Case series of tongue necrosis from vascular complications after chin augmentation with hyaluronic acid: Potential pathophysiology and management.

BACKGROUND: Even though the chin is considered a safe injection area for facial filler augmentation, tongue necrosis is a rare complication in this area. OBJECTIVE: Our aim was to present case series of rare complications from chin filler augmentation with possible pathophysiology and management. METHODS: From our thorough literature search found only one case report of tongue necrosis from chin filler augmentation. We present case series of unilateral tongue necrosis from vascular occlusion following hyaluronic acid injection in the chin, which was successfully treated with a high-dose hyaluronidase injection resulting in complete recovery in all patients. RESULTS: Variation in vascular anastomosis leads to a possible cause of vascular occlusion. The lingual artery is the primary arterial supply for the tongue, which is an exclusive target for embolism. Two main responsible arteries and branches are the deep lingual and sublingual arteries. The submental artery variation was previously described as the cause of this event. We proposed potential pathophysiology of the occlusion, not only the variation of vasculature but bone. The midline lingual foramen, an anatomical bone variation on the surface of the midline inferior jaw, was found to be another possible cause. This foramen contains a branch of the submental and sublingual artery, which includes the perforating artery, median perforating artery, or both. Filler injection with a sharp needle on the bone can potentially increase the risk of this vascular incident. A high dose of hyaluronidase administered with multiplane injections was accomplished with complete recovery. CONCLUSIONS: Tongue necrosis from vascular complications after hyaluronic acid filler injection can occur. Not only vessels but bone variation pathology were possible causes.

Outcomes of 1064-nm picosecond laser alone and in combination with fractional 1064-nm picosecond laser in tattoo removal.

BACKGROUND: Removal of the unwanted tattoo was initially focused treatment of picosecond laser in the setting of the unfractionated beam, whereas the fractionated 1064-nm picosecond lasers (Fr-Pico) has been successfully utilized in various skin conditions, including scar and benign pigmented lesions. However, no studies compared the combination of Fr-Pico and unfractional 1064-nm picosecond laser (UFr-Pico) and UFr-Pico alone in tattoo removal. OBJECTIVE: This study aims to compare the efficacy and safety of the combination of Fr-Pico and UFr-Pico and the UFr-Pico and in tattoo removal. MATERIALS AND METHODS: Nineteen black tattoos in 11 patients were treated with UFr-Pico on one half and in combination with Fr-Pico on another half over three sessions with 4-week intervals and 4-week follow-up after the last session. Treatment efficacy was assessed using digital photographs, skin imaging analysis, and patient satisfaction. RESULTS: After three treatments, tattoo clearance scores revealed that greater than 50% clearance was achieved in 11 (84.6%) tattoos treated with combination side and 9 (69.2%) tattoos with UFr-Pico alone. Significant differences were observed between the groups at 8 and 12 weeks. Skin textural changes also demonstrated significant improvements in the combination side at Week 12. Adverse events, such as blistering and textural changes, were fewer in the combination side. CONCLUSION: The combination of 1064 nm Fr-Pico and UFr-Pico may be more effective and safer in tattoo removal than UFr-Pico alone.

Nasal Dorsum Augmentation with Botulinum Toxin A: A Pilot Study.

BACKGROUND: Botulinum toxin type A (BTxA) is used for cosmetic procedures, but its use for nasal dorsum augmentation has, to our knowledge, never been studied. OBJECTIVE: Here, we describe a method for using BTxA injection for nasal dorsum augmentation. METHODS: This was a pilot study. Participants aged 20 to 60 years were recruited and injected with BTxA in the upper nasal area with either Xeomin® (Merz Pharmaceuticals GmbH, Frankfurt, Germany) or Dysport® (Galderma Laboratories, Fort Worth, Texas). The primary outcome measured was the upper nasal area's volume change from baseline, calculated using a Quantificare camera (San Francisco, California). The volumizing effect was subjectively graded by two blinded dermatologists and participants, and pain scores and adverse events were recorded. RESULTS: Fourteen participants, including two men and 12 women, aged 35.78±9.16 years were recruited. Overall, the volume of the upper nasal area increased after BTxA injection (p<0.001). The volume increase immediately and, at one week after injection, presented a statistically significant difference from baseline, with median (interquartile range) volume differences of 0.095mL (0.010-0.205; p<0.001) and 0.095mL (0.0475-0.155; p<0.001), respectively. Two blinded dermatologists and all participants observed volumizing of the nasal dorsum. The effect appeared to last for one month. CONCLUSION: This study suggests that injecting BTxA in the upper nasal area is a convenient, minimally invasive technique with minimal side effects for nasal dorsum augmentation.

