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Background: Aliaxin fillers (HAALI), produced by IBSA Farmaceutici Italia SrL (Italy), are biodegradable, non-pyrogenic, 1,4-butanediol diglycidyl ether cross-linked hyaluronic acid (HA) hydrogels. The formulations are tailored for different clinical indications, ensuring precise and natural outcomes. Their cohesivity and tissue integration capabilities are associated with relatively few adverse events (AEs), supporting their widespread use in aesthetic treatments. This article examines the real-world safety profile of HAALI fillers derived from worldwide post-marketing surveillance data. Methods: Post-marketing surveillance was registered by the manufacturer from January 2018 to September 2023. During this period, product complaints were globally gathered from healthcare practitioners and consumers, relating to technical issues or safety and productrelated adverse events. Results: No discernible trend or substantial escalation in AEs across the entire product range were observed during the surveillance period (p>0.05). No statistically significant increases (p>0.05) in the frequency or severity of safety incidents and AEs were observed. The most frequently observed AEs were oedema (26%) and swelling (19%). Conclusion: The analysed data further support and confirm the high safety profile of the HAALI fillers for different approaches in aesthetic medicine. This evaluation also highlights the importance of post-marketing analysis by continuing to foster a robust understanding of products currently used in daily clinical practice.

Introduction: The rising popularity of facial filler injections has corresponded with an increase in reported complications. While a filler emergency kit was previously introduced, advancements in the field have highlighted certain limitations, prompting the development of the updated filler emergency kit (UFEK). Methods: The authors conducted literature research up to February 2023, focusing on PubMed and open web searches for articles referred to filler emergent complications: vascular occlusion, blindness and anaphylaxis. Approximately 1200 articles were obtained from PubMed and other sources, and 45 articles were reviewed. Results: The developed UFEK protocol delineates specific interventions meticulously tailored to address diverse emergent scenarios linked to soft tissue fillers complications. This protocol emphasizes the urgent requirement for timely and personalized interventions. Conclusion: The UFEK offers a standardized, comprehensive and effective approach. This work contributes to the responsible and informed progression of the field of aesthetic medicine, providing more value and safety, both for clinicians and patients. 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. [ABSTRACT FROM AUTHOR]

Hyaluronic acid (HA) filler, a transient injectable used for rejuvenating facial treatments, has become increasingly popular over time since it doesn’t require surgery. Although these procedures are generally safe, there are some application-related complications. These issues fall into three categories: reactions with early, delayed, or late onset. This case report features a 55-yearold female patient who developed widespread facial edema as a result of a delayed hypersensitivity reaction that happened after HA filler was applied. [ABSTRACT FROM AUTHOR]

A patient was treated with tear trough filler and developed a retrobulbar haemorrhage. This was managed acutely with a lateral canthotomy and cantholysis with no lasting visual compromise. This is the first reported case of an orbital compartment syndrome following filler injection and highlights the potential blinding complications which can occur. There should be an increased awareness of this complication amongst practitioners administering tear trough filler. [ABSTRACT FROM AUTHOR]

Although permanent fillers have been introduced in order to get long-lasting results, many studies have shown numerous severe and disfiguring complications. Nonsurgical procedures may mitigate those adverse events but the only way to remove the filler previously injected is represented by surgical excision. We present a pathway of facial surgical accesses to be performed achieving two goals: permanent filler removal and restore facial aesthetic balance. The proposed surgical accesses are already standardized in aesthetic surgical practice in order to avoid direct excision and unpleasant facial scar. A total of 231 patients underwent surgery for permanent filler removal and aesthetic restoration of the involved facial area, represented by forehead, glabella, nose, cheeks, eyelids, chin, jawline, and lips. Magnetic resonance evaluation was performed with the exception of lip patients who were evaluated with ultrasound. Postoperative follow-up was 12 months to 6 years. Subjective and objective methods were used for outcome evaluation according to the FACE-Q questionnaire. Functional and aesthetic correction was scored using the patient-graded Global Aesthetic Improvement Scale (GAIS), overall patient satisfaction was assessed by a five-point scale questionnaire. Functional and aesthetic restoration was globally recognized as improved according to the GAIS. Patients reported high levels of satisfaction assessed by a five-point scale questionnaire. A very good satisfaction level was registered in both subjective and objective judgment scores. To the best of our knowledge, we present the largest case series regarding surgical removal of permanent facial fillers. A proper preoperative evaluation, filler removal followed by restorative facial aesthetic surgery technique is paramount to approach challenging cases. [ABSTRACT FROM AUTHOR]

