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Balazic E, Nazarian RS, Hawkins K, Kobets K. Vessel infiltration with microcannula during filler injection: a rare but consequential occurrence. J COSMET LASER THER 2023; 25:74-76. [PMID: 38198746 DOI: 10.1080/14764172.2024.2304310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024]
Abstract
Serious complications of cosmetic filler injections include vascular necrosis if the filler is injected into an artery. The use of a microcannula for filler injection has been reported to be safer with lower rates of vascular occlusion. We report a case of vessel infiltration that was noted prior to injection with microcannula which identifies an additional safety step for injectors. This case highlights the potential for devastating vascular occlusion with microcannula use while also demonstrating methods to identify vascular infiltration prior to filler injection. The purpose of this report is to educate and encourage injectors to inspect the introducer needle prior to any filler injection in order to avoid vascular occlusion during filler injection.
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Affiliation(s)
| | - Roya S Nazarian
- Division of Dermatology, Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Kelly Hawkins
- Division of Dermatology, Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Kseniya Kobets
- Division of Dermatology, Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
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2
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Xiong M, Chen C, Sereda Y, Garibyan L, Avram M, Lee KC. Retrospective analysis of the MAUDE database on dermal filler complications from 2014-2020. J Am Acad Dermatol 2022; 87:1158-1160. [PMID: 35202776 DOI: 10.1016/j.jaad.2022.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/24/2022] [Accepted: 02/15/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Michelle Xiong
- Warren Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Christine Chen
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Yuliia Sereda
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Lilit Garibyan
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Mathew Avram
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Kachiu C Lee
- Main Line Center for Laser Surgery, Ardmore, Pennsylvania
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3
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Siperstein R, Montes JR, Speranza A. A Retrospective Review of the Safety and Efficacy of Low-dose Triamcinolone Mixed with Hyaluronic Acid Fillers to Reduce Post-injection Infraorbital Swelling. J Clin Aesthet Dermatol 2022; 15:13-19. [PMID: 35465031 PMCID: PMC9017664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE This retrospective review assesses the efficacy and safety of low-dose triamcinolone (1mg/cc) added to hyaluronic acid fillers to decrease swelling after infraorbital injection. METHODS This retrospective analysis includes 447 patients who underwent 706 infraorbital hyaluronic acid filler treatments from April 2013 to March 2020 by a single injector. Short-term post-procedural swelling (≤2 weeks) was assessed through follow-up phone calls, which were documented in patient charts. The effect of triamcinolone, filler type, volume, and patient characteristics on the rate of post-procedure swelling were analyzed. RESULTS Swelling after infraorbital hyaluronic acid filler occurred in over half of the patients (51%, 103/202), but significantly decreased (23%, 29/124) when 1mg/cc of triamcinolone was mixed with the filler (x2[1, N=326]=24.296, p<0.00001). The incidence of swelling was directly correlated with the amount of hyaluronic acid filler injected (37% ≤ 0.55cc, 51% 0.56-1cc, and 60% >1cc) [x2[1, N=95]=3.9231, p=.048]. There was no significant difference in patient age, sex, Fitzpatrick skin type, or history of allergies on incidence of post-procedure swelling. Adverse events were limited to expected injection-site reactions, and there were no reports of hypopigmentation or atrophy from the addition of triamcinolone. LIMITATIONS This is a retrospective study that used patient reporting for short-term post procedure swelling. CONCLUSION This is the first retrospective study showing the safety and efficacy of a novel technique adding low-dose triamcinolone (1mg/cc) to hyaluronic acid filler to reduce post-procedure swelling within the first few weeks following infraorbital injection. Additionally, using lower volumes is also effective at reducing post-procedure swelling. Larger, randomized, controlled trials are needed to support our findings.
