Nonsurgical rhinoplasty was performed in 5000 patients. The commonest indication was dorsal hump (44 percent). Swelling and erythema were self-limiting side effects encountered in approximately half of patients. Infection was seen in two patients, and localized skin necrosis was observed in three patients.

CONCLUSIONS

Nonsurgical rhinoplasty is a safe procedure with positive aesthetic results when performed by an experienced clinician. Knowledge of nasal anatomy, comprehensive training, and use of appropriate materials are key in ensuring safety and results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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

Background and Objectives

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

Materials and Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Eruptive granuloma after injection of Ellansé® successfully treated using methotrexate]

BACKGROUND

Collagen stimulators such as Ellansé® are soft tissue fillers able to induce nucleogenesis. We describe a case of eruptive foreign body granulomas following injection of Ellansé® that were successfully treated using methotrexate.

CASE REPORT

A 47-year-old woman received injections of Ellansé® for the wrinkled aspect of her cheeks. She had previously undergone injections of hyaluronic acid on the nasolabial folds. Nine months after the Ellansé® injections, the patient consulted for the recent appearance of multiple nodules on her face. Histological analysis of one of these nodules confirmed the presence of foreign-body granulomas developed in contact with spherical gaps of a size substantially identical to the Ellansé® vacuoles. Methotrexate 10mg per week for 3 months followed by 20mg per week for 9 months resulted in complete regression of the nodules.

DISCUSSION

Ellansé® is composed of two biocompatible and bioabsorbable polymers: carboxymethylcellulose, responsible for immediate volume creation, and polycaprolactone, which promotes collagen synthesis. However, any injected product can cause varying degrees of granulomatous reaction. Hyaluronic acid was previously injected at several other sites on the patient's face. These lesions were not the result of poor injection technique.

CONCLUSION

Although collagen stimulators are biocompatible and bioabsorbable substances, the development of foreign-body granulomas, while rare, is still possible. Methotrexate resulted in significant regression of nodules as of the third month of treatment.

Complications of botulinum toxin and fillers: A narrative review

BACKGROUND

Cosmetic surgery and esthetic procedures have become a billion dollar industry owing to the ever-growing demand of the population to stay young. The injectable treatments including fillers and botulinum toxin have become highly popular because of their quick, predictable and lasting results in the management of facial wrinkles and rejuvenation. Although these treatment modalities are relatively safe, they are associated with certain side effects.

AIMS

In this review, we will focus on the complications of fillers and botulinum toxin.

PATIENTS/METHODS

The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. Only articles available in English were considered for this review.

RESULTS

Brow ptosis and asymmetry are common adverse effects of botulinum toxin while the most common adverse effects associated with fillers are the local injection related effects manifesting as erythema, edema, pain, and ecchymosis.

CONCLUSION

It is important that the treating physician is well verse with the various fillers and botulinum toxin complications and their management as some of the complications can be severely debilitating.

Anatomical Map of the Facial Artery for Facial Reconstruction and Aesthetic Procedures

BACKGROUND

The facial artery (FA) is the main blood vessel supplying the anterior face and an understanding of its anatomy is crucial in facial reconstruction and aesthetic procedures.

OBJECTIVES

The aim of this study was to assess the many anatomical features of the FA utilizing a multidimensional approach.

METHODS

Head and neck computed tomographic angiographies of 131 patients (255 FAs) with good image quality were evaluated. The FA was classified according to its termination pattern, course, and location with reference to soft tissue/bone surrounding structures.

RESULTS

In total, each branch was present as follows: the submental artery (44.8%), the inferior labial artery (60%), the superior labial artery (82.2%), the lateral nasal artery (25.1%), and the angular artery (42.5%). The most common FA course was the classic course, situated medially to the nasolabial fold (27.1%). In total 65.5% of the arteries were located medially to the nasolabial fold, and only 12.3% of them were totally situated lateral to the nasolabial fold. The median distance (with quartiles) from the inferior orbital rim reached the FA after the superior labial artery branched off in 50.2% of cases and was 36.6 mm (33.4; 43.3). The angle between the FA and the inferior border of the mandible was 49.8o (31.9; 72.4). The horizontal distances between the oral commissure and naris to the FA were 8.5 ± 4.0 mm and 12.1 ± 6.7 mm, respectively.

CONCLUSIONS

An anatomical map summarizing the major measurements and geometry of the FA was generated. The detailed anatomy and relative positioning of the FA should be considered to avoid any unexpected complications in plastic surgery.

