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Dermal filler treatments require constant reassessment for improving and safeguarding the rapidly evolving aesthetic field. Suboptimal injection technique, patient selection and product knowledge have touted a concerning increase in filler complications, with new challenges such as the COVID-19 pandemic leading to new paradigms in the understanding...
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Microneedle patch (MNP) is an alternative to the oral route and subcutaneous injection with unique advantages such as painless administration, good compliance, and fewer side effects. Herein, we report MNP as a prominent strategy for drug delivery to treat local or systemic disease. Hyaluronic acid (HA) has advantageous properties, such as human au...
Background and Objectives: Preeclampsia is a multisystem disorder that affects maternal endothelium. The glycocalyx lines and protects the endothelial surface. In severe systemic diseases, like sepsis, it is shed and glycocalyx degradation products can be detected in increased concentrations in plasma. The aim of this study was to compare circulati...
Citations
... Such side effects are, however, avoidable and depend on the skill, experience, and knowledge of the injector. Crosslinked dermal fillers differ in their rheological properties and an expert aesthetic practitioner would be able to choose the most appropriate product for each anatomic location and desired cosmetic outcome [98][99][100][101][102][103][104]. ...
Dermal injections of hyaluronic acid gel for aesthetic skin rejuvenation are becoming increasingly popular nowadays. Although these products are classified as medical devices, the regulations on their administration by licensed practitioners are still weak, whereas their manufacturers increasingly highlight and advertise the cellular effects that underpin the efficacy of these injections. In this review, we discuss all current knowledge on the mode of action of dermally injected hyaluronic acid and the potential toxicological implications, especially from crosslinked gels, in conjunction with the current global regulations. We also highlight the urgent need for further research to elucidate the therapeutic implications and underscore the imperative need for robust regulatory frameworks to safeguard public health. We conclude that dermal injections of hyaluronic acid have several therapeutic implications that warrant further research and that strict regulations must be applied to their manufacture/quality control and the required qualifications of licensed aesthetic injectors.
... Such side effects are however avoidable and depend on the skill, experience, and knowledge of the injector. Crosslinked dermal fillers differ in their rheological properties and an expert aesthetic practitioner would be able to choose the most appropriate products for each anatomic location and desired cosmetic outcome [95][96][97][98][99][100][101]. ...
Dermal injections of hyaluronic acid gel for aesthetic skin rejuvenation are increasingly popular nowadays. Although these products are classified as medical devices, the regulations on their administration by licensed practitioners are still weak, whereas their manufacturers increasingly highlight and advertise the cellular effects that underpin the efficacy of these injections. In this re-view, we discuss all current knowledge on the mode of action of dermally injected hyaluronic acid and the potential toxicological implications especially from crosslinked gels in conjunction with the current global regulations. We conclude that dermal injections of hyaluronic acid have several therapeutic implications that warrant further research, and that strict regulations must be applied on their manufacture/quality control and the required qualifications of licensed aesthetic injectors.
... Some mild temporary adverse events, including redness, swelling, mild surface deformity, or even infection, may be reported, which are all self-limited without permanent effect. However, in some rare reports, the use of such synthetic facial injections led to severe adverse events such as vascular complications in the skin leading to facial necrosis, reversible or even irreversible blindness, and cerebral embolism leading to ischemic stroke and even death [6,7]. It is obvious that the severity of neurological symptoms can depend on the type of filler used, the depth of injection, the vessels involved, and the severity of the vascular obstruction. ...
Facial rejuvenation and augmentation with autologous fat injection are common and effective techniques worldwide. This procedure has few complications and is usually used for soft-tissue augmentation. Although this procedure is considered safe, many patients have experienced different complications such as visual loss, stroke, or skin necrosis after these procedures. Herein, a case of embolic stroke along with blindness and facial necrosis due to facial filler injection is described. In this case, a patient developed decreased level of consciousness, left hemiparesis, and blindness that was finally diagnosed based on imaging as embolic stroke following facial autologous fat injection. The symptoms improved partially and gradually by conservative treatment and the patient was discharged with some sequels.
... HA-based fillers are safe and effective for treating facial volume loss or deficiency [4,7]. Immediacy and predictability also make these fillers the treatment of choice for most clinical circumstances, but understanding the rheological characteristics of HA is essential for correctly choosing each facial topographic region [8,9]. Recent studies comparing the rheological capabilities of HA gels indicate the therapeutic superiority of Juvéderm® Volux™ for filling the chin and mandibular contour compared to other HA gels. ...
