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Quest’anno Agorà, con l’obiettivo della ricerca di un costante miglioramento e progresso scientifico, ha voluto approfondire la bibliografia di riferimento per le tematiche delle Sessioni Coordinate e metterle disposizione dei partecipanti alla Sessione in Sede Congressuale.

In questa pagina troverete a disposizione gli abstract degli articoli che Agorà ha selezionato come bibliografia di riferimento per la sessione coordinata "MANUALE D'USO DELLA IALURONIDASI NELLA GESTIONE DELLE COMPLICANZE NELLE AREE DELICATE: OCCHI E LABBRA". I Soci Agorà avranno inoltre la possibilità di scaricare gli articoli originali in versione integrale.



Journal of Clinical and Aesthetic Dermatology

2021 August; 14(8):E69-E75

PMID: 34840662

PMCID: PMC8570661

Guideline for the safe use of hyaluronidase in Aesthetic Medicine, including modified high-dose protocol

Gillian Murray, Cormac Convery, Lee Walker, Emma Davies

ABSTRACT: Vascular occlusions can occur with injection of dermal fillers, causing devastating outcomes for the patient. Hyaluronidase is an enzyme that was first used in general medicine in 1949, but has gained widespread use in aesthetic medicine to dissolve hyaluronic acid (HA)-based dermal fillers. Knowledge of this drug and its use for other aesthetic indications is evolving, and there is often anxiety attached to the administration of animal-derived product due to fears of an allergic reaction. This paper provides guidance on the indications for use when dissolving HA filler with hyaluronidase. It discusses formulation differences, adverse events, allergy to wasp and bee stings, and how this increases risk of allergy to hyaluronidase. It also discusses incidence of allergy, which includes a discussion of types of allergic response and how this correlates to skin tests and a discussion on skin testing for allergy.

Dermatologic Therapy

2020 November; 33(6):e14285

PMCID: 329020108

Facial vascular danger zones for filler injections

Uwe Wollina, Alberto Goldman

ABSTRACT: Filler injections are widely used for facial rejuvenation. The technique is safe as long as some precautions are respected. In this review we will focus on vascular anatomy in the upper, middle and lower face. We performed a PUBMED research on "facial danger zones" and "filler injections" and "hyaluronic acid" and "vascular compromise" with a focus on the last decade. This is of particular importance since vascular compromise is one of the most severe adverse events possibly leading to tissue necrosis and in rare cases to loss of vision. We describe the danger zones in these esthetic units and provide recommendations how to avoid severe adverse events. We report on temporal region, glabella and nose, infraorbital region, nasolabial folds and nasal triangle, lips, and chin. Although we focus on hyaluronic acid fillers, our recommendations will also scope other filler types and autologous adipose tissue transfer. We also take a closer look on innovations to improve the safety of facial filler injections. Facial rejuvenation with hyaluronic acid fillers is a popular method. It is safe if the facial danger zones are recognized and proper injection techniques and fillers are used.

Aesthetic Surgery Journal

2021 October; 41(11):NP1621-NP1632

PMCID: 33954581

A guide to doppler ultrasound analysis of the face in cosmetic medicine. Part 1: Standard positions

Peter J Velthuis, Oscar Jansen, Leonie W Schelke, Hyoungjin J Moon, Jonathan Kadouch, Benjamin Ascher, Sebastian Cotofana

ABSTRACT: Interest in Doppler ultrasound (DUS) analysis of the face has grown in cosmetic medicine, in particular for injectable fillers. When dealing with complications, DUS has the advantage of easily visualizing the filler and identifying the problem in relation to the patient's anatomy. When working with hyaluronic acid filler, ultrasound-guided injections with hyaluronidase can precisely target the problem. In addition, DUS can be used to study the anatomy of a patient, specifically to prevent intravascular injections. We predict that in a few years' time DUS will become standard equipment in the offices of cosmetic doctors. We discuss the basics of ultrasound imaging of different tissues with the concomitant terminology. With the use of 7 basic DUS probe positions, key anatomic reference points can be easily found. From these, all relevant anatomic structures in the face can be observed and analyzed. With some practice, physicians will ultimately be able to acquire a complete 3-dimensional mental image of a patient's face.

