Update on Blindness From Filler: Review of Prognostic Factors, Management Approaches, and a Century of Published Cases.

Vision loss secondary to aesthetic filler treatment is a rare but disastrous complication. The aim of this review was to update the published cases of blindness after filler injection that have occurred since our group published reviews of 98 cases in 2015 and an additional 48 cases in 2019. A literature review was performed to identify all cases of visual complications caused by filler injection published between September 2018 and March 2023. The cases were analyzed independently and in combination with previously reviewed cases. Analyses were based on the number of cases with data available. A total of 365 new cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nose (40.6%), forehead (27.7%), and glabella (19.0%). The filler injected was hyaluronic acid in 79.6% of cases. The most common associated signs were ptosis (56.2%), ophthalmoplegia (44.1%), pain (31.2%), and skin changes (73.2%). Strokelike features were seen in 19.2% of cases. Of the cases reporting visual outcomes (318), 6.0% experienced complete vision recovery, 25.8% had partial improvement in visual acuity, and 68.2% had no vision recovery. Partially preserved visual acuity at onset was a significant predictor of visual improvement (P < .001). The 3 most common treatments were subcutaneous hyaluronidase at or near the filler site (70.1%), systemic steroids (57.3%), and intraarterial thrombolytic therapy (56.0%). No treatments were significantly associated with visual improvement (P > .05). Although blindness and stroke from fillers is a rare complication, practitioners who inject filler should have a thorough knowledge of prevention and management strategies.

The Layered Anatomy of the Nose: An Ultrasound-Based Investigation.

BACKGROUND: An increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex. OBJECTIVES: The authors sought to describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement. METHODS: A total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose utilizing ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature. RESULTS: In the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n = 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% to 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip. CONCLUSIONS: Soft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared with any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.

Retrospective review of delayed adverse events secondary to treatment with a smooth, cohesive 20-mg/mL hyaluronic acid filler in 4500 patients.

BACKGROUND: Recent publications have suggested an increased risk of delayed adverse events (DAEs) with a smooth, cohesive 20-mg/mL hyaluronic acid filler, Juvéderm Voluma (HA-V). OBJECTIVE: To examine the occurrence of HA-V DAEs and identify patterns and characteristics. METHODS: Charts from patients who received HA-V between February 1, 2009, and February 28, 2018 from 2 clinics were analyzed. RESULTS: In 4500 patients who received 9324 treatments with HA-V, 44 DAEs were identified, for a combined incidence of 0.98% per patient, 0.47% per treatment, and 0.23% per syringe. Patients with DAEs received a slightly larger cumulative amount of HA-V than those who did not. Delayed swelling and nodule formation were the most common reactions and occurred a median of 4 months after treatment, with an increase in frequency between October and January. About a third were preceded by an identifiable immunologic stimulus. DAEs were transient and resolved without incident. LIMITATIONS: The retrospective nature made it difficult to capture time to resolution or remember potential triggers. CONCLUSION: In this large, long-term, retrospective review, HA-V DAEs occurred at a rate of 0.98% per patient. Although the exact cause has yet to be elucidated, we hypothesize that an increase in fragmentation during the HA-V degradation process may trigger an inflammatory response after an immunologic trigger.

Relationship Between Vertical Glabellar Lines and the Supratrochlear and Supraorbital Arteries.

BACKGROUND: Glabellar soft tissue filler injections have been shown to be associated with a high risk of causing injection-related visual compromise. OBJECTIVES: The aim of this study was to identify the course of the superficial branch of the supratrochlear and of the deep branch of the supraorbital artery in relation to the ipsilateral vertical glabellar line and to test whether an artery is located deep to this line. METHODS: Forty-one healthy volunteers with a mean age of 26.17 [9.6] years and a mean BMI of 23.09 [2.3] kg/m2 were analyzed. Ultrasound imaging was applied to measure the diameters, distance from skin surface, distance between the midline, distance between vertical glabella lines, and the cutaneous projection of the supratrochlear/supraorbital arteries at rest and upon frowning. RESULTS: The mean distance between the superficial branch of the supratrochlear artery and the ipsilateral vertical glabellar line was 10.59 [4.0] mm in males and 8.21 [4.0] mm in females, whereas it was 22.38 [5.5] mm for the supraorbital artery in males and 20.73 [5.6] mm in females. Upon frowning, a medial shift in supratrochlear arterial position of 1.63 mm in males and 1.84 mm in females and of 3.9 mm in supraorbital arterial position for both genders was observed. The mean depth of the supratrochlear artery was 3.34 [0.6] mm at rest, whereas the depth of the supraorbital artery was 3.54 [0.8] mm. CONCLUSIONS: The hypothesis that injecting soft tissue fillers next to the vertical glabellar line is safe because the supratrochlear artery courses deep to the crease should be rejected. Additionally, the glabella and the supraorbital region should be considered as an area of mobile, rather than static, soft tissues.