Introduction
The development of filler biomaterials with high hyaluronic acid concentrations, cohesiveness, and elastic modulus has become an option for chin augmentation, as the balance of these rheological properties promotes high lifting capacity, providing minimally invasive perceptible improvements in patient appearance.
Presentation of case
The present study reviewed clinical and anatomical aspects of patients referred for chin augmentation and created a flowchart to assertively diagnose patients with an indication of Juvéderm® Volux™ for defining the lower third of the face.
Discussion
The chin is vital for facial proportions and attractiveness perception. Its relevance to facial appearance is noticed the most when chin size is less than ideal, making other facial areas seem larger or smaller. The adjacent soft tissues of the neck and jaw appear prematurely aged when chin projection or width is inadequate. Hyaluronic acid-based fillers have a confirmed history of safe and effective use for treating facial volume loss or deficiency.
Conclusion
Juvéderm® Volux™ is a safe, effective, and long-lasting alternative for restoring and creating facial volume and sculpting, shaping, and contouring the chin and jaw.
... aspiration as a safety checkpoint, slow product administration, thorough patient briefing on appropriate aftercare, and follow-up telephone calls on the 2 days after treatment. 7,8 Following the procedure, the patient experienced transient edema (lasting ~10 days) and minor ecchymoses. There were no other complications, such as asymmetry, infection, vascular occlusion, or necrosis. ...
... The present author favors preinjection aspiration; although controversial in some quarters, this practice can be a valuable checkpoint when used alongside other safety measures. 7 Clinicians must always be vigilant for any unexpected pain or blanching that could be an indicator of intravascular injection. 7 In addition, practitioners should have preset protocols in place for managing major complications in the rare instances when they do occur. ...
... 7 Clinicians must always be vigilant for any unexpected pain or blanching that could be an indicator of intravascular injection. 7 In addition, practitioners should have preset protocols in place for managing major complications in the rare instances when they do occur. ...
Background
The use of hyaluronic acid (HA) fillers for correcting nasal deformities offers an increasingly popular alternative to surgical rhinoplasty. However, this can sometimes be extremely challenging, for example, in patients with a permanent defect in the nasal septum secondary to chronic drug use.
Methods
We report a case in which nonsurgical intervention with a high G’ HA filler was used therapeutically to improve the permanent nasal disfigurement of an individual with previous long-term drug use (now in remission)
Results
This approach led to high levels of patient satisfaction and empowerment in her personal and professional life. Despite the high risk in this case, only immediate minor complications were recorded, including temporary edema and ecchymoses, and these resolved spontaneously
Conclusions
Nonsurgical treatment using an appropriate HA filler may offer a safe and effective option in selected patients with nasal deformities resulting from pathological conditions.
... The risk of such reactions is increased by preparations of unknown origin, poor purification containing DNA, proteins or bacterial toxins or the presence of biofilm. [14][15][16][17][18] Moreover, it is believed that LMW-HA (low molecular weight HA) may act as dangerassociated molecular patterns (DAMPs) initiating the mechanisms of innate immunity, similarly to bacterial proteins or heat-shock proteins, while HMW-HA (high-molecular HA) has primarily an anti-inflammatory effect. 18,19 However, a recent study suggests that HA products alone do not stimulate an inflammatory/immune response, regardless of molecular weight or cross-linking. ...
... 20 The technique of the procedure and the individual immune sensitivity of the patient are also important. [14][15][16][17][18] The next trigger factor is stress. Recent studies have identified a population of proinflammatory monocytes/macrophages that are released from the bone marrow in response to the sympathetic nervous system which release proinflammatory cytokines into circulation but also have the ability to traffic to stress-and anxiety-related brain regions. ...
A continuous increase in the popularity of esthetic procedures with the use of substances as HA has been observed for many years, which might be contributing to an increase in the number of adverse events. The autoimmune/inflammatory syndrome induced by adjuvants (ASIA) can be provoked by hyaluronic acid (HA), which belongs to substances meeting the criteria of adjuvants. Mechanisms of the innate and acquired immune response are activated, leading to the dysregulation of T and B lymphocytes, inability to recognize one’s own antigens, inflammation, damage to one’s own tissues, and ultimately to autoimmunity. The objective of this article is to present a case-series study of patients who developed ASIA syndrome following HA injection after delayed inflammatory reaction (DIR) and emphasize the importance of the need for long-term monitoring after such the reaction. Lack of knowledge about ASIA can lead to delayed diagnosis and serious consequences for the patients. People with a history of immunization reactions, severe allergic reactions, individual predisposition to autoimmunity or family predisposition to autoimmunity and previous exposure to adjuvants require special attention and long-term follow-up. This applies primarily to cases of DIR after the using of bioimplants, especially with treatment resistance, as in our reported cases.