The frequency of cosmetic application and the possibility of complications are increasing day by day all over the world. It can be said that the most important complication that can be seen after cross-linked hyaluronic acid filler applications is vascular complications, because there may be results such as tissue loss and vision loss. A forty six year old female patient was consulted from the plastic surgery clinic with complaints of purple discoloration and pain on her forehead. In the anamnesis, it was learned that the patient's wrinkle in the frontal region was filled with filler 4 days ago. A bluish-purple area in a reticular pattern that does not disappear with pressing was observed, starting from the glabellar area and progressing towards the frontal hairline. Vascular complication due filler material and ischemia was considered in the patient and treatment was started immediately. Totally 300 U of hyaluronidase was injected intra and subdermally. It was recommended to mix of topical betamethasone valerate and fusidic acid three times a day and apply topically to the complained area, and apply hot compress 4 times a day for 4 minutes. The patient was referred for hyperbaric oxygen therapy for an average of 2-2.5 hours per day for 2 consecutive days. On the 7th day after the first hyaluronidase administration, the patient's physical examination revealed no signs of significant ischemia and vascular occlusion. Our aim in sharing this case was to state that although the risk of vascular complications in filler applications is related to the amount of filling, there is a risk of vascular complications even in very-very small filling applications. In addition, if there is a previous surgical, traumatic or burn scar tissue in an area, we think it would be beneficial to think twice before applying. [ABSTRACT FROM AUTHOR]

Although hyaluronic acid (HA) filler injections are associated with various non-vascular inflammatory complications, the underlying mode of action remains unclear. The hyaluronic acid filler may not be sufficiently pure, leading to an immune response. The present study attempted to identify any impurities in hyaluronic acid fillers available on the market. Particles were counted after degrading hyaluronic acid filler with hyaluronidase. Particulate matter was subsequently observed using scanning electron microscopy, and the particle components were evaluated using energy-dispersive X-ray spectroscopy. Different quantities of impurity particles (>10 and 25 μm) were detected microscopically. Silicon and aluminum isotopes were also detected. Hyaluronic acid fillers were contaminated with these particles. The degree of contamination varied substantially among the tested filler products. These contaminant particles may evoke reactions in the patient's body. Clinicians should be aware of this source of possible contamination and its effects. [ABSTRACT FROM AUTHOR]

Serious complications of cosmetic filler injections include vascular necrosis if the filler is injected into an artery. The use of a microcannula for filler injection has been reported to be safer with lower rates of vascular occlusion. We report a case of vessel infiltration that was noted prior to injection with microcannula which identifies an additional safety step for injectors. This case highlights the potential for devastating vascular occlusion with microcannula use while also demonstrating methods to identify vascular infiltration prior to filler injection. The purpose of this report is to educate and encourage injectors to inspect the introducer needle prior to any filler injection in order to avoid vascular occlusion during filler injection. [ABSTRACT FROM AUTHOR]