Anatomy of the Superior and Inferior Labial Arteries Revised: An Ultrasound Investigation and Implication for Lip Volumization.

BACKGROUND: Lips are considered a key element of facial attractiveness due to their central position in the face and their elemental role in verbal and nonverbal communication. OBJECTIVES: The authors sought to provide clinically relevant information on the 3-dimensional pathway of the superior and inferior labial arteries within the lips to increase safety during labial soft tissue filler injections. METHODS: The study enrolled 41 healthy volunteers with a mean age of 26.17 ±â€…9.6 years and a mean body mass index of 23.09 ±â€…2.3 kg/m2. Ultrasound imaging was performed at 6 different locations. The position of the labial arteries within the lips, depth of the arteries, cranio-caudal location of each artery in relation to the vermilion border, and diameter of the superior/inferior labial arteries were recorded. RESULTS: The most frequent location of both the superior and inferior labial arteries was the submucosal plane (58.5%) followed by intramuscular (36.2%) and subcutaneous (5.3%) planes. The depth of the superior labial artery in the upper lip was 5.6 ±â€…0.13 mm, whereas the depth of the inferior labial artery in the lower lip was 5.2 ±â€…0.14 mm. Both arteries were more frequently located within the red lip: upper lip (83% vs 18.7%) and lower lip (86.2% vs 13.8%). In the midline, the artery coursed within the red lip in all investigated volunteers. CONCLUSIONS: Clinically, results of this study favor a superficial injection plane for lip volumization procedures. A perpendicular approach to the lip (coming from the cutaneous lip) might increase safety because the artery is located most frequently within the red lip.

Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature.

BACKGROUND: Sudden loss of vision secondary to filler treatments is a rare but catastrophic complication. OBJECTIVES: The aim of this study was to update the published cases of blindness after filler injection that have occurred since we published our review of 98 cases in 2015, and to discuss prevention and management strategies. METHODS: A literature review was performed to identify all cases of visual complications caused by filler injection identified between January 2015 and September 2018. RESULTS: Forty-eight new published cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nasal region (56.3%), glabella (27.1%), forehead (18.8%), and nasolabial fold (14.6%). Hyaluronic acid filler was the cause of this complication in 81.3% of cases. Vision loss, pain, ophthalmoplegia, and ptosis were the most common reported symptoms. Skin changes were seen in 43.8% of cases and central nervous system complications were seen in 18.8% of cases. Ten cases (20.8%) experienced complete recovery of vision, whereas 8 cases (16.7%) reported only partial recovery. Management strategies varied greatly and there were no treatments that were shown to be consistently successful. CONCLUSIONS: Although the risk of blindness from fillers is rare, practitioners who inject filler should have a thorough knowledge of this complication including prevention and management strategies.

Highlights of Skin Disease Education Foundation's 41st Annual Hawaii Dermatology Seminar™.

New therapies, recent pathophysiological findings, and updated guidelines combined to create compelling presentations at the Skin Disease Education Foundation's 41st Annual Hawaii Dermatology Seminar™. This educational supplement summarizes the highlights of clinical sessions presented during this CME/CE conference. A growing understanding of the biology of psoriasis has facilitated the development of increasingly efficacious medications. Skin clearance used to be regarded as an impractical goal for psoriasis therapy. Now, some clinical trials of newer medications report more than half of participants attaining Psoriasis Area and Severity Index (PASI) scores of 90. Two leading investigators review the latest findings about the treatment of this condition. Recent evidence demonstrates that psoriasis and psoriatic arthritis share multiple pathological underpinnings. A T helper type 17 (Th17) lymphocyte-based pathogenesis, genes, and microbiome changes have been identified in both conditions. Many therapeutics used in psoriasis care are efficacious in psoriatic arthritis. An expert in psoriatic arthritis updates readers about this condition. Cutaneous fungal infections, including onychomycosis, pose diagnostic and treatment challenges. New topical therapies and an investigational oral agent offer expanded options for management. The American Academy of Dermatology has issued new guidelines for the treatment of acne. Appropriate antibiotic use is a prominent theme. The US Food and Drug Administration has issued a communication about the risk of unintentional injection of soft tissue fillers into facial blood vessels-including blindness. The lead author of a recent review about this topic discusses how to prevent this serious outcome. The volume of new information about pathophysiology, diagnosis, therapy, and safety challenges our ability to keep current while enabling us to improve patient care. We hope that the highlights of this seminar offer you information that can be applied to your busy practices.

