Nontraumatic orbital hematoma secondary to labor and childbirth: a case report and review of the literature.

PURPOSE: Non-traumatic orbital hemorrhage without underlying vascular malformations or predisposing conditions is uncommon, and particularly rare in the context of maternal labor. This study combines a novel case report and retrospective review to analyze reported cases and propose insights. METHODS: This study is both a unique case report and literature review examining PubMed publications with articles traced back to original sources through citations for inclusion. Analysis included clinical presentation, visual examination, hematoma characteristics, neuroimaging, management strategies, and outcomes. RESULTS: We present a 37-year-old multigravida woman at 40 weeks gestation who developed acute right-sided proptosis, diplopia, retrobulbar pain, and periorbital edema during the second stage of labor. Computed tomography (CT) revealed a subperiosteal hemorrhage, with subsequent magnetic resonance imaging (MRI) excluding vascular anomalies. Symptoms resolved within two months. Only 14 cases of maternal orbital hematoma associated with labor have been reported. The average age was 28 with 42% (6/14) being primigravid. Including our case, forty percent (6/15) developed symptoms during the second stage of labor, 40% (6/15) immediately postpartum, and 20% (3/15) over 24 hours postpartum. Overall, 33% (5/15) had potentially contributing conditions including coagulopathies, delivery complications, or vascular malformations. Unilateral orbital hemorrhage occurred in 87% (13/15). Surgical intervention was necessary in 13% (2/15). Most (87%, 13/15) underwent observation or medical management with full recovery of symptoms. CONCLUSIONS: Non-traumatic orbital hematomas associated with maternal labor are rare and likely related to increased valsalva during delivery and heightened blood volume in pregnancy. Neuro-imaging and systemic workup are recommended to assess for vascular anomalies or underlying coagulopathies. The overall prognosis is favorable with most having full recovery.

Response of 21 Hyaluronic Acid Fillers to Recombinant Human Hyaluronidase.

Background: One benefit of hyaluronic acid fillers is the ability to dissolve them using hyaluronidase. With the increasing number of fillers entering the market, it is crucial to understand each of these fillers' responsiveness to hyaluronidase. Methods: Twenty-one hyaluronic acid fillers of 0.2 mL aliquots each were placed on slides. Twenty units of recombinant human hyaluronidase were injected into the aliquots every 30 minutes for a total of 120 units recombinant human hyaluronidase injected over 3 hours. With each injection, videos and photographs were taken from bird's eye and lateral views to measure aliquot height. Stirring videos were graded by three oculoplastic surgeons, and these grades were used to categorize each filler's responsiveness. Results: Restylane Lyft, Restylane-L/Eyelight, and Resilient Hyaluronic Acid (RHA) 1/Redensity were the least resistant. The moderately resistant group comprised of Restylane Silk, Juvéderm Volbella, Revanesse Versa/Lips, and Belotero Balance on the less resistant side to Juvéderm Vollure, RHA 2, Restylane Contour, Juvéderm Ultra, Restylane Refyne, Belotero Intense, Restylane Kysse, RHA 3, Juvéderm Ultra Plus, and Restylane Defyne on the more resistant side. The most resistant were RHA 4, Juvéderm Voluma, Belotero Volume, and Juvéderm Volux. The most resistant fillers required 120 units of hyaluronidase per 0.2 mL filler to dissolve. Conclusions: With the increasing popularity of fillers comes the increasing need to dissolve them for both ischemic and nonischemic complications. The majority of hyaluronic acid fillers available on the market are very resistant to hyaluronidase, which must be considered when determining the amount of hyaluronidase to dissolve a particular filler.

An Experimental Model Exhibiting Anterograde and Retrograde Vascular Occlusion of Facial Fillers to Avoid Vision Loss.

Background: Facial filler injection techniques that help decrease the risk of vascular occlusion are an important growing area of study. This study demonstrates a model of injecting fillers into a simulated bifurcated arterial system, using different sized needle gauges at a constant injection pressure. Methods: Three facial fillers were injected into a bifurcated intravenous tubing with continuous irrigation at a constant pressure to simulate a vascular system. Videography was used to observe for retrograde flow through the simulated supratrochlear artery to the bifurcation point, where the filler was redirected by anterograde flow into the branch representing the ophthalmic artery. Results: Filler injection with retrograde flow to the bifurcation occurred with all the 27G needle trials. In comparison, the 30G needle trials were only able to reach the bifurcation point in three of the nine trials. The average time to the bifurcation point with subsequent ophthalmic artery anterograde flow with the 27G and 30G needles were 8.44 (95% confidence interval ±2.06) and 33.33 (95% confidence interval ±16.56) seconds, respectively. Conclusions: Larger 27G needles consistently reached retrograde flow and the bifurcation point faster than 30G needles. This study suggests thinner needles may be less likely to cause retrograde occlusion.

Infraorbital Hollow Rejuvenation: Considerations, Complications, and the Contributions of Midface Volumization.