A Cross-sectional Analysis of Adverse Events and Litigation for Injectable Fillers

Importance

Injectable fillers are increasing in popularity as a noninvasive option to address concerns related to facial aging and volume loss. To our knowledge, there have been no large-scale analyses of adverse events and associated litigation related to filler injections.

Objectives

To determine risks of injectable fillers and analyze factors raised in litigation related to injectable fillers.

Design, Setting, and Participants

In this cross-sectional review, the US Food and Drug Administration's (FDA) manufacturer and user facility device experience (MAUDE) database was evaluated for complications from the use of the following fillers: Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill, and Juvederm Voluma from 2014 to 2016. The Westlaw Next database was used to identify jury verdicts.

Main Outcomes and Measures

Complications were organized by type of filler used, location of injection, and severity. Intra-arterial injections without sequelae and those resulting in blindness or necrosis were considered severe complications. Factors raised during the litigation process were also analyzed.

Results

Of 1748 adverse events analyzed, most cases stemmed from cheek (751 [43.0%]) or lip (524 [30.0%]) injection. Commonly reported adverse events reported included swelling (755 [43.2%]) and infection (725 [41.5%]). Among FDA-reported complications, blindness was significantly associated with dorsal nasal injections (P < .001). Vascular compromise with and without sequela of dermal necrosis and blindness were significantly associated with Radiesse injections P < .001. Of the 9 malpractice cases identified, two-thirds involved allegations of inadequate informed consent, and the median award in cases resolved with payment was $262 000.

Conclusions and Relevance

Although specific complication profiles vary by material and injection site, common adverse events associated with injectable fillers include swelling and infection. More serious events include vascular compromise, resulting in necrosis and blindness; these events are also raised in cases involving litigation. This analysis illustrates the importance of outlining these risks in a comprehensive preoperative informed consent process.

Level of Evidence

NA.

Complications and Litigation Associated With Injectable Facial Fillers: A Cross-Sectional Study

PURPOSE

Soft-tissue injectable fillers are a popular treatment option for patients seeking minimally invasive facial rejuvenation. The use of soft-tissue fillers has increased significantly in the past 10 years. In 2017 alone, clinicians administered nearly 2.7 million soft-tissue fillers, up from 1.3 million in 2007. Although injectable fillers have a relatively high safety profile compared with more invasive rejuvenation procedures, serious adverse events, including intra-arterial injections, necrosis, and visual symptoms such as blindness, have been documented. Complications from injectable fillers have also been a source of litigation, which has been shown to be associated with a perceived lack of informed consent. We sought to document the reported complication rates associated with injectable facial fillers from a national database and to report on the available cases of malpractice litigation.

MATERIALS AND METHODS

The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was used to collect the reported complications from 2013 to 2017 for the following injectable fillers: Artefill, Bellafill, Belotero, Juvederm, Radiesse, Restylane, Sculptra, and Kybella. Complications were organized by filler type, injection location, and complication type. The Thomson Reuters Westlaw Edge database was used to collect the reported jury verdicts and settlements from 2008 to 2017 for injectable facial fillers.

RESULTS

A total of 2813 adverse events were analyzed. The most common locations for complications were the cheek (915 [32.5%]), lips (503 [17.9%]), and nasolabial fold (412 [14.6%]). The commonly reported adverse events were swelling (1,691 [60.1%]), nodule (948 [33.7%]), and pain (636 [22.6%]). Severe complications included intra-arterial injections resulting in necrosis and visual symptoms (eg, blurred vision and blindness). Forehead and dorsal nasal injections were significantly associated with intra-arterial complications resulting in necrosis and visual symptoms (P < .01). Injections with Radiesse were significantly associated with intra-arterial injections resulting in necrosis and visual symptoms (P < .01). A total of 11 malpractice cases were analyzed. The median award in the cases resolved by a verdict in favor of the plaintiff or settlement was $600,000. In 10 of the 11 cases, a lack of informed consent had been alleged.

CONCLUSIONS

The complications associated with injectable facial fillers varied greatly, depending on factors involved with their application. The most common adverse effects were swelling, nodule formation, and pain. Serious complications stemming from intra-arterial injections included necrosis and visual disturbances, including blindness. These complications have been raised in legal cases, in which the lack of informed consent was frequently alleged. The present analysis has documented some of the potential risks involved with injectable facial fillers and demonstrated the need for a thorough informed consent process before their administration.