... To ensure patient safety and avoid mistakes, various guidelines have been developed [39][40][41]. ...
... For beginners, we recommend attending qualified courses by established, serious providers to increase their knowledge and skills. Early recognition and management of unwanted side effects are of great importance to minimize risks of an unfortunate outcome [7,[39][40][41]. ...
Background: Injection of dermal fillers for facial esthetics has become a very popular procedure. Although usually safe in the hands of the experienced user, filler injections may bear a risk of un-wanted side effects.
Material and Methods: This is a narrative review on dermal filler migration after facial injec-tions. We performed literature research on Pubmed and Google Scholar. Inclusion criteria were observational studies, case reports, and clinical trials which investigated the association of facial filler injections to filler migration. Animal studies have not been considered. Intravascular injec-tions were excluded. Results: We identified 28 reports that met the inclusion criteria. The age range of affected patients was 21 to 86 years (mean standard deviation: 47 14.8 years). Wom-en were 25 times more reported than males. Hyaluronic acid and polyalkylimide were the most common encountered filler substances. Injections into the nose, lips, nasolabial folds, and fore-head (including glabella) are more often reported for filler migration than injections into the cheeks. Tear-trough correction bears a risk for orbital migration. The delay from injection to presentation of filler migration was highly variable. Very late filler migration was more com-monly seen with permanent fillers than non-permanent products. Conclusions: Filler migration distant from the injection site can occur even several years after the primary treatment. All filler types can be involved. Permanent fillers bear a higher risk of very late filler migration. Migration of permanent fillers needs surgical treatment, while HA fillers respond to hyaluronidase injec-tions. Detailed knowledge of facial anatomy, safer injection techniques, and filler qualities are preventive measures.
... Heydenrych et al. (2021) developed a 10-point algorithm to increase patient safety with HAF injection. The included (1) patient's medical history, (2) assessment (ethnicity, gender, and beauty), (3) consent, (4) product reversibility, (5) product characteristics (i.e., HA concentration, crosslinking, and G'), (6) product layering, (7) photo-documentation, (8) procedural planning and aseptic technique, (9) anatomy of injections, and (10) technical knowledge [87]. ...
Background: Hyaluronic acid fillers (HAF) are a versatile tool in esthetic medicine. They also have a potential for medical indications including facial rehabilitation. Materials and methods: We performed a literature search on PUBMED and Google Scholar until December 2022. Clinical trials, clinical studies, review articles, systematic reviews, meta-analyses, case series, and case reports were considered for review. Keywords “facial rehabilitation”, “acne scars”, “traumatic scars”, “oral restoration”, “facial lipoatrophy”, “facial asymmetry”, “periocular correction”, “nasal obstruction”, “ear lobe restoration”, “morphea”, AND “hyaluronic acid filler” were used to select articles. Results: We prepared a narrative review on the use of HAF for correction of facial asymmetry and asymmetric lips, improvement of different types of scars, improvement of the jaw line, improvement of ear lobes, periocular and oral restoration, and the treatment of nasal obstruction and morphea en coub de sabre. The amount of HA used in these indications is often less than 1 mL. The bolus technique, fanning, and dual-plane injections can be utilized for treatment. Duration of clinical effects depends upon the anatomical region and is usually maintained between 2 months and 2 years. Adverse events are often mild and temporary. Vascular occlusion is a severe adverse event, but it has not been reported yet for these medical indications. Repeated injections are recommended to obtain a longer-lasting improvement. In cases of morphea, only stable and non-inflammatory plaques should be treated. The advantage of HAF compared to permanent and semipermanent fillers is the availability of hyaluronidase for rapid removal of filler material and to revise overcorrection. Conclusions: HAF play an auxiliary role in facial rehabilitation. Knowledge of filler qualities, anatomy, and underlying diagnoses is important for their safe application. More prospective controlled trials are necessary to improve evidence.
