Treatment of Danger facial areas with fillers

The use of latest generation of reticular purified hyaluronic acid for dermal filler treatment gives excellent results which last for 12-18 months in majority of the cases with minimal side effects.

The injections of hyaluronic acid should be followed by a use of the good aseptic technique. Usually, chlorhexidine is used for this purpose which is a good cleanser as well as a disinfectant. By using a good aseptic technique as well as the disposable and sterile materials, the risk of infections can be reduced to minimal. However, there is some possibility of subcutaneous bleeding suffusions which generally lasts for about 7-12 days. This can be accompanied by swelling or oedema of the treated area which usually subsides in 24-48 hours. There are few rare cases of erythema[1] that extended from the nasal tip and lasted for about 1 month.

Practically speaking, most of the complications of medical rhinoplasty occur due to accidental injections in regions of arterioles or venules with anterograde or retrograde embolization. The use of modern rhinoplasty materials particularly hyaluronic acid with medium reticulation does not cause edemas which sometimes occurs in and around the nasal region.

In the case of any accidental injection or any incorrect injection technique of hyaluronic acid into the blood vessels, the use of hyaluronidase is recommended by research studies[2][3]. The hyaluronidase should be injected as early as possible because its effectiveness of reducing the effects of hyaluronic acid decreases within four hours[4].

In injecting the nasal area, there can be instances of tissues distress due to injections into the intra-arterial region or due to extrinsic compression. Instances of blindness have also been reported due to injections of filler into the periocular area (mostly with fat injections but in few cases with hyaluronic acid and other types of resorbable fillers)[5][6][7]. It is certain that the nasal dorsal artery has retrogate communications with the central retinal artery as well as with internal carotid artery. That is why large boluses should be avoided while injecting in the danger areas including nasal ridge.

Guidelines for treating nasal ischemia from intra-arterial or para-arterial injections

Follow these latest guidelines and steps for injecting intra-arterial or para-arterial injections of hyaluronic acid for treating nasal ischemia[8][9][10].

• Ask the patients to sign an informed consent form in which it is written that the use of filler, in this case, is off-label and is not authorised in many European as well as extra-European
• Inform patient that the use of hyaluronidase can cause even strong allergic reactions.
• Don’t provide any treatment for common allergic reactions because allergy tests are not taken before administration, therefore, it is not known whether the treatment is preventing allergic reaction or stimulating it.
• Make a diluted solution of 150U of hyaluronidase with 1ml of 0.9% saline. There is no scientific research to support that using lidocaine without or with adrenalin is useful.
• Slowly inject minimal amounts from 0.05ml to 0.1 ml (7.5-15U).
• For superficial injection into the middle dermis, use 30G needle while for sub-dermis injections 27G needles can also be used.
• Nodule reduction is not instant but it becomes noticeable in 24-48 hours.
• The effectiveness of intra-artery injections is not supported by any scientific documentation. So if you decide to give these injections, it should be done in the shortest possible period as soon as ischemia and blanching are noticed in the nasal area where the patient may feel a dull burning sensation.
• In instance of noticeable blanching of the region, application of 5-10 mg nitroglycerine patch for 12 hours proves useful.

Injecting glabellar region

The glabellar region is a complicated area that is known for potential ischemia risks after filler or fat injections. The mechanism or emobilization in this region determine the appearance of complications which are not evidently identified but incorporate;

• A particular organisation and terminal division of the facial artery distant branches
• Product’s deep injection
• The sufficiently significant quantity of product being injected whose migration is likely to become more distal preventing contralateral supply.

In order to prevent such type of complication in the glabellar region, the injection technique used should be very superficial because the arterioles in this region are deeper located in the deep subcutaneous tissue or through the muscles[11],[12],[13]. It is necessary to avoid over-pressure during injection. In fact, using blunt cannula for injections in this region is a much safer option.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4248003/

[2] https://www.ncbi.nlm.nih.gov/pubmed/26964838

[3] Dr Maurizio Cavallini, Dr Riccardo Gazzola, Dr Marco Metalla, and Dr Luca Vaienti, ‘The Role of Hyaluronidase in the Treatment of Complications From Hyaluronic Acid Dermal Fillers’, Aesthetic Surgery Journal 33(8) (2013), 1167–1174

[4] Inglefield C, Collins F, Duckett M, Goldie K, Huss G, Paun S, Williams S, Expert consensus of Botulinum Toxin and Dermal Filler Treatment second edition (UK: Aesthetic Medical Expert Group, 2014)

[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865975/

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686337/

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404720/

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4298868/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4248003/

[10] Hwang Catherine J. Periorbital injectables: Understanding and avoiding complications. Journal of Cutaneous and Aesthetic Surgery. Year : 2016 | Volume:  9 | Issue Number:  2 | Page: 73-79

[11] Funt, D., & Pavicic, T. (2013). Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clinical, Cosmetic and Investigational Dermatology, 6, 295–316. http://doi.org/10.2147/CCID.S50546

[12] Kim YK, Jung C, Woo SJ, Park KH. Cerebral Angiographic Findings of Cosmetic Facial Filler-related Ophthalmic and Retinal Artery Occlusion. J Korean Med Sci. 2015 Dec;30(12):1847-55. doi: 10.3346/jkms.2015.30.12.1847. Retrieved: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689831/

[13] Peter, S. and Mennel, S. (2006), Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clinical & Experimental Ophthalmology, 34: 363–364. doi:10.1111/j.1442-9071.2006.01224.x