24 HOW TO TREAT : HYALURONIC ACID TISSUE FILLERS
24 HOW TO TREAT : HYALURONIC ACID TISSUE FILLERS
2 JUNE 2023 ausdoc . com . au which may be complicated by tissue loss and scarring .
Treatment of intravascular injection of a filler is always hyaluronidase ; this should be administered when signs are first seen and multiple times until the vascular refill appears normalised . Early and immediate treatment with hyaluronidase may prevent infarction and tissue loss . If intravascular injection is not recognised , then tissue healing support — such as initial antibiotic ointments and , later , silicon gels , and in-clinic scar treatments — may need to be added to hyaluronidase as required . 34
Visual disturbance
Visual problems with fillers are an extension of the complication of vascular embolism . The prevailing theory is that filler injection overcomes the ophthalmic artery pressure and travels retrograde through the ophthalmic artery branches to reach the back of the eye , blocking the retinal or other vessels supplying the visual apparatus . 35 Visual disturbance may also be accompanied by stroke as the filler can travel past the retinal vessels and retrograde along the ophthalmic artery into the internal carotid artery . 35 , 36 This is very uncommon , with an incidence of about one in 100,000 syringes used for visual loss and fewer than that for stroke . 35
Once this intravascular incident has occurred — either visual disturbance or stroke — the race begins to save these structures . There is both limited time and treatment options . This is truly an emergency as the time for vision restoration is limited , and it often requires a multidisciplinary approach .
Hyaluronidase is the mainstay of therapy , and attempts have been made to bathe the embolism with intravascular , perivascular and retrobulbar techniques . 37 All these are variably effective , and preventive measures are more important , with injections to the nose , nasolabial fold , glabella and forehead thought to carry a much higher risk . 35
Misplacement of filler
Misplacement of filler may be seen years after the initial injection , and the patient may have forgotten about the injection . Sometimes the filler is simply injected suboptimally , resulting in the immediate development of nodules . Other times , the appearance is delayed , such as with injections under eyes — where the orbicularis oculi muscle brings the filler to the surface over time .
Although it is often said that hyaluronic acid fillers are temporary , only lasting a year or two , this is not accurate . Fillers degrade slowly , with gradual decay ; remnants often last several years and , in certain areas , such as the periorbital area , decay is particularly slow . These unwanted filler remnants may be dissolved , if necessary , with hyaluronidase ( see figure 9 ).
Delayed inflammatory nodules
This is a distressing complication that may occur weeks , months or
18 , 38 years after product implantation . Hyaluronic acid is an implant , and it may become inflamed because of the combination of implanted or haematogenous pathogens interacting with decaying and inflammatory LMWHA on the surface of the filler bolus and the patient ’ s immune surveillance ability .
These nodules may also arise
Figure 7 . A patient before and after hyaluronic acid fillers in the perioral and lip regions .
Figure 8 . A patient who has had an intravascular accident with embolisation of the facial artery and ophthalmic artery .
Figure 9 . A patient who has had hyaluronic acid excess under the eyes dissolved with injection of hyaluronidase .
during times of extreme heightened immune response , such as with viraemia or post vaccination ; the latter has been seen with COVID-19 vaccinations . 39 Nodules are variably difficult to resolve : some resolving with resolution of an interceding illness and some persisting despite multiple treatment initiatives ( see figure 10 ).
Exaggeration of features
All patients have the right to seek their desired health and wellbeing outcomes ; however , they may be swayed in the area of cosmesis . The optimal outcome can be hindered by aspects of body dysmorphia and further impacted by social media and peer and celebrity influences . Practitioners are required to have an understanding PAGE 26