Infraorbital hollows are one of the most common target areas for facial aesthetic treatment; however, they are often perceived to be challenging to treat due to the complex anatomy of the periorbital area, concurrent deformities, and risk of complications. Treatment options include surgical (eg, lower eyelid blepharoplasty with fat transposition or injections) and nonsurgical approaches (eg, fillers). Among these approaches, filler injections have become common practice because they are minimally invasive and provide long-term patient satisfaction. In particular, hyaluronic acid (HA) fillers have been shown to be safe and effective for infraorbital hollow rejuvenation. This review provides an overview of infraorbital hollows, including periorbital anatomy, etiology, clinical assessment, and overlapping deformities, such as malar mounds, festoons, and dark circles under the eyes. Patient and HA filler product selection, injection techniques, as well as potential adverse events, such as bruising/swelling, lower eyelid and malar edema, and vascular occlusions, are discussed. This review also highlights the importance of midfacial volumization to improve outcomes in the infraorbital region and in the overall aesthetic appearance. By selecting appropriate patients and attaining proficiency in periorbital anatomy and infraorbital hollow rejuvenation techniques, clinicians can safely and successfully perform HA filler injections that result in high patient satisfaction.

How Much Does Filler Apparatus Influence Ease of Injection (and Hence, Potential Safety)?

PURPOSE: To document the relative contributions of intrinsic filler fluid dynamics versus delivery systems for ease of injection-specifically, to measure extrusion force variability across different syringes and needles (with the characterization of intrinsic rheological fluid properties vs. delivery apparatus contributions to ease of injection). METHODS: Six different fillers were tested: Belotero balance (Bel), Juvederm Voluma XC (Vol), Revanesse Versa (Rev), Restylane Lyft (Res), Radiesse (Rad), and Teosyal RHA3 (RHA). Extrusion force was measured in Newtons (N) for each by testing using the provided injection apparatus (needle + syringe), and also by standardizing all fillers to the same syringe and then varying needle sizes (30-ga, 27-ga, 25-ga/1.5-inch, 25-ga/2-inch, and 22-ga). Five trials were conducted for each scenario, with comparison via t -test (2-tailed, unpaired, assuming unequal variance). RESULTS: The following results were noted: (1) in order of least to highest extrusion force in box-provided syringe + needle at 0.2 ml volume, the following were noted: Vol < RHA = Bel (27-ga) < Bel (30-ga) < Rev < Res = Rad; (2) for each filler (except for Vol which was similar), the box-provided syringe involved greater extrusion force than the standardized syringe used in this study (each 1-cc, p < 0.05); (3) for 27-ga and 30-ga needles, after standardization of delivery syringe at 0.2 ml volume, a significant difference was noted (proportional to increasing resistance): Bel = Vol = RHA3 < Res < Rev < Rad (for needles of 30-ga [ p < 0.05] and 27-ga [ p < 0.01]); (4) for testing cannulas after standardization of syringes no reproducible order was noted with increasing resistance when using 25-ga/1.5-inch long, 25-ga/2-inch, and 22g/2-inch cannulae; and (5) confirming expectation (validating study technique), the extrusion force was significantly higher for smaller needles and longer needles. CONCLUSIONS: The delivery apparatus appeared to be the most influential contributor to filler injection extrusion force, with significant changes in ease of injection correlated to the filler's intrinsic rheological properties, such as viscosity (when standardized to the same syringe for needles tested). Knowledge of such data could influence the injector's ability to maximize patients' safety and clinical results.

Accuracy Assessment of Three-Dimensional Surface Imaging-Based Distance Measurements of the Face: Comparison of a Handheld Facial Scanner and a Stationary Whole-Body Surface Imaging Device.

Three-dimensional surface imaging (3DSI) has been shown to be a useful tool for plastic surgeons in the preoperative, intraoperative, and postoperative setting. The objective of this investigation was to compare the accuracy of facial surface distance measurements using both a handheld facial 3DSI device and a stationary whole-body 3DSI device. Users should be aware of deviations when obtaining 3DSI using the presented imaging devices but should not refrain from using them, as the absolute differences might be too small to play a role in both, clinical and research, settings.

Anatomic Differences Between the Asian and Caucasian Nose and Their Implications for Liquid Rhinoplasties.

The demand for surgical and nonsurgical esthetic procedures in the nasal region has increased sharply in the past. Anatomic differences of the nose between different ethnicities need to be investigated thoroughly. The objective of this article is to analyze and compare morphometric features of the nose in a mixed Asian-Caucasian study population. The nasal length in Asians was statistically significantly greater than in Caucasians, also after having adjusted for facial height. The nasal dorsal bridge and the nasal base showed statistically significant differences. By keeping these anatomic differences in mind while treating patients, greater efficacy and safety can be achieved.

Facial Recognition Pattern before and after Lower Eyelid Blepharoplasty: An Eye Tracking Analysis.

This study investigated eye movement patterns using eye tracking technology when looking at preoperative and postoperative images of patients that underwent bilateral periorbital cosmetic surgery. The sequence of facial recognition before surgery was periorbital-nose-perioral, whereas following surgery it was nose-periorbital-perioral. This study revealed that the sequence of facial feature recognition is influenced by the aesthetic liking of the observer and that alteration to facial features influences the sequence of facial feature recognition. The eye movement pattern, however, seems to follow the internal representation of beauty where aesthetically pleasing facial features are observed later during first image exposure and are viewed shorter.