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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 "DANGEROUS ZONES: TIPS&TRICK PER EVITARE COMPLICANZE VASCOLARI NELLE DIVERSE AREE ANATOMICHE". I Soci Agorà avranno inoltre la possibilità di scaricare gli articoli originali in versione integrale.



Neurological Research and Practice

2022 July; 4(1):40

PMID: 35850779

PMCID: PMC9290300

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

Alexandra Lucaciu, Patrick Felix Samp, Elke Hattingen, Roxane-Isabelle Kestner, Petra Davidova, Thomas Kohnen, Jasmin Rudolph, Andreas Dietz, Helmuth Steinmetz, Adam Strzelczyk

BACKGROUND: The ongoing expansion of the cosmetic armamentarium of facial rejuvenation fails to uncover the inherent risks of cosmetic interventions. Informed consent to all risks of cosmetic filler injections and potential sequelae, including ocular and neurological complications, should be carefully ensured. We present two cases of complications following facial hyaluronic acid filler injections.

CASE PRESENTATIONS: Case 1: A 43-year-old woman presented with monocular vision loss of the left eye, associated ptosis, ophthalmoplegia, periocular pain and nausea, cutaneous changes of the glabella region and forehead, and sensory impairment in the left maxillary branch dermatome (V2) after receiving a hyaluronic acid (HA) filler injection into the left glabellar area. On ophthalmological examination, an ophthalmic artery occlusion (OAO) was diagnosed upon identification of a "cherry-red spot". Magnetic resonance imaging (MRI) revealed a left ischemic optic neuropathy. Supportive therapy and hyaluronidase injections were initiated. A follow-up MRI of the head performed two months after presentation corresponded to stable MRI findings. The patient had irreversible and complete vision loss of the left eye, however, the ptosis resolved. Case 2: A 29-year-old woman was admitted to hospital a few hours after a rhinoplasty and cheek augmentation with hyaluronic acid, presenting with acute monocular vision loss in the right eye, retrobulbar pain, fatigue and vomiting. In addition, the patient presented a harbinger of impending skin necrosis and a complete oculomotor nerve palsy on the right side, choroidal ischemia and vision impairment. Supportive treatment and hyaluronidase injections into the ischemic tissue were initiated. A small scar at the tip of the nose, vision impairment and an irregular pupillary margin on the right side persisted at follow-up.

CONCLUSION: These two case reports and the literature review emphasize the pathophysiological mechanisms leading to potentially devastating complications. In order to reduce the risk of vision loss secondary to cosmetic filler injections, practitioners should possess a thorough knowledge of anatomy and preventive strategies.

Journal of Cosmetic Dermatology

2021 May; 20(5):1532-1540

PMID: 33615645

The clinical spectrum of periorbital vascular complications after facial injection

Ko-Eun Lee, Gye-Jung Kim, Ho-Seok Sa

BACKGROUND: Serious complications due to periorbital vascular occlusion can occur after facial injections, including skin necrosis, ophthalmoplegia, blepharoptosis, and visual loss. Visual loss after facial filler injection is particularly rare, but it is known to have a poor prognosis despite treatment.

AIMS: This study aimed to describe the prognosis and various clinical features of periorbital vascular complications after facial injection of cosmetic filler or local anesthetic.

PATIENTS/METHODS: This single-center retrospective study included 10 consecutive patients who presented with occluded periorbital vessels after facial injection.

RESULTS: Nine patients were injected with cosmetic facial fillers: seven with hyaluronic acid, one with collagen, and one with poly-Llactic acid. The other patient was injected with lidocaine mixed with epinephrine. Injection sites included the glabella (n = 5), nasal dorsum (n = 4), and temporal fossa (n = 1). Presumed arteries affected included the central (n = 2) or branch (n = 3) retinal artery, ophthalmic artery (n = 4), and angular artery (n = 1). Nine patients (90%) had purpura and blisters, and eight patients (80%) had ophthalmoplegia at presentation, but all of them recovered within 3 months. Six patients (60%) were blind at the last follow-up, and five of them had occlusion of the central retinal artery or ophthalmic artery. There was a patient with sequelae of phthisis bulbi, which was cosmetically managed with retrobulbar filler injections.