Clinical Observations and the Anatomical Basis of Blindness After Facial Hyaluronic Acid Injection

Background

Blindness or visual loss is the most serious complication resulting from facial hyaluronic acid (HA) injection. In this study, three recent clinical cases were analyzed, and the relevant anatomy of cadavers was evaluated to investigate the mechanism behind visual impairment due to HA injection.

Methods

Three patients with different extents of visual loss after HA injection were studied. Ophthalmic testing and corresponding treatments were performed, and the clinical progress was observed. In addition, thirty-six fresh Asian cadaver hemifaces were anatomized to investigate the morphology of the ophthalmic artery and its branches. The minimum dose of HA for central retinal artery embolism was calculated based on the ophthalmic arterial volumes of cadavers.

Results

Visual impairment was more severe in central retinal artery occlusion and combined intraocular branch occlusion than in posterior ciliary artery occlusion. During follow-up, no improvement was observed in terms of visual impairment. Cadaver study reconfirmed that the ophthalmic artery included facial and intraocular branches. The ophthalmic arterial volumes running from the supraorbital artery and supratrochlear artery to the central retinal artery were 0.083 cm³ and 0.089 cm³, respectively.

Conclusions

The severity of blindness caused by HA injection may be associated with the occlusion site. Our clinical observations indicate that conventional treatments, such as retrobulbar hyaluronidase injection, are insufficient to relieve visual impairment. Injecting as little as 0.08 ml of HA into the facial branch is enough to cause central retinal artery embolism. Limiting the volume per injection could represent a simple prophylactic strategy.

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.

Practical Approach and Safety of Hyaluronic Acid Fillers

Supplemental Digital Content is available in the text.

Soft-tissue filler use has grown considerably related to the increasing popularity of minimally invasive cosmetic procedures. Hyaluronic acid products are currently the most utilized soft-tissue fillers. Proper working knowledge of individual products, limitations to use, and anatomic principles can improve outcomes. Prevention is key to minimize complications; however, when present, complications must be managed methodically. Complications are categorized based on the timing of presentation and include early, late, and delayed. Vascular compromise and tissue necrosis are among the most devastating complications seen with filler use. Nodules can be related to an inflammatory or infectious etiology but should be distinguished as treatment varies. Hyaluronidase is mandatory to have available as a reversal agent for hyaluronic acid products and can be used in treatment for many complications and untoward sequela.

Dermatologic Surgical Care for Transgender Individuals

BACKGROUND

Transgender individuals experience common and unique dermatologic concerns from severe acne associated with testosterone therapy in transmen to complications due to illicit silicone injections in transwomen. Currently, 2 survey studies and 4 reviews have addressed the dermatologic care of transgender individuals. However, none of them provide a focus on the dermatologic surgeon.

OBJECTIVE

To assess the dermatologic considerations in transgender individuals and the role of dermatologic surgeon in their care.

METHODS

The PubMed and MEDLINE databases were reviewed in June 2018 using keywords, such as transgender, procedures, hair removal, laser, and hormone therapy.

RESULTS

In total, 48 relevant publications addressing dermatologic care in transgender patients were reviewed. According to the literature, there are several critical dermatologic considerations in transgender patients, including hair growth and removal, acne vulgaris, facial procedures to masculinize and feminize the face, scar removal, and sexually transmitted infections.

CONCLUSION

As dermatologic surgeons have the privilege to improve the health care of transgender patients, they must understand the common and unique concerns of transgender individuals. Given the considerable spectrum of physical goals expressed by transmen and transwomen, individual patient preference must ultimately guide his/her/their dermatologic care.

Another face of dermal fillers

Potential complications related to dermal fillers depend on the type of the fillers and the site of their application. The classification of dermal filler complications can be divided into early and late, and into minor and major events. According to their mechanism, they can be divided into non-ischaemic and ischaemic complications. The aim of this study is to present possible complications related to dermal fillers, to explain their aetiology and to propose preventive management and treatment. Non-ischaemic complications can be technique-dependent and include the reactions at the site of the injection, contour irregularities, and inflammatory and infectious reactions. They are usually resolved as a matter of course after 2-7 days. Arterial or venous occlusion leads to ischemia, with subsequent necrosis of the skin and/or vision loss.

