Long-term Prognosis of Vision Loss Caused by Facial Hyaluronic Acid Injections and the Potential Approaches to Address This Catastrophic Event.

BACKGROUND: Vision loss is a serious complication of hyaluronic acid (HA) filler injections, and long-term observations regarding the prognosis, particularly with angiography, are rare. OBJECTIVES: This study aimed to investigate the long-term prognosis and living status of patients with visual defects due to HA filler injections. METHODS: Nine patients with vision loss caused by HA filler injections and receiving different treatments were included and followed up for 2 to 6 years after their accident. Follow-ups, including outpatient ophthalmologic examinations, were performed. RESULTS: In the follow-up observation, all patients had reintegrated into society and work. The prognosis was similar for all hyaluronidase treatments, including retrobulbar injections and superselective ophthalmic artery thrombolysis. The facial appearance was not remarkably affected, and only 3 patients reported slight scarring. Ptosis disappeared in all the patients, and slight strabismus was found in 5 patients. However, vision improvement was very limited, even in the patients whose occluded retinal central artery received reperfusion. CONCLUSIONS: This long-term follow-up showed that the patients with vision loss caused by HA filler injections could reintegrate into society after treatment. Although the embolization of the retinal central artery led to reperfusion, vision was not restored, which further demonstrated the difficulty of recovering vision with the current treatment and the importance of prophylaxis. Autohydrolysis of HA by incorporating hyaluronidase-containing stimuli-responsive nanoparticles and a dual-pipe syringe are potential future approaches to address this catastrophic event.

Blindness After Facial Filler Injections: The Role of Extravascular Hyaluronidase on Intravascular Hyaluronic Acid Embolism in the Rabbit Experimental Model.

BACKGROUND: Blindness caused by ophthalmic artery embolism is the most catastrophic complication of facial hyaluronic acid (HA) injections. Extravascular (retrobulbar) injection of hyaluronidase has been suggested as a salvage in this calamitous situation. However, the effectiveness of this treatment still lacks consensus. OBJECTIVES: The aim of this study was to investigate the role of extravascular hyaluronidase in dissolving intravascular HA occlusion. METHODS: Two different animal experiments were performed: (1) isolated rabbit abdominal aorta segments filled with HA were treated with extravascular immersion of highly concentrated hyaluronidase for 90 minutes, followed by gross observation, microscopic examination, particle size analysis, and immunohistochemical staining; and (2) live rabbit auricular arteries were first occluded with HA and then immediately treated with extravascular injection of hyaluronidase. The ears were then evaluated by gross observation, microscopic examination, and perfusion studies after 60 minutes and again after 90 minutes. RESULTS: The HA within the aorta segments showed no gross or microscopic changes after treatment with extravascular hyaluronidase. Hyaluronidase could only be detected in adventitia of the aortae, instead of in vascular smooth muscle, tunica intima, or vascular lumen. The occluded auricular arteries showed no reperfusion after extravascular injection of hyaluronidase. CONCLUSIONS: In this rabbit model, extravascular hyaluronidase was unable to penetrate into the arterial lumen of the isolated abdominal aorta or the live auricular artery of the rabbit to dissolve intravascular HA within a 90-minute time limit, thus casting doubt on whether extravascular (retrobulbar) hyaluronidase injection has a role in treating ophthalmic artery embolism caused by HA injections.

A Flexible Suspension Technique of Blepharoplasty: Clinical Application and Comparison with Traditional Technique.

