Steve Yoelin MDPrivate Practice

Newport Beach, California

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Disclosures–Allergan: Consultant, Paid Research

–Galderma: Consultant

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Treatment Goals for Botulinum Toxin Therapy

Effacement of hyperfunctional rhytides

Recontour facial proportions and achieve symmetry

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Injectable Botulinum Toxins

Produced by various strains of Clostridium botulinum

Serotype A

– onabotulinumtoxinA = BOTOX® Cosmetic

– abobotulinumtoxinA = Dysport®

– incobotulinumtoxinA = Xeomin®

onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA are FDA-approved for

cosmetic use (glabellar lines); onabotulinumtoxinA approved for crow’s feet

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Know

Your Anatomy!

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Complications

Brow Ptosis

Eyelid Ptosis

HeadacheBruising

(Hematonia)

Asymmetry

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Video

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Video

DERMAL FILLERS

TREATMENT GOALS FOR DERMAL FILLERS

Volume restoration

Recontour facial proportions and achieve symmetry

WHICH DERMAL FILLER TO USE

Videos

Videos

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Vascular Complications

Background Mechanisms Findings Prevention & Treatment Personal Experience Blindness

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Background

Soft-Tissue Fillers Widespread use in the 1980s with advent of bovine

collagen In North America, second-most popular nonsurgical

aesthetic procedure behind botulinum toxins (Botox) The popularity of soft-tissue fillers in part due to their

favorable side effect profile Adverse effects from soft-tissue filler injection are

generally mild and self-limited

“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.

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Injection site reactions

– Bruising

– Swelling

– Erythema

Infections

Nodules / asymmetry

Hypersensitivity

Vascular compromise

Delayed (Can Be Years Later)

Infection

Granuloma formation

Biofilm formation

Adverse Events from Soft-Tissue Augmentation

Early (Within 1 Week)

Adapted from Glashofer MD, Flynn TC. Complications of temporary fillers. In: Carruthers J, Carruthers A. Soft

Tissue Augmentation. Toronto: Elsevier Saunders; 2013:179-187.

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Vascular Compromise

Most ominous adverse event

Partial or complete interruption of vascular supply by extravascular compression

Complete occlusion of vascular supply from intravascular injection

– Subsequent necrosis and scarring are potentially permanent sequelae

“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.

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Vascular Compromise

All soft-tissue fillers can lead to vascular compromise, including:

– Hyaluronic acids

– Calcium hydroxylapatite

– PMMA

– PLLA

– Collagen

– Fat

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Mechanisms

Not completely understood

Extravascular– Results from vessel compression due to injectable filler

– Secondary inflammation and edema can further put pressure on vessels

Intravascular– Results from direct injection of the filler into the vasculature causing

obstruction and damage to the wall of the blood vessels

– This presentation may be immediate and has also been reported with a delayed presentation at 6 hours post-injection

“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.

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Findings

Typically, the first indication of vascular damage after filler injection is painless blanching

– This can be subtle and may go unnoticed

Over the next couple of days, progression to a painful, violaceous, reticulated patch may occur

A necrotic eshar may develop on top of an ulcer with subsequent scar formation

Treatment should be instituted at first sign of this complication to prevent necrosis and scarring

“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.

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Incidence

Presented as 0.001% in the literature, but believed to be higher (the “elephant in the room”)

– Underreported

– Fillers are now being injected into deeper planes of the face, which poses greater risk of vascular occlusive events

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Prevention

There are a number of preventative strategies that can reduce the risk of occlusion

– Choose a reversible hyaluronic acid filler

– Exercise caution when injecting high-risk areas

– Aspirating before injecting

– Use low volumes of product

– Use a cannula technique

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Personal Experience

Before After

• Age: 28

• Date of Incident: May 2016

• Treatment Area: Tear Trough

• Product: Biphasic HA

• Findings:

• Blanching to right cheek

• Violaceous reticulated patch

• Treatment

• Hyaluronidase

• Aspirin

• Massage

• Warm packs

• Nitroglycerine paste

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Blindness

Mechanism

– Arterial pressure can be overcome and retrograde movement of material into the more proximal arterial network can occur

– Then embolization of the ophthalmic artery can deprive the retina of oxygen and lead to blindness

“Dermal fillers in aesthetics: an overview of adverse events and treatment approaches” Clin Cosmet Investig

Dermatol. 2013 Dec 12;6:295-316

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Blindness

Angiographic findings of a hyaluronic acid-injected

patient. A 39-yr-old woman after hyaluronic acid

injection in the glabella and nasal dorsum. (A)

Fundus photograph reveals segmented and

attenuated retinal vessels. (B) Fundus fluorescein

angiography shows markedly compromised retinal

and choroidal perfusion.

“Cerebral Angiographic Findings of Cosmetic Facial Filler-related Ophthalmic and Retinal Artery Occlusion” J Korean Med Sci. 2015 Dec;

30(12): 1847–1855.

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Blindness

High-risk areas

– The glabella

– The forehead

– The nose

– The periorbita

“Complications Following Injection of Soft-Tissue Fillers” Cemile Nurdan Ozturk MD, Yumeng

Li BS, Rebecca Tung MD, Lydia Parker MD, Melissa Peck Piliang MD, James E. Zins MD

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Blindness

Treatment

– Document vision

– Evaluate pupils

– Retro or PeriBulbar High-Dose Hyaluronidase Injection

– Oral aspirin

“Retro or PeriBulbar Injection Techniques to Reverse Visual Loss After Filler Injections.” Dermatol Surg. 2015 Dec;41 Suppl

1:S354-7. doi: 10.1097/DSS.0000000000000558.

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Final Thoughts

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Thank you!