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Affiliation(s)
- Robyn Siperstein
- Dr. Siperstein is with the University of Miami in Miami, Florida
- Dr. Montes is with the Ophthalmology Department at the University of Puerto Rico in San Juan, Puerto Rico
- Dr. Speranza is with the University of Tampa in Tampa, Florida
| | - Jose Raul Montes
- Dr. Siperstein is with the University of Miami in Miami, Florida
- Dr. Montes is with the Ophthalmology Department at the University of Puerto Rico in San Juan, Puerto Rico
- Dr. Speranza is with the University of Tampa in Tampa, Florida
| | - AnnMari Speranza
- Dr. Siperstein is with the University of Miami in Miami, Florida
- Dr. Montes is with the Ophthalmology Department at the University of Puerto Rico in San Juan, Puerto Rico
- Dr. Speranza is with the University of Tampa in Tampa, Florida
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Dua A, Bhardwaj B. Delayed Onset Nodules After Hyaluronic Acid Fillers: A Case Series. J Cutan Aesthet Surg 2022; 15:91-94. [PMID: 35655648 PMCID: PMC9153319 DOI: 10.4103/jcas.jcas_200_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Non-surgical techniques with hyaluronic acid fillers to rejuvenate face are very popular treatment due to ease of administration and achievement of faster improvement. Although they are considered to be safe procedures, few rare adverse effects have been reported in literatures. The number of these cosmetic procedures being performed is increasing every year. Simultaneously, the rate of filler complications has also increased. This case series presents three clinical cases of delayed onset nodules after hyaluronic acid fillers after 1-5 months post-procedure. Juvederm Volift was used in all the mentioned patients. Granulomatous reactions can occur with any of the hyaluronic acid fillers. These are generally localized immunological reactions. An awareness about these rare side effects helps us in the assessment and ensurance of accurate diagnosis and treatment.
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Affiliation(s)
- Aman Dua
- A. K. Clinics, Ludhiana, Punjab, India
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Lee W, Moon HJ, Kim MS, Cheon GW, Yang EJ. Pre-injection ultrasound scanning for treating temporal hollowing. J Cosmet Dermatol 2021; 21:2420-2425. [PMID: 34559940 DOI: 10.1111/jocd.14471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hyaluronic acid filler injection is commonly administered to correct temple hollowness, typically through deep temporal injection. Since the vascular distribution at the injection site can be diverse, studies on avoiding damage to the corresponding blood vessels are needed. AIMS To assess the commonly used hyaluronic acid filler injection site in the temple region, 1cm lateral and 1 cm above from the end of eyebrow, using a Doppler ultrasound to detect any anatomic variations in the blood vessels. PATIENTS/METHODS Thirty patients (60 temples, right and left) were examined using Doppler ultrasonography. An 8-17 MHz ultrasound probe was used to discriminate between the anatomic layers of the temple. Blood vessels found in each anatomical layer were subsequently investigated. RESULTS Among the 30 patients included in this study, we found temporal region arteries 1 cm above and 1 cm lateral to the distal end of the eyebrow in 9 patients; However, no arteries were detected in the temples of 21 patients. The presence or absence of arteries was bilateral in all patients. CONCLUSIONS The anatomical layers with blood vessels varied among patients. The variability could give rise to complications. Possible anatomic variations at the temple should be carefully identified using pre-injection ultrasonography, and harming blood vessels should be avoided while injecting hyaluronic acid filler for temple augmentation.
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Affiliation(s)
- Won Lee
- Yonsei E1 Plastic Surgery Clinic, Anyang, South Korea
| | | | | | | | - Eun-Jung Yang
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seodaemun-gu, South Korea
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Kapoor KM, Saputra DI, Porter CE, Colucci L, Stone C, Brenninkmeijer EEA, Sloane J, Sayed K, Winaya KK, Bertossi D. Treating Aging Changes of Facial Anatomical Layers with Hyaluronic Acid Fillers. Clin Cosmet Investig Dermatol 2021; 14:1105-1118. [PMID: 34471372 PMCID: PMC8405095 DOI: 10.2147/ccid.s294812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/05/2021] [Indexed: 12/17/2022]
Abstract
The aging process affects every anatomical layer of the face. Improved knowledge of how aging occurs in each anatomical layer of the face has helped evolve the facial rejuvenation strategies with HA fillers. Understanding the age-related changes in the anatomical facial layers, including their time of onset and how the changes occur in the different tissue layers, an injector can provide much more targeted and refined HA filler treatments. As fillers’ use has increased, there has been a distinct shift away from procedures lifting the skin and SMAS. We can selectively target the anatomical facial layers with HA fillers for more refined and predictable outcomes. An extensive range of HA filler variants is now available. Each filler type is optimized and designed to be injected into specific tissue planes for the best results. Knowing the predictable aging changes in the different tissue layers of the face is crucial as this guides the optimum filler choice. Working knowledge of the individual characteristics of the numerous HA-based products allows for their effective placement in the correct layer. Familiarity with the correct HA product may also help to minimize the downtime and risk of adverse events.