Rejuvenation of the Upper Face and Periocular Region: Combining Neuromodulator, Facial Filler, Laser, Light, and Energy-Based Therapies for Optimal Results.

BACKGROUND: The upper face and periocular region is a complex and dynamic part of the face. Successful rejuvenation requires a combination of minimally invasive modalities to fill dents and hollows, resurface rhytides, improve pigmentation, and smooth the mimetic muscles of the face without masking facial expression. METHODS: Using review of the literature and clinical experience, the authors discuss our strategy for combining botulinum toxin, facial filler, ablative laser, intense pulsed light, microfocused ultrasound, and microneedle fractional radiofrequency to treat aesthetic problems of the upper face including brow ptosis, temple volume loss, A-frame deformity of the superior sulcus, and superficial and deep rhytides. RESULTS: With attention to safety recommendations, injectable, light, laser, and energy-based treatments can be safely combined in experienced hands to provide enhanced outcomes in the rejuvenation of the upper face. CONCLUSION: Providing multiple treatments in 1 session improves patient satisfaction by producing greater improvements in a shorter amount of time and with less overall downtime than would be necessary with multiple office visits.

Combination Therapy in Midfacial Rejuvenation.

BACKGROUND: Facial aging in the midface reflects cumulative results of multiple intrinsic and extrinsic factors over time. Midfacial rejuvenation procedures can make a positive impact on facial attractiveness and patient satisfaction. OBJECTIVE: To review evidence and clinical experience using combination treatments for midfacial rejuvenation to achieve optimal outcomes. MATERIALS AND METHODS: This article provides a review of published scientific evidence supporting the use of combination therapy in midfacial rejuvenation. In addition, the authors share their cumulative clinical experience and best practices for combination treatments in the midface. RESULTS: Clinical experience and evidence shows that combining multiple aesthetic therapies targeting multiple aspects of the aging process provides optimal results, with greater overall efficacy and a higher level of patient satisfaction.

Avoiding and Treating Blindness From Fillers: A Review of the World Literature.

BACKGROUND: As the popularity of soft tissue fillers increases, so do the reports of adverse events. The most serious complications are vascular in nature and include blindness. OBJECTIVE: To review the cases of blindness after filler injection, to highlight key aspects of the vascular anatomy, and to discuss prevention and management strategies. METHODS: A literature review was performed to identify all the cases of vision changes from filler in the world literature. RESULTS: Ninety-eight cases of vision changes from filler were identified. The sites that were high risk for complications were the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%). Autologous fat (47.9%) was the most common filler type to cause this complication, followed by hyaluronic acid (23.5%). The most common symptoms were immediate vision loss and pain. Most cases of vision loss did not recover. Central nervous system complications were seen in 23.5% of the cases. No treatments were found to be consistently successful in treating blindness. CONCLUSION: Although the risk of blindness from fillers is rare, it is critical for injecting physicians to have a firm knowledge of the vascular anatomy and to understand key prevention and management strategies.

Delayed-onset nodules secondary to a smooth cohesive 20 mg/mL hyaluronic acid filler: cause and management.

BACKGROUND: The shift from 2- to 3-dimensional soft tissue augmentation has allowed the development of hyaluronic acid (HA) fillers, which are long lasting and also reversible. Delayed-onset inflammatory nodules have recently been reported with the use of HA fillers. OBJECTIVE: The authors document their experience with delayed-onset nodules after 3-dimensional facial injection of Juvéderm Voluma (HA-V) over 68 months. MATERIALS AND METHODS: The authors conducted a retrospective chart review of patients who were treated with HA-V between February 1, 2009, and September 30, 2014, to evaluate for delayed-onset nodules. RESULTS: Over 68 months, 4,702 treatments were performed using 11,460 mL of HA-V. Twenty-three patients (0.5%) experienced delayed-onset nodules. The median time from injection to reaction was 4 months, and median time to resolution was 6 weeks. Nine of the 23 (39%) had an identifiable immunologic trigger such as flu-like illness before the nodule onset. In the authors' experience, prednisone, intralesional corticosteroids, and hyaluronidase were effective treatments. CONCLUSION: Although delayed nodules are uncommon from HA-V (0.5%), it is important to be aware of this adverse effect and have a management protocol in place. It is the authors' opinion from the patients' responses and from the literature that these nodules are immune mediated in nature.