Hyaluronic Acid Filler Emergency Kit

Widespread use of facial filler has led to a rise in reports of associated complications. The aim of this kit is to encompass all needed items to treat the patient and to be organized and prepared to provide correct treatment in urgent situations. A search was performed to gather information on the treatment of complications that occur after injection of soft tissue fillers. The search included reports published in English up to June 2018. We focused on reports of complications arising from emergent/urgent situations following the use of hyaluronic acid injectables; these included filler embolization resulting in impending skin necrosis, blindness or partial loss of vision, and anaphylaxis. We collated treatment of emergent complications from our search of published articles. There were 2 described protocols for filler complications in the literature. One protocol, the “old” protocol, was based on a low dose of hyaluronidase with longer intervals of injections and ancillary treatment. This protocol did not show good results in comparison with the “new” protocol, which was needed to improve these results. The new protocol demonstrated that a high dose of hyaluronidase had better efficacy; this protocol involves hourly injections with no ancillary treatment required except for aspirin. We propose a filler emergency kit (FEK) to deal with complications of hyaluronic acid fillers according to the new protocol to manage the stresses caused by these situations. Every physician needs to be prepared for any potential complication; therefore, there is a need to have a FEK as a crash kit in the clinic to avoid distressing the physician and the patient.

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Complications of glans penis augmentation

Despite the controversy regarding penile augmentation (PA), glans penis augmentation (GPA) is used in penile reconstructive surgery in selected patients with small glans penis. Since 2003, injectable hyaluronic acid (HA) gel has been used for GPA. The attractiveness of HA gel fillers and interest in this technique have led to the use of other fillers for GPA, particularly irreversible fillers that improve the longevity of HA gels. Conversely, indirect glans augmentation via implantation of dermofat grafts or scaffolds between the corpus spongiosum and the distal tip of the corpus cavernosum is used to overcome poor longevity of the gel and glans surface undulation, which are the primary limitations of GPA using HA gel. Unfortunately, these implants form hard painful lumps over time in most patients and are difficult to remove. Blunt dissection is an invasive procedure that may cause vascular compromise and consequent glans necrosis in a few patients. We present our review regarding the current status of GPA for a more comprehensive understanding of this subject. Additionally, we have discussed a few complicated cases that were referred to us.

A 10-point plan for avoiding hyaluronic acid dermal filler-related complications during facial aesthetic procedures and algorithms for management

The recent rapid growth in dermal filler use, in conjunction with inadequate product and injector control, has heralded a concerning increase in filler complications. The 10-point plan has been developed to minimize complications through careful preconsideration of causative factors, categorized as patient, product, and procedure related. Patient-related factors include history, which involves a preprocedural consultation with careful elucidation of skin conditions, systemic disease, medications, and previous cosmetic procedures. Other exclusion criteria include autoimmune diseases and multiple allergies. The temporal proximity of dental or routine medical procedures is discouraged. Insightful patient assessment, with the consideration of ethnicity, gender, and generational needs, is of paramount importance. Specified informed consent is vital due to the concerning increase in vascular complications, which carry the risk for skin compromise and loss of vision. Informed consent should be signed for both adverse events and their treatment. Product-related factors include reversibility, which is a powerful advantage when using hyaluronic acid (HA) products. Complications from nonreversible or minimally degradable products, especially when layered over vital structures, are more difficult to control. Product characteristics such as HA concentration and proprietary cross-linking should be understood in the context of ideal depth, placement, and expected duration. Product layering over late or minimally degradable fillers is discouraged, while layering of HA of over the same brand, or even across brands, seems to be feasible. Procedural factors such as photographic documentation, procedural planning, aseptic technique, and anatomical and technical knowledge are of pivotal importance. A final section is dedicated to algorithms and protocols for the management and treatment of complications such as hypersensitivity, vascular events, infection, and late-onset nodules. The 10-point plan is a systematic, effective strategy aimed at reducing the risk of dermal filler complications.

Injection Rhinoplasty Using Filler

Rhinoplasty is a commonly performed cosmetic surgery in Asia. Rhinoplasty using filler is preferred because has fewer side effects and shorter down time. The part of external nose between the skin and bone or cartilages consists of 4 layers. To prevent vascular compromise, the injection should be into deep fatty layer, preventing embolization. Filler is usually injected in the order of radix, rhinion, tip, and the supratip area. To minimize asymmetry, the surgeon should always mark the midline on the nasal bridge and perform the procedure without deviating from it.