CONCLUSION: Facial injections can cause periorbital arterial occlusion, and the clinical features are diverse according to the site and extent of vascular occlusion and injection materials. Visual prognosis was associated with the site of vascular occlusion and initial visual acuity. Other common complications, such as skin lesions, blepharoptosis, and limited extraocular movement, can fully resolve only with supportive treatments in most cases.


2019 December; 235(2):156-163

PMID: 30650420

Influence of the topographic vascular distribution of the face on dermal filler accidents

Maria Angustias Palomar-Gallego, Francisco Gòmez-Esquer, Stella Maris Gòmez-Sànchez, Gema Dìaz-Gil, Rafael Linares Garcìa-Valdecasas

OBJECTIVE: Dermal fillers are an important tool in the field of aesthetic dermatology. Fillers are relatively noninvasive and easy to use but are not free of secondary complications. The main complications are vascular and are due to either the compression of an artery or the direct introduction of the product into the arterial lumen. The aim of this study is to provide an overview of the vascular territories of the face to avoid many possible complications when using facial fillings. Anatomical localization of the main arterial supply to the face has been described to assess the risk of vascular injury.

METHODS: The authors dissected 17 hemifaces of embalmed adult cadavers that had previously been injected, through the common carotid artery, with latex containing a red dye.

RESULTS: A topographic distribution was generated by facial regions following a clinical approach from where the facial fillings were placed and related to the pathways of the arteries. Following these criteria, we established 8 topographic regions (I-VIII) that indicate the main vascular problems of each of these regions. Detailed anatomical localizations of the main arteries in these topographic regions of the face and their relationships are described.

CONCLUSIONS: The highest index of vascular lesions and especially visual alterations occurred for fillings of the upper third of the face. To prevent and avoid this type of lesion, it is advisable to avoid, as much as possible, treatments with filling materials in the upper third of the face, mainly including the glabellar and nasal region (III) and supraorbital region (VIII).

Journal of Cosmetic and Laser Therapy

2020 July; 22(5):171-173

PMID: 33709866

Specific complications associated with non-surgical rhinoplasty

Tuyet A. Nguyen, Shivani Reddy, Nima Gharavi

ABSTRACT: Non-surgical rhinoplasty is becoming an increasingly common procedure to alter the appearance and cosmesis of the nose. Although rare, complications with this procedure do exist, some of which can be devastating. Major complications include infection, vascular compromise, skin necrosis, and blindness. Here we discuss the nasal anatomy, complications associated with non-surgical rhinoplasty, and techniques to prevent these complications.

Journal of Cosmetic Dermatology

2018 August; 17(4):637-642

PMID: 30058278

Topography of the dorsal nasal artery and its clinical implications for augmentation of the dorsum of the nose

Da-Yae Choi, Jung-Hee Bae, Kwan-Hyun Youn, Wooram Kim, Atchima Suwanchinda, Tansatit Tanvaa, Hee-Jin Kim

BACKGROUND: Injections of filler into the nose for dorsum augmentation have a higher risk of complications due to the complicated blood supply and anastomotic channels in this area.

OBJECTIVES: The aim of this study was to determine the anatomical features and location of the dorsal nasal artery (DNA), and to provide clinical anatomical information to reduce side effects and severe complications in the perinasal area.

METHODS: Using the 31 cadaveric noses in Asians, dissections and histologic examinations were performed to identify the location and depth of the vascular structures including DNA.

RESULTS: Dorsal nasal artery ran downward at 20.3 ± 3.5 mm from the intercanthal line and the communicating branch that connected the bilateral DNAs was located 8.5 ± 3.5 mm inferior to the intercanthal line. The DNA was located at 4.4 ± 3.2 mm, 4.6 ± 4.4 mm, and 5.2 ± 4.4 mm lateral to the midline of the nose on the intercanthal, quadrisected, and bisected lines, respectively. At the level of nasal bone, DNA was located superficial to the muscular layer and it runs inferolaterally on dorsum on nose. It was running more deeply and located beneath the fibromuscular layer at the cartilaginous portion of the dorsum of nose.

