An Anatomical Analysis of the Supratrochlear Artery: Considerations in Facial Filler Injections and Preventing Vision Loss.

BACKGROUND: Embolia cutis medicamentosa (ECM) is a rare phenomenon attributed to intra-arterial drug injection. Glabellar filler injections can result in potentially devastating visual loss from inadvertent retrograde arteriolar embolization due to the extensive vasculature within the upper face. The minimum amount of filler necessary to potentiate this complication has not yet been reported. OBJECTIVES: We aim to determine the volume of filler necessary to occupy the supratrochlear artery from the glabella to the bifurcation of the ophthalmic and central retinal arteries. We specifically examine the volume of the supratrochlear artery from the glabella to orbital apex. METHODS: The study was approved by Duke University Institutional Review Board and involved surgical dissection of six fresh tissue cadaver heads (12 hemifaces). The arterial system in each cadaver head was injected with latex for visualization. The supratrochlear arteries were isolated anteriorly from the glabella to the orbital apex posteriorly. Intra-orbital vessel radius and length were measured. The vessel volume was calculated by water displacement of the intra-arterial latex. RESULTS: The vessel volumes ranged from 0.04 to 0.12 mL. The average vessel volume was calculated as 0.085 mL, the average length as 51.75 mm, and the average radius as 0.72 mm. CONCLUSIONS: Vascular occlusion from filler injections can lead to devastating visual consequences due to inadvertent retrograde intra-arterial embolization. Our findings indicate that the average entire volume of the supratrochlear artery from the glabella to the orbital apex is 0.085 mL. Injectors should be aware that a bolus of this critical volume may lead to a significant adverse outcome.

The Role of Adjunctive Therapies in the Management of Invasive Sino-Orbital Infection.

OBJECTIVE: Invasive sino-orbital fungal infections are life-threatening complications of immunonosupression that are difficult to treat. Currently there are no standard treatment guidelines. The most widely accepted therapy includes parenteral anti-fungal therapy and surgical debridement of sinuses with orbital exenteration, a procedure that is not only disfiguring, but may increase morbidity. Injection of retrobulbar Liposomal Amphotericin B (L-AMB) is an alternative approach that provides local administration to infected tissues. The adjunct use of anti-fungal retrobulbar injections not been extensively reviewed in treating sino-orbital infection. We are reporting the multimodal approach of using L-AMB retrobulbar injections in combination with sinus debridement, intravenous (IV) anti-fungal therapy, and hyperbaric oxygen (HBO) for the management of sino-orbital infection. METHOD & RESULTS: Review of literature of 12 cases and retrospective evaluation of one patient with sino-orbital Aspergillus flavus infection on chemotherapy for T-cell acute lymphocytic leukemia treated with retrobulbar Amphotericin B, IV anti-fungal agents, and hyperbaric oxygen therapy. Clinical characteristics, radiographic features, management techniques, and clinical outcomes are described. CONCLUSION: Retrobulbar Amphotericin B injection may be an effective adjunct to hyperbaric oxygen and parenteral anti-fungals in the control of sino-orbital fungal infections.

Safety and efficacy of combining microfocused ultrasound with fractional CO2 laser resurfacing for lifting and tightening the face and neck.

BACKGROUND: Microfocused ultrasound (MFU) and ablative fractionated laser (AFL) resurfacing techniques have been used separately to noninvasively improve skin laxity and rhytides on the face and neck. Simultaneous combination treatment would be anticipated to provide further improvement but has not previously studied. METHODS: A retrospective analysis of 100 combination face and neck treatments from 3 centers was performed, including collective treatment protocols, postoperative recovery, side effect profile, and clinical results. RESULTS: Skin laxity and photodamage (rhytides and texture) showed significant improvement with combination MFU + AFL treatment. Except for increased facial swelling in a small percentage of patients, postoperative recovery and side effects were comparable with those obtained after application of individual treatments. CONCLUSION: Combination MFU-AFL on the face and neck is a safe and effective method for targeting multiple facets of facial and neck skin aging and can be safely performed in a single treatment session.

Ocular manifestations of acute graft versus host disease after allogeneic bone marrow transplant.

A 17-year-old-male with Sickle Cell Disease underwent allogenic bone marrow transplant. Two years after the transplant the patient developed violaceous lichenoid papules coalescing into plaques over the face and upper extremities complaining of decrease visual acuity, foreign body sensation, and eye pain. A slit lamp examination showed injected conjunctiva, superficial I punctate keratopathy and decreased baseline Schirmmer test. Dermatologic evaluation and biopsy demonstrated chronic graft versus host disease along with the diagnosis of secondary keratoconjunctivitis sicca.