Objectives: To review efficacy and safety of Pyridostigmine as a treatment to refractory Botulinum-toxin related blepharoptosis

Introduction: Pyridostigmine is viable therapeutic in the reversal of botulinum toxin-related blepharospasm that potentiates contraction of the levator palpebrae superioris. Its acts to inhibit destruction of acetylcholine, increasing its concentration at the presynaptic cleft, allowing the transmission of nerve implulses across the neuromuscular junction, effectively contracting the muscle. This is a presentation of two cases of botulinum toxin-induced blepharoptosis refractory to Brimonidine 0.2% ophthalmic solution that showed considerable improvement upon treatment with oral Pyridostigmine.

Materials / method: Two healthy patients with unilateral blepharoptosis 5 days post post-botulinum toxin injection of the corrugator muscle were each given Pyridostigmine 60 mg/tab, 1 tablet every 6 hours on full stomach for 1 week as a monotherapy.

Results: Retraction of the upper eyelid at 2mm was initially reported by both patients following 8 doses (2 days of treatment of Pyridostigmine 60 mg. Sustained effect was noted with 6-hourly dosing. The first patient reported lid retraction of 3 mm on day 5 of treatment and the second patient on day 6. Full lid retraction was reported on the 15th and 16th day of treatment, respectively.

Conclusion: Pyridostigmine, when used correctly, decreases recovery period of from post-botulinum toxin blepharoptosis (15-16 days) compared to no treatment (28-42 days) with tolerable side effects. Further studies are recommended to strengthen the hypothesis and to explore its viability as a monotherapy or part of a combination regimen.

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Objectives: What is Hyaluronidase?
How to use it?
How to recognise vasculat oclusion?

Introduction: Hyaluronidases, a family of enzymes that can degrade hyaluronic acid (HA), are employed in medicine to increase drug diffusion and reverse the effects of HA filler injections. Hyaluronidases can dissolve subcutaneous nodules or to correct excessive quantities of injected filler. Knowledge of the use, methods of application, and adverse effects of hyaluronidases is essential for the aesthetic practitioner.

Materials / method: , these complications may occur with the application of any kind of filler, including HA, calcium hydroxyapatite or poly-L-lactic acid. However, to the best of our knowledge, the availability of a specific antidote (hyaluronidase) for the management of adverse effects is limited to HA-based fillers and may be the best reason to choose these products for tissue augmentation.

Results: Photos of patient swith complications

Conclusion: Infiltration of hyaluronidase is a rapid, safe and currently the only effective option for the management of side effects following HA-filler injections.

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Objectives: Vascular compromise after using non solvable polycaprolactone-based dermal filler- protocol of action.

Introduction: PCL-based fillers cannot be immediately removed by injection of an enzyme. I performed a mid face filler volumisation using polycaprolactone-based dermal filler according to the producer's protocol that ended with vascular occlusion of the cheek and nose. The patient came back to me one day after the procedure showing signs od vascular occlusion.

Materials / method: It's a case report- I'll show day by day worsening and treatment steps to get the result- avoiding necrosis and scars. I'll also show pictures and video.

Results: The treatment worked well and the patient avoided permament damage.

Conclusion: Using PCL-based fillers that cannot be immediately removed by injection of an enzyme makes every physician uneasy.
If such an adverse event happens- using the producers protocol plus hyaluronidase and PRP and energy based devices may be very helpful to avoid the permanent damage to the skin and other tissues.

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Objectives: The durability of hyaluronic acid (HA) fillers can persist around 2-5 years. Due of this longevity, sometimes delayed inflammatory reactions (DIR) can be trigger by HA filler.
The exact mechanism of action for the delayed reaction is unclear, sometimes DIR to fillers following infectious processes, are already known. Our main goal is to achieve a protocol to manage DIR, due to viral COVID-19 illness and vaccination reactions.

Introduction: COVID-19 infections with the SARS-CoV-2 virus continue and this is an issue that should be known by the injector. Viral spike protein uses angiotensin converting enzyme 2 (ACE2) for intracellular invasion.
ACE2 is expressed in cells of the vascular system and skin cell types as fibroblast, keratinocytes, and adipose tissue.
ACE 2 plays a critical role as an immune-regulator in the conversion of Angiotensin I to the proinflammatory metabolites, Angiotensin II-VII. As such, localized blockade of dermal ACE could result in a proinflammatory cascade.

Materials / method: Five women with hyaluronic acid soft tissue filler shown DIR. They were fully vaccinated, receiving at least 2 doses of mRNA vaccines (Ptizer-BionTech or Moderna).
Four of the patients had already passed the COVID-19 infection, and only one had been only vaccinated without being infected.
We treated DIR with antihistamines, double antibiotic treatment and oral corticosteroids. Three of them developed intermittent swelling and need to take lisinopril with total resolution after 1 week.
Only one had to be treated for a nodule in upper lip, with fully resolution after intralesional treatmen

Results: All five patients were treated with Cetirizine 20mg/day, Ciprofloxacin 500/twice a day, azithromycin 500mg/day, deflazacort 30mg/decreasing 10mg dose every week.
Intermittent swelling resolved with lisinopril 5mg every 12 hrs for 3-5 days.
Inflammatory nodules needed to be treated with intralesional corticosteroids (triamcinolone) and hyaluronidase with full resolution.
Six months clinical follow up was used to evaluate the clinical result and clinical follow up, with great degree of total resolution.