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Affiliation(s)
- Krishan Mohan Kapoor
- Anticlock Clinic, Chandigarh, India.,Department of Plastic Surgery, Fortis Hospital, Mohali, India
| | | | | | | | | | | | - Jake Sloane
- Infinity Skin Clinic, Surry Hill, NSW, Australia
| | - Karim Sayed
- Faculty of Health and Social Sciences, University of South-East Norway, Drammen, Norway
| | | | - Dario Bertossi
- Department of Maxillo-Facial Surgery, University of Verona, Verona, Italy
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Kapoor KM, Murthy R, Hart SLA, Cattin TA, Nola PF, Rossiter AP, Singh R, Singh S. Factors influencing pre-injection aspiration for hyaluronic acid fillers: A systematic literature review and meta-analysis. Dermatol Ther 2020; 34:e14360. [PMID: 33002269 DOI: 10.1111/dth.14360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/01/2020] [Accepted: 09/23/2020] [Indexed: 02/01/2023]
Abstract
Pre-injection aspiration of hyaluronic acid filler is a well-recognized yet controversial safety technique. Many consider aspiration to be an important safety measure to prevent inadvertent intravascular filler injection. To assess factors influencing pre-injection aspiration by understanding the relationship between aspiration time and a range of product, needle, and procedural characteristics. We conducted a systematic review and meta-analysis of data, adopting the preferred reporting items for systematic reviews and metaanalyses guidelines. Our literature search identified four articles presenting data on variables associated with aspiration time for different HA filler brands. Statistical models pooling data from the four articles suggest a robust association between aspiration time and a filler's elastic modulus (G'), drop weight (cohesivity), and cross-sectional area of the needle lumen. However, there is insufficient evidence to confirm a robust association between aspiration time and HA concentration, viscous modulus (G″), needle length, and pullback volume. A deeper understanding of the relationship between product, needle, and procedural characteristics, and aspiration time can provide a sound base for discussing the role of pre-injection negative aspiration as a safety measure. The understanding of the effect of various factors on preinjection aspiration would further benefit from studies under clinical conditions.
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Affiliation(s)
| | - Rachna Murthy
- Department of Ophthalmology and Oculoplastic Surgery, FaceRestoration, London, UK
| | | | | | | | - Anthony Paul Rossiter
- Centre of Excellence for Biosecurity Risk Analysis, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Shobhna Singh
- Nitai Medical and Cosmetic Centre, Melbourne, Victoria, Australia
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Kapoor KM, Chatrath V, Li CQ, Bertossi D. Pinch anatomy: An injection guide for temple filler injections. Dermatol Ther 2020; 33:e13983. [PMID: 32638473 DOI: 10.1111/dth.13983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/14/2020] [Accepted: 07/04/2020] [Indexed: 11/28/2022]
Abstract
Filler injections have become exceedingly popular in the last decade, and injectors across the globe are using them for facial contouring and reversing the age-related changes. Thorough knowledge about the anatomy of important vessels and tissue planes is essential for injectors. During filler injections, injectors generally tend to pinch or pull the tissues with the nondominant hand for the ease of the procedure. These deformational forces lead to some changes in the anatomy of tissue layers held in a pinch. During pinch maneuver, the important arteries in that region can get pulled up in the tissue layers held in a pinch or stay in their position unaffected. The pinch can also increase the tissue space for injections by moving the mobile tissue layers away from the fixed ones. Knowledge of this "pinch anatomy" in the temple can be used to the injector's advantage to avoid important arteries and to place filler in the correct plane.