Background: Hyaluronic acid (HA) fillers are commonly used in esthetic medicine for facial contouring and rejuvenation. However, complications such as overcorrection, vascular occlusion, and irregular filler distribution necessitate the use of hyaluronidase to dissolve the fillers. This study aimed to evaluate the efficacy of hyaluronidase in degrading different types of HA fillers and provide clinical guidelines for its use based on filler type, dosage, and application techniques., Methods: A series of in vitro and in vivo experiments were conducted to assess the dissolution of biphasic and monophasic HA fillers using varying concentrations of hyaluronidase. The in vivo component used animal models to determine the duration of hyaluronidase activity in biological tissues, whereas the in vitro study examined the dissolution rates of HA fillers in response to different hyaluronidase concentrations and application methods. A control study using saline was also performed to compare the natural hydration process of the fillers., Results: Hyaluronidase efficacy was found to vary based on the type of HA filler and the enzyme's concentration. Biphasic fillers dissolved more rapidly at lower concentrations of hyaluronidase compared to monophasic fillers, which required higher concentrations and longer exposure times for effective breakdown. The study also demonstrated that direct injection of hyaluronidase into the filler mass was more effective than surface application. Pharmacokinetic analysis revealed that hyaluronidase activity diminished within 30 min in biological tissues, highlighting the need for timely intervention in clinical scenarios., Conclusion: Hyaluronidase is effective in dissolving HA fillers, with its efficacy dependent on the type of filler, concentration, and application technique. Biphasic fillers respond more quickly to hyaluronidase, whereas monophasic fillers require higher doses and multiple treatments. Clinical recommendations include using direct injection techniques, tailoring hyaluronidase dosage based on the filler type, and considering hypersensitivity reactions. Future research should focus on the long-term effects of hyaluronidase and refining clinical protocols for its use., (© 2025 The Author(s). Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Krishan Mohan Kapoor,1,2 Deasy Indra Saputra,3 Catherine Ellen Porter,4 Ligia Colucci,5 Catherine Stone,6 Elian Elisabeth Anne Brenninkmeijer,7 Jake Sloane,8 Karim Sayed,9 Ketut Kwartantaya Winaya,10 Dario Bertossi11 1Anticlock Clinic, Chandigarh, India; 2Department of Plastic Surgery, Fortis Hospital, Mohali, India; 3Project Skin BMDerma Clinic, Jakarta, Indonesia; 4All Saints Skin Clinic, Darlinghurst, NSW, Australia; 5Clinica Ligia Colucci, Belo Horizonte, MG, Brazil; 6The Face Place Medspa, Auckland, New Zealand; 7Elian Brenninkmeijer Cosmetic Dermatology, Amsterdam, the Netherlands; 8Infinity Skin Clinic, Surry Hill, NSW, Australia; 9Faculty of Health and Social Sciences, University of South-East Norway, Drammen, Norway; 10Department of Dermatology, Udayana Public University Hospital, Bali, Indonesia; 11Department of Maxillo-Facial Surgery, University of Verona, Verona, ItalyCorrespondence: Krishan Mohan KapoorAnticlock Clinic, #1508, Sector 33 D, Chandigarh, 160022, IndiaTel +91-9814600600Email kmkapoor@gmail.comAbstract: The aging process affects every anatomical layer of the face. Improved knowledge of how aging occurs in each anatomical layer of the face has helped evolve the facial rejuvenation strategies with HA fillers. Understanding the age-related changes in the anatomical facial layers, including their time of onset and how the changes occur in the different tissue layers, an injector can provide much more targeted and refined HA filler treatments. As fillers’ use has increased, there has been a distinct shift away from procedures lifting the skin and SMAS. We can selectively target the anatomical facial layers with HA fillers for more refined and predictable outcomes. An extensive range of HA filler variants is now available. Each filler type is optimized and designed to be injected into specific tissue planes for the best results. Knowing the predictable aging changes in the different tissue layers of the face is crucial as this guides the optimum filler choice. Working knowledge of the individual characteristics of the numerous HA-based products allows for their effective placement in the correct layer. Familiarity with the correct HA product may also help to minimize the downtime and risk of adverse events.Keywords: facial aging, facial anatomy, filler injections, filler procedures, fillers, hyaluronic acid, filler complications