Comparison of Fractional Picosecond 1064-nm Laser and Fractional Carbon Dioxide Laser for Treating Atrophic Acne Scars: A Randomized Split-Face Trial.

BACKGROUND: To date, no studies have compared the fractional picosecond 1064-nm laser (FxPico) and fractional carbon dioxide laser (FxCO2) for the treatment of acne scars. OBJECTIVE: To compare the efficacy and safety between FxPico and FxCO2 for treating facial atrophic acne scars. MATERIALS AND METHODS: Twenty-five Asian patients with mild to moderate atrophic acne scars underwent single sessions of randomized split-face treatment with FxPico and FxCO2. Clinical efficacy was assessed by photographs, skin imaging analysis, and patient satisfaction. The adverse events were recorded on every visit. Skin biopsies were performed immediately and 3 months after treatment. RESULTS: The physician improvement scores for skin texture and atrophy significantly increased on the FxPico sides, but no significant difference was observed between FxPico and FxCO2. Skin imaging also showed significant improvement on both sides for scar volume. Postinflammatory hyperpigmentation (PIH) was not reported on FxPico sides, whereas 6 patients (24%) experienced mild PIH on FxCO2 sides. Immediate post-FxPico skin biopsy revealed laser-induced optical breakdown with photoacoustic columns. Collagen and elastic fibers increased at 3 months after both treatments. CONCLUSION: FxPico was as effective as FxCO2 in treating atrophic acne scars, correlating with evidence of tissue remodeling with more safety profiles.

Case Report: The role of intradermal micro-droplet hyaluronic acid injection in the correction of filler nodules complication.

Filler injection has been widely used as a non-surgical intervention for skin rejuvenation and augmentation for the past decade. Hyaluronic acid (HA) is considered the most common treated material with high safety profile. Various mechanisms, including promoting collagen synthesis are postulated the efficacy of this powerful skin rejuvenation. The greater number of its used, the more complications were seen. Among the non-vascular complications from filler injection, the most frequent one is nodule formation. It could occur as early or late onset even with HA injection. One of the causes of these nodule formation is from poor injection technique leading to visible skin beads and lumps. The current treatments of these filler side effects mainly aim to remove or reduce excessive or displaced filler product. To the best of our knowledge, there has been no report of using the intradermal injection of the micro-droplet HA to correct filler nodule and simultaneously revitalize the skin quality. This novel treatment technique could be a safe alternative for nodule formation correction.

Botulinum toxin type A injection-related suppurative granuloma: a case report.

Botulinum toxin type A (BoNTA) injection has become increasingly popular for esthetic minimally invasive procedures worldwide, owing to its efficacy and safety. Serious and long-term complications are rare. Here, we report a case of painless skin-colored cutaneous nodules on the face that developed a few days after BoNTA injection. The histopathology revealed a suppurative granuloma which yielded negative results for all organisms on histochemical staining and tissue culture. While waiting for the results of polymerase chain reaction (PCR), we started administration of systemic broad-spectrum antibiotics that were effective against atypical mycobacteria, since suppurative granuloma is usually related to mycobacterial infection, and a negative result of histochemical staining is common among these organisms. The nodules were flattened down after antibiotics started 6 weeks . All lesions were clear without any scar after 6 months of treatment.

Alopecia Induced by Autologous Fat Injection into the Temporal Area: Case Report and Review of the Literature.

Alopecia secondary to facial filler injections is a highly unusual sequela. Only 2 cases of hyaluronic acid-induced alopecia have been reported to date. Accumulating evidence suggests vascular compromise as its etiology, which can be accidental intravascular injection or external compression by overfilled materials. We hereby present, to the best of our knowledge, the first case of localized nonscarring and scarring alopecia secondary to autologous fat grafting and review the literature regarding filler-induced alopecia.

The study of histological changes of the arterial vascular structure after hyaluronidase exposure.

BACKGROUND: Hyaluronic acid (HA) filler injection is commonly used for soft tissue augmentation. Uncommon but serious complication from filler injection is vascular occlusion. Hyaluronidase enzyme can be used to dissolve HA filler. Evidence demonstrates that hyaluronidase can penetrate through vessel wall after incubation. However, studies regarding effects of hyaluronidase on vessel wall after intraluminal injection are limited. The objective of this study is to evaluate histological changes of postmortem arteries after intravascular injection of hyaluronidase enzyme. METHODS: This was an ex vivo experiment including arterial specimens from four cadavers which recently deceased within 24 hours. All vessels were examined at baseline and then were divided into two groups. The first was the control group treated with normal saline and the second hyaluronidase-treated group was intra-luminally injected with hyaluronidase enzyme (1500 IU/mL). Gross and histological examination was performed at baseline, 30-minutes and 4 hours after. RESULTS: Gross examination of vessels revealed no significant difference at baseline, 30 minutes and 4 hours after injection in both groups. Histological examinations at baseline and 30 minutes after injection revealed viable endothelial cells in both experimental and NSS-control group. At 4 hours after hyaluronidase injection, two of the four arterial specimens had degeneration of endothelial cell, and one artery showed separation of tunica intima from tunica media. CONCLUSION: There were endothelial injuries in the arterial specimens after intravascular concentrated hyaluronidase injection.