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Affiliation(s)
- Krishan Mohan Kapoor
- Anticlock Clinic, Chandigarh, India.,Department of Plastic Surgery, Fortis Hospital, Mohali, India.,University of London, St George's, London, UK
| | | | | | - Dario Bertossi
- Maxillo-Facial Surgery, University of Verona, Verona, Italy.,Maxillofacial Plastic Surgery Unit, Policlinico G.B., Verona, Italy
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Jitaree B, Phumyoo T, Uruwan S, Jiirasutat N, Pratoomthai B, Tansatit T. Clinical implications of the arterial supplies and their anastomotic territories in the nasolabial region for avoiding arterial complications during soft tissue filler injection. Clin Anat 2020; 34:581-589. [PMID: 32372520 DOI: 10.1002/ca.23617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The nasolabial fold (NLF) causes particular concern during aging in the middle face region. However, arterial complications of filler injections at this site have been continually reported during recent years. The aim of this study was to investigate the arterial locations and their anastomotic pathways related to filler injection sites in the NLF. MATERIALS AND METHODS Thirty hemi-faces of 15 embalmed Thai cadavers were dissected. Three anatomical landmarks of NLFs were assigned: the inferior margin level (NLF1), the mid-philtral horizontal line level (NLF2), and the inferior alar level (NLF3). Ten hemi-faces of five soft embalmed Thai cadavers underwent a modified Sihler's staining procedure to investigate the arterial anastomoses. RESULTS The artery closest to all of the landmarks was the facial artery. It was located inferomedial to NLF1 in 28%, and the mean distances along the X- and Y-axes were 3.53 ± 2.11 mm and 3.53 ± 1.75 mm, respectively. It was also located medial to NLF2 in 52.1% with an X-axis distance of 4.93 ± 1.53 mm. Several arteries were located close to NLF3, including the facial (33.3%), lateral nasal (33.3%), and infraorbital (30.0%) arteries. Anastomoses of the nasolabial arteries served to connect both the external-external and internal-external carotid systems. CONCLUSIONS Several arteries are located close to NLF1-NLF3. To prevent arterial injury, the locations and anastomotic pathways, as possible sources of severe complications, should be recognized prior to NLF filler injection.
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Affiliation(s)
- Benrita Jitaree
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Thirawass Phumyoo
- Department of Basic Medical Science, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Sukanya Uruwan
- Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Benjamart Pratoomthai
- Department of Basic Medical Science, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Tanvaa Tansatit
- Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Abstract
Injection of dermal fillers, like hyaluronic acid (HA), is a safe procedure, with few and transient side effects such as erythema, bruising and swelling etc. The aim of this report is to provide our protocol for the early treatment of necrotic complications after facial treatment with dermal fillers. We present two cases of skin suffering of the face after dermal infiltration of HA, treated successfully with our early protocol. Our protocol includes the early infiltration of hyaluronidase in the treated areas. We start with infiltration of hyaluronidase distributed over the area to be treated through micro-injections with dosage 40 IU per cm 2. Our protocol includes the use of systemic corticosteroids for 4 days, anti-aggregation therapy, oral antibiotic, topical cream with nitric oxide and compresses with gauze and warm water. In the skin complications after dermal filler treatment, marked pain and characteristic reticulated erythema in the skin distribution of the affected vessels is often developed. Due to the implementation of our protocol in these patients, we managed to avoid an irreversible necrotic complication of the face in both cases. In this report, our protocol was compared with results published in the literature and allowed us to avoid complications such as skin necrosis with permanent damage.
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Affiliation(s)
- Francesco Ciancio
- Department of Plastic and Reconstructive Surgery, University of Bari, Bari, 70124, Italy
| | - Maria Stella Tarico
- Department of Plastic and Reconstructive Surgery, University of Catania, Catania, 95100, Italy
| | - Giuseppe Giudice
- Department of Plastic and Reconstructive Surgery, University of Bari, Bari, 70124, Italy
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Abstract
Injection of dermal fillers, like hyaluronic acid (HA), is a safe procedure, with few and transient side effects such as erythema, bruising and swelling etc. The aim of this report is to provide our protocol for the early treatment of necrotic complications after facial treatment with dermal fillers. We present two cases of skin suffering of the face after dermal infiltration of HA, treated successfully with our early protocol. Our protocol includes the early infiltration of hyaluronidase in the treated areas. We start with infiltration of hyaluronidase distributed over the area to be treated through micro-injections with dosage 40 IU per cm 2. Our protocol includes the use of systemic corticosteroids for 4 days, anti-aggregation therapy, oral antibiotic, topical cream with nitric oxide and compresses with gauze and warm water. In the skin complications after dermal filler treatment, marked pain and characteristic reticulated erythema in the skin distribution of the affected vessels is often developed. Due to the implementation of our protocol in these patients, we managed to avoid an irreversible necrotic complication of the face in both cases. In this report, our protocol was compared with results published in the literature and allowed us to avoid complications such as skin necrosis with permanent damage.
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Affiliation(s)
- Francesco Ciancio
- Department of Plastic and Reconstructive Surgery, University of Bari, Bari, 70124, Italy
| | - Maria Stella Tarico
- Department of Plastic and Reconstructive Surgery, University of Catania, Catania, 95100, Italy
| | - Giuseppe Giudice
- Department of Plastic and Reconstructive Surgery, University of Bari, Bari, 70124, Italy
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