Journal of Cosmetic Dermatology

2020 December; 19(12):3453-3455

PMCID: 32979892

Multiple oral granulomatous nodules to hyaluronic acid filler

Carmen Caldas Pozuelo, Julia Domìniguez De Dios, Xenia Mota Rojas

ABSTRACT: A 74-year-old Caucasian woman presented with a 2-week history of multiple nodules in both lips and perioral region that caused her mild discomfort while eating. The patient reported hyaluronic acid infiltration on both lips 5 months prior to presentation. The examination revealed multiple, well-defined, millimetric, and firm nodules on both lips and oral mucosa. An excisional biopsy of one of the nodules was performed under local anesthesia. Histopathological analysis demonstrated acute eosinophilic inflammation, fibrosis, and granulomas on mucoid material, positive for colloidal iron stain and Alcian blue stain, alongside a minor salivary gland showed mild atrophy, fibrosis, and fat infiltration. Enhancement of the aged lip using hyaluronic acid, to restore the bulkiness and elasticity that have been lost with age, is very common. Nevertheless, soft tissue fillers are used in a wide age range. Hyaluronic acid represents 78% of the dermal filler injections in the United States, been the second most popular nonsurgical cosmetic procedure after botulinum toxin injection. Foreign body granulomatous reaction is a rare delayed complication that has been well documented elsewhere and it has been associated with poor injection technique. Although it also has been related to hypersensitivity reactions that may be caused by impurities developed during the bacterial fermentation process, treatment of granulomatous reactions with hyaluronidase is recommended.

Aesthetic Plastic Surgery

2021 August; 45(4):1573-1578

PMCID: 33770216

An efficacy and safety study of intra-arterial recanalization of occluded ophthalmic arteries in patients with monocular blindness caused by injection of hyaluronic acid in facial tissues

Jianfeng Wang, Haiyang Shen, Tao Liu, Qian Li, Zhaoyang Lyu, Youtao Yu

PROPOSE: To evaluate the efficacy and safety of recanalizing hyaluronic acid-occluded retinal central artery by intra-arterially infusing hyaluronidase.

METHODS: Between December 2015 and December 2016, 30 patients with monocular blindness due to the injection of hyaluronic acid in facial tissue underwent ophthalmic artery recanalization. The outcome of the intra-arterial treatment was retrospectively reviewed. The fundus was examined 24 hours after the treatment to observe revisualization of the retinal arteries. The success rate of intra-arterial recanalization of the ophthalmic artery, procedure-related complications, visual acuity recovery, eyeball and eyelid movement restoration was followed up for up to 3 months.

RESULTS: The success rate of ophthalmic arterial catheterization was 100%. No interventional procedure-related adverse events were found. Twenty-six patients presented ptosis and 23 patients presented ocular motility disorders. The ptosis disappeared and 18 patients had normal eye movement after the intra-arterial therapy. Five of the 30 patients had visual improvement and four patients with complete vision loss gained some light perception. After the intra-arterial thrombolysis, digital subtraction angiographic imaging revealed enlarged and numerous branches of the ophthalmic artery and a clearer ring around the eye.

CONCLUSION: Intra-arterial infusion of hyaluronidase and mechanical recanalization is an effective and safe approach for recovering the visual acuity in the patients with monocular blindness caused by the migration of hyaluronic acid injected in the facial tissues.

Facial Plastic Surgery Clinics of North America

2021 May; 29(2):349-357

PMID: 33906766

Complications of periocular dermal fillers

Yao Wang, Guy Massry, John B Holds

ABSTRACT: Dermal fillers, in particular hyaluronic acid gel (HAG) fillers, are used in the treatment of aging changes in the periocular area. Filler treatment requires in-depth knowledge of specific issues relating to product performance and administration, safety protocols, and recognition and treatment of complications. There are different approaches to treatment of the tear trough. Prior filler treatment must be suspected in patients presenting for aesthetic evaluation, and the possibility of migration with a dysmorphic appearance and/or Tyndall effect appearance always is kept in mind. Treatment with hyaluronidase injection generally is effective in reducing overcorrection or migration of HAG in this area.