Background: Hyaluronic acid filler injection is commonly administered to correct temple hollowness, typically through deep temporal injection. Since the vascular distribution at the injection site can be diverse, studies on avoiding damage to the corresponding blood vessels are needed. Aims: To assess the commonly used hyaluronic acid filler injection site in the temple region, 1cm lateral and 1 cm above from the end of eyebrow, using a Doppler ultrasound to detect any anatomic variations in the blood vessels. Patients/Methods: Thirty patients (60 temples, right and left) were examined using Doppler ultrasonography. An 8‐17 MHz ultrasound probe was used to discriminate between the anatomic layers of the temple. Blood vessels found in each anatomical layer were subsequently investigated. Results: Among the 30 patients included in this study, we found temporal region arteries 1 cm above and 1 cm lateral to the distal end of the eyebrow in 9 patients; However, no arteries were detected in the temples of 21 patients. The presence or absence of arteries was bilateral in all patients. Conclusions: The anatomical layers with blood vessels varied among patients. The variability could give rise to complications. Possible anatomic variations at the temple should be carefully identified using pre‐injection ultrasonography, and harming blood vessels should be avoided while injecting hyaluronic acid filler for temple augmentation. [ABSTRACT FROM AUTHOR]

Background: The interest in youthful appearance and rejuvenating procedures is unbroken in our society. Besides surgical procedures, permanent fillers are utilized. The incorrect and unprofessional use of these substances, auto-injections in particular, have devastating results for patients and are challenging for the plastic surgeon. The aim of this retrospective study was to delineate the differences between permanent and non-permanent filler complications and appropriate treatment options. Methods: We conducted a retrospective study and researched the hospital information system in the time period from 2001 to 2020. Patients with unprofessional use of permanent fillers, auto-injections and injections of unformulated substances were determined. Age, gender, localization, complications, length of hospital stay, comorbidities, histopathological workups and surgical salvage procedures were noted. Descriptive statistics were calculated. Results: Seventeen patients were identified from 2001 till 2020. In four cases, auto-injections by the patients were the cause, whereas in the other patients the injections were performed by medical staff. Ages range from 18 to 57 years. Fourteen patients were female and three were male. The injected substances could be recognized as synthol, silicone, vaseline, fat tissue, hyaluronic acid as well as non-medical substances. Surgical procedures were necessary in eleven cases. One patient died because of the underlying diseases. Conclusion: Our results indicate different sequels of filler materials injected in an unprofessional way, possible complications, conservative and surgical techniques to resolve these rare complications. We suggest a staged therapy adjusted to the clinical symptoms. Milder symptoms can be handled conservatively, whereas severe infections, skin breakdowns or persistent granuloma are justifying indications for surgical treatment. Level of Evidence V: 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. [ABSTRACT FROM AUTHOR]

Filler injections have become very popular in recent years, and injectors globally use them for facial shaping and reversing age-related changes. Detailed knowledge about important vessels' and tissue planes' anatomy is essential for injectors. While giving the filler injections, injectors tend to gently pinch or pull the tissue fold with the nondominant hand during the procedure. The deformational forces cause some changes in the anatomy of tissue layers held in a pinch. During the pinch and "pinch and pull" maneuver, the crucial vessels in the area can get pulled up in the tissue layers in a pinch or stay in their position unaffected depending on the force applied. The "pinch and pull" maneuver also increases the tissue space for injections by moving the mobile tissue layers away from the fixed ones. The injector can use knowledge of the "'pinch anatomy" in the forehead to avoid important arteries and place filler in the correct plane. With the understanding of the anatomical changes occurring during the pinched state of tissue layers, filler injection can be performed in the right and safer tissue plane in the forehead. This study reflects level of evidence V. [ABSTRACT FROM AUTHOR]