BACKGROUND: Double-eyelid blepharoplasty is one of the most popular aesthetic surgeries in China. But the traditional method produces a hidebound double eyelid due to its rigid suturing between the skin and the tarsus. The authors of this article concluded a novel technique of "flexible suspension technique" compared with traditional blepharoplasty which is considered as a "rigid fixation technique." METHODS: This is a retrospective study of two groups of 100 Chinese Han females, on whom double-eyelid blepharoplasty was performed, 50 cases by "flexible suspension technique" and the other 50 by "rigid fixation technique." The basic procedure of "flexible suspension technique" is suturing the orbicularis oculi muscle to the septal extension. Thus, the surgical connection between skin and tarsus is flexible. The surgical results were evaluated and compared using the Global Aesthetic Improvement Scale and Visual Analogue Scale/Score. RESULTS: The "very much improved" rate in the "flexible suspension technique" group was higher than that in the "rigid fixation technique" group (p < 0.05). Postoperative appearances of the "flexible suspension technique" group were also better than the "rigid fixation technique" group with less edema (p < 0.05) and slighter incision scars (p < 0.05). However, the incidences of asymmetry and fold loss were higher in the "flexible suspension technique" group (p < 0.05). CONCLUSION: The flexible suspension technique blepharoplasty can obtain a more natural appearance and has less adverse effects and shorter recovery time. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Repair of Large Full-Thickness Scalp Defects Using Biomaterial and Skin Grafting.

The reconstruction of large full-thickness scalp defects remains a surgical challenge, especially when the skull is exposed completely without periosteum. Surgical technique options for wound coverage have included tissue expansion, skin grafting, local or regional flaps, and microvascular free tissue transfer. In recent years, some authors have reported to use biological material as an alternative for repairing complex wounds. The authors report the successful reconstruction of a large defect with bare skull in bilateral temporal regions of a 3-year-old child. The patient was treated with artificial biomaterial followed by skin grafting, without making multiple cranial burr holes or burring out the outer bony cortex. The relevant literatures were reviewed and the vascular anatomy evidence of the blood supply at temporal region was also demonstrated on cadaver. This case suggests that artificial biomaterial followed by skin grafting is a potential alternative for the treatment of large full-thickness scalp defects in pediatric patients.

Anatomic Study of Ophthalmic Artery Embolism Following Cosmetic Injection.

INTRODUCTION: Cosmetic injections of dermal fillers or fat could cause ophthalmic artery embolism and even blindness, the high-risk regions of which are considered glabellar, nasal dorsum, and nasolabial fold. Understanding anatomy of the related arteries is important for a physician to safely perform filler injections. To investigate the mechanisms of ophthalmic artery embolism following the injections, cadaver anatomy was studied. METHODS: Ophthalmic artery, facial artery, their branches, and anastomoses among them were anatomized in 12 fresh cadavers. Mimetic injections of hyaluronic acid were performed in glabellar region, nasal dorsum, and nasolabial fold, the relationships between injected filler and related arteries were then investigated. RESULTS: It was clearly found that 4 arteries were located in common injection regions and connected to ophthalmic artery: supratrochlear artery, supraorbital artery, dorsal nasal artery, and angular artery. In the glabellar region, the deep injection on the periosteum will be risky to injure supratrochlear artery and supraorbital artery, whereas in nasal dorsum and nasolabial fold, the sub- superficial musculo aponeurotic system layer injection has the possibility to injure dorsal nasal artery, angular artery, and facial artery. CONCLUSION: The anatomic mechanism of ophthalmic artery embolism is the anastomoses among the related arteries and ophthalmic artery. Based on the findings of the study, injections in periosteum layer at glabellar region or sub-superficial musculo aponeurotic system layer of nasal dorsum and nasolabial fold are not advised.

Treatment of melasma with oral administration of tranexamic acid.

BACKGROUND: Melasma is a common pigmentary disorder among Asian women. The available therapies such as bleaching agents, chemical peeling, laser, and intense pulsed light are not satisfactory or safe. In the search to find a new treatment therapy for melasma, oral administration of tranexamic acid (TA) was studied clinically in Chinese patients. METHODS: The study enrolled 74 patients. Tranexamic acid tablets were prescribed at a dosage of 250 mg twice daily for a therapeutic period of 6 months. All the patients were followed up for more than 6 months after the treatment. The effects of treatment were evaluated by two physicians independently and by the patient based on improvement of pigmentation and reduction in melasma size. These were graded into four levels: excellent, good, fair, and poor. RESULTS: After 6 months of treatment, the effects were graded as follows: excellent (10.8%, 8/74), good (54%, 40/74), fair (31.1%, 23/74), and poor (4.1%, 3/74). Side effects of TA such as gastrointestinal discomfort (5.4%) and hypomenorrhea (8.1%) were observed, but no severe complications were found. The recurrence of melasma was observed in seven cases (9.5%). CONCLUSIONS: Oral administration of TA is an effective and safe therapy for the treatment of melasma. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Combined anchor suture with external upper eyelid blepharoplasty in Asian patients.

