26 HOW TO TREAT : HYALURONIC ACID TISSUE FILLERS
26 HOW TO TREAT : HYALURONIC ACID TISSUE FILLERS
2 JUNE 2023 ausdoc . com . au
PAGE 24 of both facial anatomy and aesthetics . Exaggeration of features beyond aesthetic norms appears to be common : overfilled cheeks and lips are the most prominent examples , but almost any feature is at risk of this phenomenon .
Compounding the common issue of body dysmorphia is the practitioner distorting the patient ’ s treatment choices . Social media and celebrity influence , and the resultant peer pressure , are unfortunate , with many just copying what they see and their practitioner willing to accommodate these exaggerations .
CASE STUDIES
Case study one
ABIGAIL , in her late 20s , underwent filler injection in various parts of her face , including the nasolabial fold , by an injecting nurse . She was eventually referred to the author ’ s clinic some nine days after injection .
She reports there was pain at the time of injection and mild pain after she went home . No other treatments were performed other than the tissue filler injection .
On day two , Abigail developed tissue erythema and blotchy discolouration in the right upper lip , on both sides of the nose and in the glabella region . Pustules and scabbing followed on the right upper lip and the nasolabial fold on days three and four . She was initially advised that the colour changes were normal but was then diagnosed with a bacterial and then herpetic infection . At no stage was consideration given to the possibility of intravascular injection of tissue filler . She then sought assistance from the filler company , which referred her to the author ’ s clinic . On presentation , there is a livedoid appearance , suggesting vascular ischaemia , involving the entire nose , right upper lip , right nasolabial fold , right medial cheek and glabella ( see figure 8 ).
Despite the fact it is day nine following injection , it is still thought that most of the tissue , although compromised and worsening , can be salvaged . High-dose hyaluronidase — in the order of 500 units per cosmetic region ( four cosmetic regions were identified : nose , right upper lip , right cheek and glabella ) — is administered . This is repeated on the day and the following day . The obviously compromised area is infiltrated , as well as the truncal feeding vessels , such as the facial , superior labial and lateral nasal ,
How to Treat Quiz .
1 . Which ONE statement best describes HA ? a A permanent filler . b A non-autologous filler . c A protein . d A biostimulatory filler .
2 . Which THREE statements regarding tissue fillers are correct ? a Tissue fillers may be divided into autologous and non-autologous agents . b Fat may be enhanced as a filling agent by using fat-derived stem cells or collagen . c Permanent fillers are prone to complications that can be difficult to treat . d Collagen fillers have been largely superseded by HA .
3 . Which TWO statements regarding HA are correct ? a Initially comprises HMWHA . b Eventually degrades and excites toll-like receptors . c When injected , is intensely immunoreactive . d HA is an inert substance .
4 . Which TWO statements regarding injected HA are correct ?
Figure 10 . Patient with a recent history of gastroenteritis and consequent filler reaction .
and supratrochlear arteries ; this is because hyaluronidase can cross arterial walls to dissolve implanted hyaluronic acid .
Vascular reflux time improves over subsequent days . Gradually everywhere but a small area in the nasolabial fold heals adequately . This responds well to several microneedling sessions and leaves only mild textural change .
Without intervention , widespread tissue breakdown can be expected . It is fortunate that Abigail did not experience embolisation to the eye or brain . The dorsal nasal vessels and the supratrochlear vessels that were impacted are end arteries of the ophthalmic system and have ready access to the central retinal artery ,
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a Acts as rigid support when injected superficially . b Has viscoelastic properties . c Is always best injected with needles . d Moves with the muscles of expression when injected superficially .
5 . Which ONE is NOT a role played by the masticatory muscles ? a Gender dimorphism . b Attractiveness . c Aiding in expressions . d Age determination .
6 . Which THREE are indications for HA fillers ? a Correction of pigmentation abnormalities . b Correction of volume deficiency . c Alteration or enhancement of gender dimorphism . d Superficial skin rejuvenation .
7 . Which THREE statements regarding intravascular injection of filler are correct ? a A substantial amount of filler injected into a vessel may lead to a thrombotic embolism . b Bruising following HA injections is usually minor . c Early and immediate treatment with hyaluronidase may prevent infarction and tissue loss . d The first sign of intravascular injection is a flash of pallor or livedo .
8 . Which TWO statements regarding visual disturbance following injection of filler are correct ? a Visual problems with filler are an extension of the complication of vascular embolism . b Stroke is more common than visual loss following filler injection . c Visual disturbance may also
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HYALURONIC ACID TISSUE FILLERS
ciliary vessels and , beyond this , the internal carotid vessels .
Case study two
Nicola , generally well and healthy , presents to the author ’ s clinic with significant left-sided facial tissue swelling . She has a history of an uneventful injection of hyaluronic acid into her cheeks nine months earlier . Nicola has been relatively well since then , reporting only a significant bout of gastroenteritis 48 hours before presentation .
On waking that morning , she was pain free but had sufficient swelling to prevent her from opening her left eye , which made visual examination impossible .
On examination , she appears well and not toxic , afebrile and her face is
be accompanied by stroke . d Injections to the masseter and temporalis carry a higher risk .
9 . Which THREE statements are correct ? a Misplacement of filler may be seen years after the initial injection . b Delayed inflammatory nodules may arise following vaccination . c Decay is particularly fast in the periorbital area . d Delayed inflammatory nodules are variably difficult to resolve .
10 . Which THREE statements regarding HA fillers are correct ? a Delayed inflammatory nodules may occur weeks , months or years after product implantation . b Exaggeration of features beyond aesthetic norms appears to be rare . c Practitioners are willing to accommodate exaggerated features . d Overfilled cheeks and lips are the most prominent examples of exaggerated features . not tender . The left check and periorbital area have obvious objective swelling . The right side of her face is objectively normal . The differential diagnoses considered are extreme tissue nodule reaction , the beginnings of an anaphylactic reaction or orbital cellulitis .
Nicola is immediately referred for urgent imaging and hospital admission . MRI reveals subcutaneous swelling on both cheeks , with the left side more severe than the right .
The working diagnosis is infection of the tissue filler by a bacteraemia invoked by the gastroenteritis , and broad-spectrum IV antibiotics are initiated . Over the next week , Nicola gradually improves back to baseline . The filler is not removed at her request because she has “ returned to normal ”. No additional treatment is required ( see figure 10 ). The delay between initial treatment and reaction was instrumental in this complication as the HMWHA gave way to more inflammatory LMWHA . This transformation takes time and sets up the environment for attachment of circulating pathogens and induction of intense inflammation .
Under the influence of native hyaluronidases and reactive oxygen species , her initial HMWHA had probably degraded on the outer rim to LMWHA . This new environment is a pro-inflammatory one ; a significant reaction was induced when the surface of the filler was seeded by a virulent bacteraemia from the gastroenteritis .
CONCLUSION
DESPITE modern tissue fillers being a much safer technology than previous products , these still carry associated risks . There is still the requirement for adequate training in facial anatomy , injection techniques , filler characteristics and the need to develop an understanding of aesthetics .
The practitioner ’ s role is to understand what the patient wants to accomplish , what has been treated and how and , most importantly , to be able to help when things do not go to plan .
There are many nuances involved in the best use of these materials , and practitioners require an understanding of what to do when things do not go to plan . We are fortunate in that there is an off-label antidote to many of the complications of hyaluronic acid .
References Available on request from howtotreat @ adg . com . au