Objective: This retrospective review assesses the efficacy and safety of low-dose triamcinolone (1mg/cc) added to hyaluronic acid fillers to decrease swelling after infraorbital injection.Methods: This retrospective analysis includes 447 patients who underwent 706 infraorbital hyaluronic acid filler treatments from April 2013 to March 2020 by a single injector. Short-term post-procedural swelling (≤2 weeks) was assessed through follow-up phone calls, which were documented in patient charts. The effect of triamcinolone, filler type, volume, and patient characteristics on the rate of post-procedure swelling were analyzed.Results: Swelling after infraorbital hyaluronic acid filler occurred in over half of the patients (51%, 103/202), but significantly decreased (23%, 29/124) when 1mg/cc of triamcinolone was mixed with the filler (x2[1, N=326]=24.296, p<0.00001). The incidence of swelling was directly correlated with the amount of hyaluronic acid filler injected (37% ≤ 0.55cc, 51% 0.56-1cc, and 60% >1cc) [x2[1, N=95]=3.9231, p=.048]. There was no significant difference in patient age, sex, Fitzpatrick skin type, or history of allergies on incidence of post-procedure swelling. Adverse events were limited to expected injection-site reactions, and there were no reports of hypopigmentation or atrophy from the addition of triamcinolone.Limitations: This is a retrospective study that used patient reporting for short-term post procedure swelling.Conclusion: This is the first retrospective study showing the safety and efficacy of a novel technique adding low-dose triamcinolone (1mg/cc) to hyaluronic acid filler to reduce post-procedure swelling within the first few weeks following infraorbital injection. Additionally, using lower volumes is also effective at reducing post-procedure swelling. Larger, randomized, controlled trials are needed to support our findings. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This retrospective review assesses the efficacy and safety of low-dose triamcinolone (1mg/cc) added to hyaluronic acid fillers to decrease swelling after infraorbital injection. METHODS: This retrospective analysis includes 447 patients who underwent 706 infraorbital hyaluronic acid filler treatments from April 2013 to March 2020 by a single injector. Short-term post-procedural swelling (<2 weeks) was assessed through follow-up phone calls, which were documented in patient charts. The effect of triamcinolone, filler type, volume, and patient characteristics on the rate of post-procedure swelling were analyzed. RESULTS: Swelling after infraorbital hyaluronic acid filler occurred in over half of the patients (51%, 103/202), but significantly decreased (23%, 29/124) when 1mg/cc of triamcinolone was mixed with the filler (x2[1, N=326]=24.296, p<0.00001). The incidence of swelling was directly correlated with the amount of hyaluronic acid filler injected (37% < 0.55cc, 51% 0.56-1cc, and 60% >1cc) [x2[1, N=95]=3.9231, p=.048]. There was no significant difference in patient age, sex, Fitzpatrick skin type, or history of allergies on incidence of post-procedure swelling. Adverse events were limited to expected injection-site reactions, and there were no reports of hypopigmentation or atrophy from the addition of triamcinolone. LIMITATIONS: This is a retrospective study that used patient reporting for short-term post procedure swelling. CONCLUSION: This is the first retrospective study showing the safety and efficacy of a novel technique adding low-dose triamcinolone (1mg/cc) to hyaluronic acid filler to reduce post-procedure swelling within the first few weeks following infraorbital injection. Additionally, using lower volumes is also effective at reducing post-procedure swelling. Larger, randomized, controlled trials are needed to support our findings. [ABSTRACT FROM AUTHOR]

With the increase of cosmetic injectable hyaluronic acid (HA), there have been more cases with serious complications, including skin necrosis, blindness, and cerebral embolism. Patients who have recovered from HA filler-induced total vision loss are extremely rare. We report a case of a 27-year-old female who developed severe ocular pain on the right side and total vision loss following a 1.0 ml HA filler injection in the nasal dorsum. She arrived at our hospital 4 hours later. Her visual acuity was no light perception (NLP), and she exhibited eyelid ptosis, ophthalmoplegia, and frontal and nasal ecchymosis. She was promptly treated with subcutaneous and retrobulbar hyaluronidase injections, as well as intra-arterial 1500 IU hyaluronidase injections into the right ophthalmic artery with DSA assistance. Her vision improved from NLP to counting fingers at 1.0 meters. Unfortunately, 13 hours later, she felt an intense headache, and her vision again decreased to NLP. We immediately performed an injection of 1500 IU hyaluronidase combined with 8 mg alteplase for intra-arterial thrombolysis (IAT) into the right ophthalmic artery. Her vision improved immediately afterward. After 3 months, her visual acuity had significantly recovered from NLP (admission vision status) to 20/50 (Snellen chart with glasses). Similarly, skin, conjunctival, eye movement, and ptosis symptoms completely recovered. This case demonstrates that reversal of complete blindness due to embolism of the ophthalmic and central retinal arteries could be accomplished through multidisciplinary therapies, especially IAT using fibrinolytic agents combined with hyaluronidase followed by an anticoagulant regimen. Level of evidence VThis 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 Table of Contents or online Instructions to Authors www.springer.com/00266. [ABSTRACT FROM AUTHOR]