Beyond photoaging: additional factors involved in the process of skin aging

Studies assessing the impact of extrinsic factors on skin aging have increased during the last with the increase in life expectancy. Although most of the studies are about the sun radiation impact, many factors should be considered in elderly people, beyond environmental conditions. Lifestyle factors, like diet, sleeping, smoking, should be analyzed carefully, as common age-related conditions (menopause, diabetes, pulmonary diseases, etc.). All these factors could accelerate the natural decline of skin structure and functions, possibly affecting the responses to treatments and drugs. This review demonstrates that growing evidence regarding environmental factors that are associated with lifestyle and comorbidities deserve greater attention from researchers and dermatologists and may require new approaches in the management of skin aging.

Filler Nodules: Inflammatory or Infectious? A Review of Biofilms and Their Implications on Clinical Practice

BACKGROUND

The numbers of minimally invasive cosmetic procedures performed in the United States have steadily increased each year. Concurrently, the rates of filler complications have also increased. Delayed filler reactions and granulomas have recently been attributed to biofilm infections.

OBJECTIVE

The biology and pathogenesis of biofilms, and their diagnosis, treatment, and prevention will be discussed.

METHODS

The relevant and recent literature on delayed filler reactions and biofilms was reviewed.

RESULTS

Increasing evidence implicates biofilm infections in the pathogenesis of delayed filler reactions. Therapeutic and preventative measures can be taken to minimize the occurrence of these potentially devastating consequences of dermal fillers.

CONCLUSION

Awareness of biofilm infections is key in the assessment of filler reactions in order to ensure timely and accurate diagnosis and treatment.

Differentiating Nonpermanent Injectable Fillers: Prevention and Treatment of Filler Complications

Though the incidence of complications and adverse events with dermatological fillers is inherently low, practitioners should be well versed in both prevention of filler complications and the treatment algorithms for addressing "granulomas," nodules, infection, and vascular compromise. Appropriate preventative measures, coupled with timely and effective treatment, are critically important for patient safety and satisfaction. In addition to the preventive measures and treatment algorithms outlined here, the authors emphasize that the broad classification and treatment of nodules as "granulomas" is likely to lead to ineffective treatment, or worse, unnecessary exposure to incorrect treatment. In practice, nodules are classified and treated based on clinical manifestation (eg, late vs early or noninflammatory vs inflammatory) rather than on histology. Indeed, classification of a nodule as a granuloma requires a histological examination, rarely available (or necessary) in clinical practice to guide treatment. Thus, the apparent inflammatory nature of the nodule and the time of onset should drive treatment approach. The treatment algorithms presented here are based on these clinically meaningful parameters.

Optimizing outcomes with polymethylmethacrylate fillers

INTRODUCTION

The ideal filler should be long-lasting, biocompatible, chemically inert, soft and easy to use, and have a long history of safety. This review focuses on the evolution and development of the PMMA-collagen gel, Bellafill, and the 10 years of postmarketing experience of Bellafill since it received premarket approval (PMA) from the FDA as Artefill in 2006. Artefill was rebranded to Bellafill in 2015.

METHODS

The authors conducted a literature search on PubMed for key articles describing the steps in which Arteplast, a PMMA filler developed in 1989, led to the development of Bellafill, the only PMMA filler approved by the US FDA for the treatment of nasolabial folds and acne scar correction. The factors governing efficacy and safety were also evaluated for the major PMMA fillers available in the world.

RESULTS

The process of manufacturing and purifying PMMA has played a major role in minimizing adverse events for Bellafill. Postmarketing surveillance data for the 2007-2016 period show that for more than 530 000 Bellafill syringes distributed worldwide, 11 confirmed granulomas (excluding clinical trial data) (0.002% of syringes sold) have been reported. Data on other PMMA fillers are limited and inconsistent. The authors suggest that adverse events are often attributable to lack of proficiency in treatment technique and other factors.

CONCLUSION

Bellafill has demonstrated an excellent safety and effectiveness profile in multiple clinical studies, customer feedback, and 10 years of postmarketing surveillance experience. Adverse events occur with all fillers for a variety of reasons. In addition to quality of the product, injector skill and technique are critical to ensuring good clinical outcomes.

Demarcative Necrosis Along Previous Laceration Line After Filler Injection

In recent years, fillers have been widely used for soft tissue augmentation. Although they are generally considered to be safe, many complications have been reported to date. Nose and nasolabial fold augmentations with fillers can lead to an implementation of nasal skin necrosis, possibly caused by intravascular embolism and/or extravascular compression. Herein, we present a case of a successfully treated patient who experienced skin necrosis after an injection of dermal fillers into the nasolabial fold. Interestingly, we discovered that the patient had experienced a laceration 8 years ago around the area in which the filler was injected.