Filler injections for Wrinkles: Blindness and Prevention

-From 2016, articles commented in the Journal and Focus will be posted here (selection by Prof. JH Saurat M.D.)

Filler injections for Wrinkles: Blindness and Prevention

Postby CFH » Thu Dec 03, 2015 3:39 pm

Study 1. Avoiding and Treating Blindness From Fillers: A Review of the World Literature.
Beleznay K, Carruthers JD, Humphrey S, Jones D.
Dermatol Surg. 2015 Oct;41(10):1097-117. doi: 10.1097/DSS.0000000000000486.

Study 2. Blood Aspiration Test for Cosmetic Fillers to Prevent Accidental Intravascular Injection in the Face.
Casabona G.
Dermatol Surg. 2015 Jul;41(7):841-7. doi: 10.1097/DSS.0000000000000395.

-It is now a widely accepted practice to treat wrinkles both in women and men.
-There are many fillers on the market but they almost all are based on hyaluronic acid

Treating facial wrinkles and volume loss seems a straightforward process, but there are serious potential side-effects.

In experienced hands, these are rare but they include injection of the filler in blood vessels, which leads to embolization (retrograde embolization and necrosis of the tissue fed by the artery). If not dealt immediately, this can lead to blindness and otherwise irreversible disfigurement through tissue loss.

Before mentioning the study let's summarize the vascularization of the face. The head area depends on the carotid arteries which are divided at the lateral neck area (C4) into external and internal carotid arteries.
-The latter vascularizes the brain (Central Nervous System (CNS))
-The former feeds the face. The normal return of blood goes through the external jugular vein…however it is not that simple as there are potential communications between the external and internal venous drainage: the angular vein is located lateral to the nose and communicates with the cavernous sinus and ophtalmic vein: injection into this vein can lead to thrombosis of the CNS. (Injection into the artery can cause nasal tissue necrosis)
As for vision, numerous arteries are present, they have anatomical variations and injecting in them can have functional effects because of retrograde emblolization. (one example is when injecting in the glabellar area)
For the sake of simplicity, we will not elaborate further but it is NOT straightforward: (the author of this summary spent one whole trimester dissecting a face)

Study 1: Visual Risks
This US study is a review of the literature of visual complications (up to January 2015)
-98 cases weer identified
-the affected ares were the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%) (Virtually all injected regions are at risk)
-the most likely filler to cause visual complications is autologous fat (half of reported cases), followed by hyaluronic acid (one quarter of cases; comment it is also widely used)
-Patients experienced sudden visual loss (Blindness) and pain. Most cases did NOT recover and the CNS was involved in a quarter of the cases
-No treatment to treat blindness was effective.

Study 2: Prevention
It is widely accepted than aspirating in the lesion before injecting will be reliable to see if there is blood before injecting the filler.
It should be done but it is only reliable when the needle diameter is sufficient

In this study from Brazil, the authors tried to aspirate red ink from a cup using the syringe of 16 filler products:
-positive aspiration was defined by the presence of the ink in the syringe less than 10 seconds after the product was aspirated
-In 7 filler products, the aspiration test was initially negative: Juvederm ultra XC, Juvederm Ultra Plus XC, Perlane, Emervel Classic, Emervel Lips, Radiesse 1.5 mL (mixed with 0.25 mL
lidocaine), Radiesse 1.5 mL (mixed with 0.5 mL lidocaine). After adjusting for a larger needle diameter, the aspiration test became positive
-In 9 filler products, the aspiration tests was initially positive: Voluma 1 mL and 2mL, Volift, Volbella, Restylane, Restylane Vital, Esthelis/Belotero, Rennova Lift, Sculptra (mixed with 10 mL saline and 2 mL lidocaine—final solution, 12 mL). When reducing needle size for Esthelis (27), Emervel lips (27), Emervel Classic (27), Radiesse (23), Juvederm Ultra XC (25), Juvederm Ultra Plus XC (25), the aspiration test remained positive.
-These differences can be explained by the size of the needle: as smaller needles minimize pain and adverse events such as bruising may be decreased or avoided by using a small-gauge needle (27) In addition, a slow injection speed may decrease the risk of vessel occlusion or obstruction of peripheral flow

Patients benefit greatly from those treatments but to minimize risks, no hesitation should exist whereas to ask and even check the credentials of doctors doing those injections, especially to check if they have a detailed knowledge of the facial anatomy, prevention and management strategies when things go wrong (There is a study of the safety of cosmetic procedures when done by dermatologists

To end on a positive note, the risk of permanent vision is quite low, the incidence being estimated at 0.0001%.

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