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

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.

Split face comparison between common concentration vs double dilution of intradermal abobotulinum toxin type A (Dysport) injection for facial lifting in Asians.

BACKGROUND: The most efficacious concentration of botulinum toxin for facial lifting is not well established. OBJECTIVE: This study compared the efficacy of common concentration vs double dilution of intradermal abobotulinum toxin type A (Dysport) injection for facial lifting in Asians. METHODS: In all, 10 women aged 32-61 years with mild to moderate facial laxity participated in this study. Each patient received one session of intradermal injection of double diluted abobotulinum toxin type A (Dysport) (dilution of 15 mL to give 3.33 units per 0.1 mL) on one side of the face and common concentration (dilution of 7.5 mL to give 6.67 units per 0.1 mL) on the opposite side of the face. Clinical improvement of facial lifting, wrinkling, and subjective satisfaction was evaluated at every visit (baseline, 2, 4, 8, and 12 weeks). RESULTS: Both concentrations offered reduction of facial laxity and wrinkles, with no statistical difference. The effects gradually increased and lasted for a minimum 12 weeks with both concentrations. CONCLUSION: Common concentration and double dilution of intradermal abobotulinum toxin type A (Dysport) injection were effective and safe for facial lifting in Asians. There were no statistically significant differences between the two concentrations.

Fractional ablative and nonablative radiofrequency for skin resurfacing and rejuvenation of Thai patients.

BACKGROUND: Fractional radiofrequency (RF) technology is often the preferable skin resurfacing treatment, especially among Asian patients. Second generation fractional RF technology has exclusive capability to produce separate biological responses (ablation, coagulation, or a combination of both) with 3 distinguished penetration depth programs. AIMS: The aim of this study was to evaluate the efficacy and safety of a fractional RF handpiece such as this, on the Thai population. METHODS: Fifty-five Thai patients were treated with a fractional RF handpiece. The clinical assessment included a pain score, satisfaction survey, physician assessment, a combined patient and physician's assessment of skin condition, and clinical photographic assessments. The wound healing response was evaluated according to 5-time points: immediately after applying a pulse, post 24 hours, post 7 days, post 1 month and post 8 weeks. RESULTS: The obtained patient satisfaction score was "very satisfied" among 74% of the patients, post 3 sessions. Positive correlation was found between patient satisfaction and the physician's assessment. The skin condition assessment showed an increase from an average of 4.2 to 7.9. All treated symptoms improved after each treatment and the clinical outcome lasted at least up to 3-5 months. No significant adverse events were recorded. The in vivo prospective study showed a dose-related response in the deepness of the coagulation injury. In addition, there was evidence for a progressive healing process beginning shortly after exposure and completed within a week. CONCLUSIONS: This study clinically and histologically supports the efficacy of fractional RF handpiece in question with a high safety profile.

A Novel Technique of Supra Superficial Musculoaponeurotic System Hyaluronic Acid Injection for Lower Face Lifting.

BACKGROUND: Various methods attempting to correct sagging of the lower face focus mainly on manipulation of the superficial musculoaponeurotic System. Each technique has its own limitation. The authors propose a relatively simple, conservative method utilizing hyaluronic acid injection just above the superficial musculoaponeurotic System. OBJECTIVE: To address a novel hyaluronic injection technique to lift the lower face. METHODS: Details of the injection techniques are described. The Position of the hyaluronic acid injected and the effect of hyaluronic acid on the superficial musculoaponeurotic System were confirmed by ultrasonography in one of the cases. RESULTS: Sonogram images demonstrated the location of the injected hyaluronic acid and pressure effect of hyaluronic acid on the superficial musculoaponeurotic System, confirming the ability to manipulate the superficial musculoaponeurotic System by this injection technique. The lifting result of this Single injection technique was immediately visible and maintained for at least 26 weeks. CONCLUSION: This is a less invasive, reproducible method that provides a sustained face lifting result. The authors propose the term "supraSMAS lift" for this novel injection technique.