... Overall, there is no accepted universal protocol for the use of hyaluronidase in management of vascular complications caused by HA injections. Localised injections of 500-1500 units of hyaluronidase with hourly intervals as soon as vascular occlusion is detected has been suggested [8,79]. It appears that lower doses (150-300 units), delayed injection, or localised infiltration of hyaluronidase [16,57] are less effective in management of vascular complications compared to intra-arterial injections of higher doses (1500 units) of hyaluronidase [16]. ...
... Heydenrych et. al. [79] recommended an intralesional injections of 4-40 IU per 0.1 mL of injected HA filler [79]. This all bears similarity to the findings of the 5 reviewed RCTs in this systemic review, which was 1.25-37.5 units of hyaluronidase (single injections) per 0.1 mL of injected HA filler. ...
... Heydenrych et. al. [79] recommended an intralesional injections of 4-40 IU per 0.1 mL of injected HA filler [79]. This all bears similarity to the findings of the 5 reviewed RCTs in this systemic review, which was 1.25-37.5 units of hyaluronidase (single injections) per 0.1 mL of injected HA filler. ...
Background
Hyaluronidase is used as an adjunct or main treatment to manage complications associated with cosmetic hyaluronic acid (HA) filler injections such as necrosis, blindness, hypersensitivity, delayed nodules, and poor aesthetic outcomes.
Objective
To systematically map the available evidence and identify the gaps in knowledge on the effectiveness of hyaluronidase use in managing the aesthetic complications associated with HA injections (vascular occlusion, blindness, nodules, delayed hypersensivity, granuloma, poor aesthetic outcome).
Methods
PubMed, Medline, Embase and Cochrane databases were used up to May 2022, to look for randomized clinical trials (RCTs), clinical trials, and retrospective case-control studies reporting on the use of hyaluronidase for managing the HA filler injection complications.
Results
The database search yielded 395 studies; of those 5 RCTs (all carried out in the USA) were selected (53 subjects), indicating the effectiveness of hyaluronidase for removal of un-complicated injected HA nodules (forearm, upper arm, or back skin). The follow-ups ranged from 14 days to 4 years. The amount of HA filler injected into each site varied from 0.2 to 0.4 mL. A dose dependent response was observed for most HA fillers. No major adverse reactions were reported. Overall, for removal of every 0.1 mL of HA filler they injected 1.25–37.5 units of hyaluronidase (single injections). When 3 consecutive weekly hyaluronidase injection was used much lower doses of 0.375–2.25 unit was utilised. There was no evidence in a form of RCTs, clinical trials, and retrospective case-control studies on the removal/reversal of HA injections in the facial skin, or management of over-corrections, inflammatory nodules, or tissue ischemia/necrosis associated with HA filler injection.
Conclusion
Based on studies on the forearm, upper arm and back skin, hyaluronidase can be used for the reversal of uncomplicated HA filler injection nodule. However, further adequately powered studies are warranted to establish the ideal treatment protocol/dose of hyaluronidase for reversal of HA filler injections in the facial region or management of complications associated with aesthetic HA injection.
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 .
... The global demand for dermal filler placement necessitates a focus on patient safety. The recently updated 10-point plan for procedural safety in soft tissue filler treatments provides treating physicians with methodical strategy for avoiding and managing adverse reaction (Heydenrych et al. 2021). Patients should be well versed of their responsibility to disclose information of filler placement should a soft tissue reaction develop. ...
Background
Cosmetic dermal fillers are a sought-after procedure globally. However, despite the safety claims of filler materials by the manufacturers, adverse reactions still occur.
Case presentation
This case report is of a 66-year-old female who presented with a late-onset complication of a hyaluronic acid dermal filler that clinically mimicked a salivary gland neoplasm. The patient presented with firm peri-oral swellings of short duration that clinically mimicked a pleomorphic adenoma and mucoepidermoid carcinoma. The diagnosis was that of a foreign-body granulomatous response to dermal fillers. Although other mimics of a similar nature are reported a knowledgeable clinician, careful choice of filler material, knowledge of the product, thorough pre-procedural history taking and post-procedural patient follow-up can drastically minimize a possible misdiagnosis. The reaction was treated with a combination of hyaluronidase, betamethasone and 5-flurouracil intra-lesional injections monthly for 11 consecutive months, with total clinical resolution.
Conclusions
Patient education of the procedure, product name and the possibility of an adverse reaction occurring, even years later or at a site distant to the initial site of placement, is vital. Further, we review the recent reported adverse association of the new mRNA COVID-19 vaccines and dermal filler placement.