OBJECTIVE: To study the effect of an anchor fixation stitch in combination with the external incision technique in Asian upper blepharoplasty. METHODS: Combined with an upper eyelid blepharoplasty using a conventional external incision procedure, an anchor stitch was used to fixate the dermal layer of the pretarsal skin and the upper edge of the tarsal plate. The procedure was performed in 72 patients with creaseless eyes (50 cases) or with laxity of the upper eyelids due to aging (22 cases). The patients were followed up for 6 to 12 months. The upper eyelid folds were evaluated by the surgeons and by the patients, and the outcome was graded as excellent, good, fair, or poor. RESULTS: Of the 72 patients, 52 (72%) had excellent results and 20 (28%) had good results; no patients had fair or poor results. There were no cases of crease loss after 6 to 12 months of follow-up. All patients were satisfied with the results. CONCLUSIONS: The findings show that the combined anchor suture with external surgery is a reliable approach to Asian upper eyelid blepharoplasty both in young creaseless eyelids and in eyelids with laxity due to aging. We suggest that the anchor suture could be used as a routine procedure in Asian blepharoplasty.

Laser lipolysis used to treat localized adiposis: a preliminary report on experience with Asian patients.

BACKGROUND: Localized deposits of fat (adiposis) located in the face, chin, neck, and arms usually are more compact and difficult to treat using conventional liposuction. It is necessary to find an effective approach for this type of localized adiposis. This study aimed to investigate the clinical application of laser lipolysis for the treatment of localized adiposis in Asian patients. METHODS: In this study, 35 patients with localized adiposis were treated by laser lipolysis. Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser energy was transferred through an optic fiber into the adipose tissue. The optimal energy and frequency of the laser were controlled precisely to melt and destroy the adipose tissue without damage to the skin and deeper tissues. The histologic study of treated adiposis tissues, the postoperation reaction, and the clinical results were observed and studied. RESULTS: After laser lipolysis, the localized adipose tissues were liquefied effectively, and the compact fibrous tissues were broken down into a looser structure. Bleeding was noted to be less than with conventional liposuction due to the coagulation of capillary vessels and the thermal effect of the laser. Laser lipolysis caused less edema, petechiae, and other postoperative complications, producing rapid recovery and satisfactory results. CONCLUSION: The Nd:YAG laser has a definite lipolysis effect on compact adipose tissue and is a more effective approach for the treatment of localized adiposis than conventional liposuction.

Dual-energy X-ray absorptiometry (DEXA): a novel approach for the evaluation of abdominal liposuction results.

BACKGROUND: It is difficult to measure exactly the amount of adipose tissue by which the body is reduced after liposuction. Dual-energy X-ray absorptiometry (DEXA) has been widely used in not only the diagnosis of osteoporosis but also the analysis of body composition such as the amount of bone mineral, adipose tissue, and other soft tissue. With this technique we can determine the exact amount of adipose tissue removed by liposuction. METHODS: Twenty-eight subjects who underwent abdominal liposuction were enrolled in the study. DEXA scans were performed before and 2-3 months after liposuction. Data were collected and statistical analysis was performed. CONCLUSION: DEXA is a feasible alternative for the evaluation of liposuction results.

[Endoscope assisted transaxillary subglandular breast augmentation].

OBJECTIVE: To investigate the feasibility of endoscope assisted transaxillary subglandular breast augmentation in order to minimize the bleeding and tissue injury. METHODS: Since 2005, 27 patients underwent endoscope assisted transaxillary subglandular breast augmentation. Intraoperative bleeding and dissection injury were markedly decreased. RESULTS: There was no hematoma, seroma and infection except for one case with partial poor incision healing. 16 cases were followed-up for six months to one year. Only one case developed fibrous capsular contracture (Baker II). Good results achieved in all the other cases. CONCLUSIONS: Endoscope assisted breast augmentation can reduce the pain, bleeding and tissue injury. It can also help to put implants to right position.