Conclusion: We must wait at least for 15 days after the COVID-19 vaccine or COVID-19 infection before treating patients with soft tissue fillers. Moreover, it would be even better 3 weeks as it may take up to 21 days for the peak immune response.
If DIR appears, antihistamines, antibiotics, corticoids are the first line of treatment, and to avoid interment swealling lisinipril can be added for 3-5 days.
Vaccination should not be discouraged, and if previous DIR antecedents existis , concomitant usage of oral corticosteroids vs lisinopril, should be considered 2 days prior, in every booster vaccine.

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Objectives: In this study it is found that laser therapy started at the onset of symptoms of arterial obstruction after filler injection can be an effective modality in treatment and decreases symptoms and makes a better outcome.

Introduction: Arterial obstruction in filler injection although rarely happens can be considered a catastrophic complimcation. An effective intervention in ischemic phase can decrease the severity of pathology and therefore prohibit tissue necrosis completely or partially to have no scar or a smaller and more desirable one.
In addition to formal treatment we tried laser therapy. Known photobiomodulative effects of low power laser such as increasing circulation and ATP production and decreasing inflammation can be effective in treatment.

Materials / method: We asked colleagues to refer their probable complicated cases of filler injection to our office two years ago to add laser therapy to their usuall medical treatment ( hyaluronidase, vasodilator and antibiotic therapy) Treatment protocol for laser therapy was:
pulsed wave infrared 6J/Cm²
Continuous wave infrared 4J/Cm²
And on the wound (if had) 1J/Cm²
5 days per week
For 10 to 15 sessions.

Results: In comparison with the same cases of usuall treatment (without laser therapy), course of treatment in cases of this study had less pain and edeme.
Evaluating final result, the most important factor is scar formation due to necrosis. In these cases some had no necrosis although at the onset we expected to have it. In more severe cases that necrosis happened and scar formation was inevitable scar surface was smaller because laser therapy prohibited progression of necrotic area. In addition Appearance of scars was dramatically desirable an no more interventions such as CO2 laser was needed.

Conclusion: If laser therapy begins soon with suitable protocol it can dramatically affect course of treatment and final result. As it is noninvasive with no side effect (if used properly), significantly decreases symptoms and enhances final result can be a main part of treatment protocol for filler induced arterial obstruction.

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Objectives: General objective
The general objective will be to demonstrate that there are different protocols to avoid or treat vascular complications with different drugs, which must be administered in a timely manner so as not to generate iatrogenesis, in addition to emphasizing facial anatomical knowledge prior to the application of endodermal fillers.

1.- Specific Objective
- Identify main adverse reactions to the application of endodermal injectables
- Establish existing protocols for any adverse reaction that we present
- Emphasize knowledge of facial anatomy

Introduction: Complications are due to flow obstruction both by intra-arterial injection and by external compression of the vessel by the filling material. When intra-arterial injection generates a retrograde flow, it can obstruct arteries such as the central one in the retina. Injection in any area of the face can be dangerous, but the areas most at risk of inducing blindness are: the nose, glabella, forehead, and less frequently, the eyebrows, temples, and nasolabial fold.

In the informed consent for these procedures, it is important to include the risk of skin necrosis and visual compromise.

Materials / method: A 56-year-old female patient comes to us without an appointment at the clinic requesting medical attention, since HA (hyaluronic acid) had been placed on the lips in a place without doctors. Go to the 5th day of the application for which the following is displayed:
schema data
Scab on lips by scheme
intense neuropathic pain
Redness of the chin, submental fat and in the path of the nasolabial fold
There was presence of purulent exudate on the lips and fibrin.

Results: The protocol for a late ischemia is started, since it has 5 days of evolution, for which the most recommended is this protocol.
Application of Enoxaparin inhibitory doses (anticoagulant)
Long-acting intramuscular/IV steroids (Dexamethasone 8mg every day, for 7 days)
Aspirin as a platelet aggregator (Only 500mg) since NSAIDs cause vasoconstriction and do not favor tissue oxygenation
Hyaluronidase 1500 IU in the hyaluronic acid application site, 1500 IU of Hyaluronidase in places around the lesions (we repeat this application step of hailuronidase at least 3 times)
Nifedipine 10mg long-acting

Conclusion: Knowing how to recognize the clinical signs of arterial obstruction in a timely manner would make it possible to establish a rapid and effective treatment when this complication occurs. Initially, this is manifested by whitening of the skin during the introduction of the filler, with subsequent acute pain and erythema in the applied region. This complication is addressed with the use of hyaluronidase in case of having injected hyaluronic acid, topical vasodilators such as nitroglycerin cream, and steroids to prevent progression to necrosis.

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