CONCLUSIONS: Injection into deep fatty layer may reduce the risk of arterial injury and the consequent complications. However, in a hooked nose, the tip of the needle traveling along the deep layer approaches the superficial layer due to the convexity of the hump as it passes over it, which can increase the probability of damaging the DNA.

Dermatologic Surgery

2020 May; 46(5):678-684

PMID: 31403539

Lumen diameter and associated anatomy of the superior labial artery with a clinical application to dermal filler injection

Silas M. Money, Weston B. Wall, Loretta S. Davis, Anna C. Edmondson

BACKGROUND: Vascular compromise and subsequent tissue necrosis is a rare but disfiguring complication of dermal filler injection that frequently occurs in regions of the lip and nasolabial fold supplied by the superior labial artery (SLA).

OBJECTIVE: The purpose of this study was to examine lumen diameter and other anatomical features of the SLA relevant to dermal filler injection in the clinical setting.

MATERIALS AND METHODS: Eighteen adult cadavers were dissected. Detailed measurements of the SLA were taken at predetermined points along its course.

RESULTS: Lumen diameter of the SLA was largest at the labial commissure (0.85 ± 0.34 mm; Point P1) and smallest at the midline (0.56 ± 0.21 mm; Point P4). The deepest mean cutaneous depth of the SLA was at its branch point from the facial artery (5.49 ± 1.95 mm; SLA branch point), whereas the most superficial mean cutaneous depth was at the midpoint between the labial commissure and peak of Cupid's bow (4.29 ± 1.54 mm; Point P2).

CONCLUSION: The variable, superficial course of the SLA and its large caliber place it at significant risk for intra-arterial injection with dermal filler at all points along its course.

Aesthetic Surgery Journal

2021 May; 41(6):NP486-NP492

PMID: 32505134

A safer doppler ultrasound-guided method for nasolabial fold correction with hyaluronic acid filler

Won Lee, Ji-Soo Kim, Hyoung-Jin Moon, Eun-Jung Yang

BACKGROUND: Injection of hyaluronic acid filler, a common procedure for nasolabial fold correction, poses a risk of vascular compromise, which can result in skin necrosis and blindness.

OBJECTIVES: The aim of this study was to examine the facial arterial pathway in real time by Doppler ultrasound to avoid arterial complications during filler injections.

METHODS: The facial artery pathway of 40 patients (80 nasolabial folds; 2 men and 38 women; mean age, 46.5 years; range, 28-72 years) was examined by Doppler ultrasound before hyaluronic acid filler injection. On the basis of this ultrasound evaluation, the filler injection targeted the subdermal, subcutaneous, and deep to submuscular layers by bypassing the facial artery. The efficacy of the filler injection was evaluated for each patient.

RESULTS: The facial artery was detected lateral to the nasolabial fold in 31% of patients; it was detected beneath the nasolabial fold in the other patients as follows: subdermal layer, 13%; subcutaneous layer, 29%; muscular layer, 24%; and submuscular layer, 4%. The mean [standard deviation] Wrinkle Severity Rating Scale score was 3.68 [0.76] before injection and 2.28 [0.78] at 3 months after injection. Two patients experienced unilateral bruising of the nasolabial fold, which resolved after 2 weeks without treatment.

CONCLUSIONS: Doppler ultrasound can be considered as pretreatment tool for the prevention of vascular complications during filler injections to correct nasolabial folds.

BioMed Research International

2022 May; 26:3790546

PMID: 35663046

PMCID: PMC9162877

The superficial temporal artery and zygomatico-orbital artery: superficial arterial distribution of the anterior temple area

