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A Review Of Severe Complications Following Injection Of Soft Tissue Fillers
Cemile N. Ozturk, MD1, Yumeng Li, BS2, Rebecca Tung, MD3, Lydia Parker, MD4, Melissa Piliang, MD5, James E. Zins, MD1.
1Cleveland Clinic, Department of Plastic Surgery, Cleveland, OH, USA, 2Cleveland Clinic, Lerner College of Medicine, Cleveland, OH, USA, 3Loyola University, Stritch School of Medicine, Division of Dermatology, Maywood, IL, USA, 4Case Western Reserve University, School of Medicine, Department of Dermatology, Cleveland, OH, USA, 5Cleveland Clinic, Departments of Dermatology and Anatomic Pathology, Cleveland, OH, USA.

PURPOSE: While soft tissue filler injections offer a consistently safe profile, severe complications can and do occur. We sought to identify the facial areas that are most prone to complications, highlight their clinical presentation and course and create an algorithm for treatment.
METHODS: The complications reviewed included filler embolization, necrosis, blindness and anaphylaxis. The meta-analysis was limited to English language, to complications in the face, and to FDA approved fillers. Case reports were analyzed for type of filler, injection site, complication site, symptom interval, symptom of complication, time to therapy, modality of treatment and outcome.
RESULTS: A total of 41 articles representing 61 patients with severe complications were identified. Thirty-nine cases of significant soft tissue loss, 9 cases of “impending necrosis”, 12 cases of visual impairment and 1 case of anaphylaxis were reported. Of 61 cases, the most common injection site associated with severe complications was the nose 32.8% (n=20), followed by the glabella 26.2% (n=16) and the nasolabial fold 26.2% (n=16).
When necrotic complications were analyzed, the nose was the most common injection site (n=16, 33.3%) and hyaluronic acid was the most common filler implicated. The most consistent symptom associated with intravascular injection was immediate pain upon administration of the product. Tissue loss was located directly at the injection site in 46.2% of cases (n=18) and at the site nourished by the compromised vessel in 28.2% of cases (n=11). Of 39 cases of soft tissue loss, 11 cases (28.2%) were reported to have healed completely with minimal scarring and 15 cases (38.5%) had visible scars. In 13 of the cases (33.3%) outcomes were not reported.
When visual complications were analyzed, glabella was the most common site of injection (n=6, 50%) and collagen was the most common causative filler. Symptoms of visual loss developed within minutes and was accompanied by pain in the affected eye. Only two of the 12 reported cases (16.7%) had complete recovery of vision and one (8.3%) had partial recovery. Six of 12 cases (50%) resulted in permanent complete blindness. In 3 cases (25%) the outcome was not clearly reported.
Consensus treatment of suspected intravascular injection should include the following : immediate cessation of the injection, massage, warm compresses, topical nitroglycerine paste and hyaluronidase regardless of filler type. If visual symptoms develop prompt ophthalmology consultation is required. An algorithm for treatment upon suspected intravascular injection is presented in Figure 1.
CONCLUSION: Although rare, severe complications can occur following soft tissue fillers injections. Physicians should be aware of their presentations and have possible treatment methods handy.


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