Non-surgical techniques with hyaluronic acid fillers to rejuvenate face are very popular treatment due to ease of administration and achievement of faster improvement. Although they are considered to be safe procedures, few rare adverse effects have been reported in literatures. The number of these cosmetic procedures being performed is increasing every year. Simultaneously, the rate of filler complications has also increased. This case series presents three clinical cases of delayed onset nodules after hyaluronic acid fillers after 1-5 months post-procedure. Juvederm Volift was used in all the mentioned patients. Granulomatous reactions can occur with any of the hyaluronic acid fillers. These are generally localized immunological reactions. An awareness about these rare side effects helps us in the assessment and ensurance of accurate diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Pre‐injection aspiration of hyaluronic acid filler is a well‐recognized yet controversial safety technique. Many consider aspiration to be an important safety measure to prevent inadvertent intravascular filler injection. To assess factors influencing pre‐injection aspiration by understanding the relationship between aspiration time and a range of product, needle, and procedural characteristics. We conducted a systematic review and meta‐analysis of data, adopting the preferred reporting items for systematic reviews and metaanalyses guidelines. Our literature search identified four articles presenting data on variables associated with aspiration time for different HA filler brands. Statistical models pooling data from the four articles suggest a robust association between aspiration time and a filler's elastic modulus (G′), drop weight (cohesivity), and cross‐sectional area of the needle lumen. However, there is insufficient evidence to confirm a robust association between aspiration time and HA concentration, viscous modulus (G″), needle length, and pullback volume. A deeper understanding of the relationship between product, needle, and procedural characteristics, and aspiration time can provide a sound base for discussing the role of pre‐injection negative aspiration as a safety measure. The understanding of the effect of various factors on preinjection aspiration would further benefit from studies under clinical conditions. [ABSTRACT FROM AUTHOR]

Filler injections have become exceedingly popular in the last decade, and injectors across the globe are using them for facial contouring and reversing the age‐related changes. Thorough knowledge about the anatomy of important vessels and tissue planes is essential for injectors. During filler injections, injectors generally tend to pinch or pull the tissues with the nondominant hand for the ease of the procedure. These deformational forces lead to some changes in the anatomy of tissue layers held in a pinch. During pinch maneuver, the important arteries in that region can get pulled up in the tissue layers held in a pinch or stay in their position unaffected. The pinch can also increase the tissue space for injections by moving the mobile tissue layers away from the fixed ones. Knowledge of this "pinch anatomy" in the temple can be used to the injector's advantage to avoid important arteries and to place filler in the correct plane. [ABSTRACT FROM AUTHOR]

Background: Treatment of a sunken appearance of the temporal region using injectable fillers is a popular procedure. The temporal fossa has very complex anatomy due to multiple vessels running in the different tissue layers. A severe complication in the form of non-thrombotic pulmonary embolism (NTPE) can occur as a result of an inadvertent injection in the middle temporal vein (MTV) while performing temporal fossa filler procedures. Therefore, in-depth knowledge and understanding of the MTV anatomy are essential for successful and safer injectable procedures of the temporal fossa. Objectives: While there have been many studies to describe the arteries in this region, there is limited information about the location and course of the middle temporal vein. This literature review is aimed at providing detailed information about the course, depth, and size of the MTV to help aesthetic practitioners in performing safer temporal fossa filler injections. This information is imperative to delineate the 'venous danger zone' in the temple region. Methods: The preferred reporting items for systematic reviews and meta-analyses guidelines were used for this review. A literature search was performed to find the articles providing details about the MTV anatomy and the measurements related to its course and size. Results: A review of the literature showed that the MTV displays a consistent course and depth in the temporal region, with high variability in its diameter. The middle temporal vein width varied between 0.5 and 9.1 mm in various studies. The middle temporal vein receives many subfascial tributaries from the surface of the temporalis muscle, and for most of its course runs in the fat pad enclosed between superficial and deep layers of the deep temporal fascia. A 'venous danger zone,' in the interfascial planes of the temporal fossa, which contain the main part of the MTV and its tributaries, has been proposed in this paper. Conclusions: The temporal fossa filler procedures need great caution, and knowledge of the depth and course of the MTV is essential for avoiding NTPE. Level of Evidence III: 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. [ABSTRACT FROM AUTHOR]