Hyung Jin Park, Ji-Hyun Lee, Wonsung Jung

ABSTRACT: A hollow temple may give rise to a false impression of early facial aging. This is corrected with dermal fillers that are injected into the hollow temple area to produce a smoother facial contour. However, various complications of this procedure have been reported, with the most common being the inadvertent injection of the filler material into the superficial temporal artery (STA). The aim of this study was to investigate the topographic anatomy of the STA and zygomatico-orbital artery (ZOA) to provide essential anatomical information to aid in various clinical procedures involving the temporal region. The superficial arterial distribution of the temple area was studied in 43 hemisectioned Korean cadavers. The courses of the STA and ZOA were identified and classified based on the line connecting the tragus and the superciliary arch (TR-SA line). The ZOA was present in 85.2% of cases and bifurcated from the frontal branch of the STA, after which it ran along the TR-SA line. In this study, the STA pattern was classified into a typical pattern where the ZOA coexists with the STA and a lower pattern where the ZOA was absent. The current findings suggested that the ZOA ran close to the TR-SA line. Therefore, to minimize vascular complications during invasive procedures, injection into this area should be avoided. In addition, clinicians should verify the existence of ZOA and the course of STA before performing various clinical procedures.


2021 January; 13(1):e12929

PMID: 33654610

PMCID: PMC7910224

Lymphangioma formation following hyaluronic acid injection for lip augmentation

James Wege, Mohammed Anabtawi, Mike A. Blackwell, Alan Patterson

ABSTRACT: Administration of hyaluronic acid (HA) filler for aesthetic lip augmentation is a routine and common procedure with a low rate of adverse reactions. This case report documents an extremely rare complication of lip augmentation with HA leading to the development of lymphangiomas. Lymphangiomas are uncommon hamartomas of the lymphatic system. Although usually congenital, they can be acquired due to trauma, inflammation, or lymphatic blockage. They may be in the deep or superficial tissues, with superficial forms being either lymphangioma circumscriptum or acquired lymphangioma, also referred to as lymphangiectasia. Acquired lymphangiomas are typically formed by blockage of lymphatic drainage leading to dilation of the lymphatic channels. The diagnosis in our case report is acquired lymphangioma. A 27-year-old female presented with a two-year history of linear swellings in her upper lip. These lumps followed the line where HA filler had been injected four years earlier. Hyaluronidase had previously been used unsuccessfully to remove these lumps. The patient was treated with surgery to excise the lesions. Five masses were excised, and histopathological analysis displayed the presence of variably ectatic lacunae, lined by cells with CD34 expression, a lymph-vascular-endothelial marker. There were also scattered macrophages with CD68 expression in the interstices. These are typical features of a lymphangioma. The patient was satisfied with the excellent aesthetic and functional outcome. To our knowledge this is the first case of a lymphangioma following HA lip augmentation. Although rare, this complication can have aesthetic implications for the patient which may require further treatment or surgery to correct.

Journal of Cosmetic Dermatology

2018 October; 17(5):712-718

PMID: 30006992

Severe vision loss caused by cosmetic filler augmentation: case series with review of cause and therapy

Wilai Thanasarnaksorn, Sebastian Cotofana, Christina Rudolph, Patcharahatai Kraisak, Nongsak Chanasumon, Atchima Suwanchinda

ABSTRACT: Hyaluronic acid (HA) injection is a popular nonsurgical, facial rejuvenating procedure. Due to the rapidly expanding use of HA injections, significant potential complications have also increased in frequency. Among these complications, the rare but most devastating one is arterial occlusion, which can result in skin necrosis or blindness. To describe the mechanisms behind vision loss secondary to hyaluronic acid injection and the efficacy of treatments to restore vision and associated ocular functionality. We reviewed six cases of patients from October 2011 to December 2017 who experienced vision loss after receiving facial HA injections and the subsequent treatments undertaken to attempt to reverse the vision loss and additional eye complications. Of the six patients, four received nose, one received forehead, and another one received temple injections. All six patients developed vision loss secondary to hyaluronic acid embolization in retinal or ophthalmic arteries. Additional complications included severe periorbital pain, ptosis, impairment of extraocular muscle functionality. Recovery of vision was dependent on the type, frequency, and duration of subsequent treatment. Vision loss is a rare but catastrophic complication caused by hyaluronic injection that occurs secondary to hyaluronic acid embolization in retinal or ophthalmic arteries due to retrograde flow from facial vascular anastomoses. We suggest the early supratrochlear/supraorbital hyaluronidase injection, ocular massage, and re-breathing into a plastic bag as safe, uncomplicated and effective methods to restore the retinal circulation and reverse vision loss.



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