American Journal of Ophthalmology Case Reports

2022 February; 26:101407

PMID: 35243152

PMCID: PMC8858863

Ophthalmic artery occlusion after glabellar hyaluronic acid filler injection

Petra Davidova, Michael Muller, Yaroslava Wenner, Clara Konig, Ninel Kenikstul, Thomas Kohnen

PURPOSE: Filler injections for aesthetic purposes are very popular, but can have far-reaching and irreversible consequences. This report describes the course of a patient with devastating complications after glabellar hyaluronic acid injection, their pathomechanism, management and outcome.

OBSERVATIONS: A healthy, 43-year-old woman underwent her first hyaluronic acid injection in the glabella and went blind on her left eye immediately thereafter. Massaging of the injection area and observation were performed, before she presented with swelling of the left forehead and upper lid, ptosis, complete ophthalmoplegia and blindness in our hospital. Immediate massaging of the globe and systemic therapy including acetylsalicylic acid, tinzaparin sodium and cortisone was initiated and hyaluronidase injections in the injection area were performed. In the further course, the patient developed necrotic and hemorrhagic skin and mucosal lesions, lagophthalmos, anterior and posterior segment ischemia and globe hypotonia with consecutive globe deformation. In the follow-up of 2.5 months, lid swelling, lagophthalmos and ptosis resolved and keratopathy improved but blindness, skin lesions and strabismus with reduced eye motility were still present and madarosis and early enophthalmos were detected.

CONCLUSIONS AND IMPORTANCE: The outcome of ophthalmic artery occlusion after hyaluronic acid filler injection is poor. Sufficient knowledge about facial anatomy, the implementation of filler injections and the management of complications is essential for the practitioner. The patient should be clarified about potential and even rare risks of these procedures.

Journal of Cosmetic Dermatology

2021 October; 20(10):3205-3212

PMID: 33825341

PMCID: PMC8596545

Efficacy of intra-arterial thrombolytic therapy for vision loss resulting from hyaluronic acid filler embolization

Xiao Xu, Guiwen Zhou, Qiang Fu, Lixia Zhang, Youtao Yu, Ying Dong, Liming Liang, Minliang Chen

BACKGROUND: The incidence of hyaluronic acid (HA) embolism has increased markedly in recent years. HA embolism can lead to serious complications such as blindness, eye and eyelid movement disorders, skin necrosis, and cerebral embolism. However, there is a lack of robust clinical evidence regarding the benefits of treatment of HA embolism with intra-arterial thrombolytic therapy (IATT).

METHODS: In the present study, we enrolled 45 patients with decreased visual acuity, including 40 patients with symptoms of vision loss and eight patients with symptoms of intracranial embolism. The patients underwent emergency IATT via hyaluronidase and papaverine injections, followed by conventional sequential therapy.

RESULTS: In the 45 patients with symptoms of vision loss, 16 (36%) exhibited improvements in final visual acuity, even when the clinical application of the thrombolytic treatments was performed beyond the recommended window for optimal treatment. The facial skin necrosis of all patients was restored to near normal appearance. Notably, for eight patients with suspected symptoms of intracranial infarction we performed cerebral angiography and IATT, and in two patients obtained partial recanalization of the obstruction, the symptoms of heavy headache and binocular distension pain were improved in one patient with intracranial embolism after IATT treatment.

CONCLUSION: Our results indicate that IATT is feasible for patients with vision loss induced by HA embolism. IATT combined with conventional sequential therapy was beneficial in the recovery from other serious HA embolism complications. Nevertheless, the underlying pathophysiological mechanism needs to be clarified in future animal experiments.



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