Lupus miliaris disseminatus faciei treated with 1,565 nm nonablative fractionated laser resurfacing: a case report.

BACKGROUND: Lupus miliaris disseminatus faciei (LMDF) is a rare granulomatous disease. It presents as red-brown papules on the face that can resolve with scarring. LMDF is often resistant to treatment. OBJECTIVE: Nonablative fractionated lasers have been used effectively to treat granulomatous disorders; however, there is little data on the treatment of LMDF with lasers. Our objective was to test a novel non-ablative fractionated laser for the treatment of recalcitrant LMDF. RESULTS: A 24-year-old man had a one-year history of LMDF. He had been treated with various topical therapies, oral medications, and laser devices with no improvement and continued progression. We utilized a non-sequential scanning 1,565 nm nonablative fractionated laser to treat this patient. After only one treatment he had significant improvement. He has been subsequently treated five times in the past 6 months and has continued to improve. CONCLUSION: The novel 1,565 nm nonablative fractionated laser may be a useful tool in the treatment of granulomatous conditions such as LMDF.

Effectiveness of hyaluronic acid fillers for cheek augmentation using a treatment guide to choose between products.

BACKGROUND: Patients can have different reasons for seeking cheek augmentation; while some are in need of volume augmentation, others may request projection and lifting. A treatment guide can be useful for treating clinicians in choosing the most suitable product. AIMS: This 8-week, multicenter study was conducted to evaluate the effectiveness and safety of cheek augmentation using a treatment guide to choose between study products HACON and HALYF. PATIENTS/METHODS: Female subjects intending to undergo cheek augmentation were treated according to primary need for treatment-HACON for contouring or HALYF for projection. Treatments were performed according to approved labels. Assessments included Global Aesthetic Improvement Scale (GAIS) evaluations, subject satisfaction, subject-perceived age (FACE-Q), naturalness of facial expressions, 3D imaging analysis, and safety assessments. RESULTS: All subjects (n = 60) were assessed as aesthetically improved by the investigators 4 and 8 weeks after last injection. For all subjects, contouring or projection was achieved as planned with natural-looking results. Subject satisfaction was high in both study groups. Volume change of the cheek area was statistically significant from baseline to Week 4 (p < 0.001), in both treatment groups and on both sides of the face. Overall, treatments were well tolerated with mainly mild adverse events related to treatment. CONCLUSIONS: The proposed guide for product selection of HACON or HALYF for treatment of the cheek area was useful to achieve the primary treatment goal for both products. Treatments were well tolerated and associated with improved aesthetic appearance of the cheeks as well as high subject satisfaction.

Deliberations of the Safety Task Force: Risk factors and treatment of adverse events associated with aesthetic injectables.

BACKGROUND: The growing popularity of aesthetic procedures involving fillers, biostimulators, and neurotoxins has prompted concerns about patient safety. To address these concerns, a global Safety Task Force (STF) was formed. AIMS: The inaugural STF meeting prioritized vascular compromise prevention and management, guiding clinical trial design and materials for future meetings, and collecting data from experts on current safety methods. METHODS: The STF was formed and consisted of 16 experts from nine different countries, with each possessing distinct expertise in various fields related to aesthetic injectables. Current safety data, protocols, knowledge gaps and future research priorities were discussed and voted upon. RESULTS: The establishment of a global database for tracking filler-related AEs was favored by 93% of participants. Discussions revolved around the database's scope, data standardization, and whether non-medical contributors should be included. Aspiration as a safety technique garnered support from 73% of participants. Approximately 43% of participants incorporate ultrasound in their injections, with divergent opinions on its impact and potential when used as a standard of practice versus in AE management. Most physicians on the task force incorporated cannula use for some of their injections (93%). There were varying perspectives on treatments for vascular adverse events (VAE), the primary causes, and the adoption of new protocols in the field. CONCLUSIONS: The STF meeting underscored the need for a coordinated effort to address complications related to HA fillers, including VAE management and hyaluronidase protocols. Reliable treatment endpoints were evaluated, but improved measurement methods are needed. Future meetings will focus on addressing delayed complications, furthering safety in this field.