Objectives: While the number of filler treatments increased by more than 300 % from 2000 to 2017 in the USA, the number of adverse events also increased at the same time. The inadvertent injection of filler in the arteries that supply the facial tissues and its consequences are the most serious of these complications.
Introduction: What happens when an arterial filler embolism occurs?
- If it is a low-volume bolus (0.1 ml or less) injected slowly under low pressure, the embolism moves with the blood flow towards the distal arterioles, causing ischemia with the risk of local tissue necrosis.
- If it is a high-volume bolus injected quickly under high pressure, the embolism is displaced in a retrograde manner to a larger proximal artery. This is especially dangerous in the naso-glabellar zone, where the embolism can reach the ophthalmic artery through one of its collaterals (nasal, supra-trochlear, supra-orbital), and then the central retinal artery with the risk of definitive blindness.
The main recommendations to prevent these vascular accidents are a good knowledge of the three-dimensional anatomy especially in potential danger areas, the use of low-volume bolus injected slowly under low pressure, and the preferential use of hyaluronic acid, because treatment with hyaluronidase is possible if there is a vascular adverse event.
Conclusion: Hyaluronidase has represented a major step forward in avoiding cutaneous necrosis due to the embolization of fillers. Nowadays, the use of hyaluronidase precludes the necrotic accidents of the past. Necrosis occurs the most frequently when the injection is delivered in the upper third of the nasolabial fold or in the glabella, but other facial locations are possible. Wide and deep necrosis can leave scars for life.
Treatment with hyaluronidase should begin as soon as possible in order to avoid necrosis, and vigilance is required to recognize vascular compromise, the first symptom of inadvertent filler placement. The new high-dose pulsed hyaluronidase protocol developed by Lorenzi has the advantage of simplicity without ancillary treatments and provides a significant improvement in the quality of results.
Is the protocol applicable in the event of visual loss due to the embolism of a filler? Theoretically, it is, but the retina is more fragile than the skin. Irreversible damage occurs after 90 minutes of ischemia, so the hyaluronidase must be placed closely by retrobulbar injection to be effective. In practice, these conditions are rarely met, so avoiding blindness remains a challenge. However, two cases with a successful outcome have been published to date.
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