Fillers are injectable substances used for reduction of wrinkles when they are placed in the skin, or give volume in the tissue, improving the contour and skin texture when they are injected deep (periosteal). In accordance with regulations, fillers are recognized and categorized as medical devices. Among the many fillers that have appeared in recent decades, hyaluronic acid has become widely used by aesthetic doctors and are preferred by patients who are looking for non-invasive methods of rejuvenation. The number of hyaluronic acid injection procedures have risen, so have the number of post-injection complications. Methods: The data of patients with delayed post-injection complications were extracted from the clinic archive and the following information was analysed: complication onset date, last injection date, injected product, injection amount and type, injected area, total amount of hyaluronic acid injected in the last 20 months, history of injected products, treatment of complication(s), and time of remission. We followed 10 patients who presented with late complications from one week to 1 year after the injection. Published articles on late complications and proposed treatment algorithms have been reviewed in the literature. Results: Over a period of 8 years (2013-2020) 2,418 hyaluronic acid injection procedures were performed in our clinic in a number of 1836 patients with a total volume of 3,855 mL of hyaluronic acid. Over 95% of these patients treated were women. Delayed complications occurred between one week after injection and up to one year. The most common complications were visible or only perceived as nodules on palpation and localized edema. Among the possible causes that were discussed--nickel allergy, dental treatments, pre-existing conditions - acne, rosacea, and injection defects. Conclusions: The causes of late complications can be associated with-- the injected volume, the number of injected products, the fact that the products were injected simultaneously in the same session, and that they could be related to the patient's allergic pathology. [ABSTRACT FROM AUTHOR]

Injection of dermal fillers, like hyaluronic acid (HA), is a safe procedure, with few and transient side effects such as erythema, bruising and swelling etc. The aim of this report is to provide our protocol for the early treatment of necrotic complications after facial treatment with dermal fillers. We present two cases of skin suffering of the face after dermal infiltration of HA, treated successfully with our early protocol. Our protocol includes the early infiltration of hyaluronidase in the treated areas. We start with infiltration of hyaluronidase distributed over the area to be treated through micro-injections with dosage 40 IU per cm 2. Our protocol includes the use of systemic corticosteroids for 4 days, anti-aggregation therapy, oral antibiotic, topical cream with nitric oxide and compresses with gauze and warm water. In the skin complications after dermal filler treatment, marked pain and characteristic reticulated erythema in the skin distribution of the affected vessels is often developed. Due to the implementation of our protocol in these patients, we managed to avoid an irreversible necrotic complication of the face in both cases. In this report, our protocol was compared with results published in the literature and allowed us to avoid complications such as skin necrosis with permanent damage.

The injection of hyaluronic acid (HA), a naturally occurring biopolymer, is a common cosmetic procedure. Despite their efficacy and growing adaptation by the medical community, HA fillers occasionally give rise to adverse events. Adverse events from HA fillers range from temporary, such as edema and erythema, to more long-term effects, including granulomas or, in rare cases, sequelae from vascular occlusion. Here, we present a case of a 61-year-old Caucasian woman with prolonged infraorbital hollow edema after injection of HA filler for nasojugal groove correction. We review the anatomy of the nasojugal area and differing injection techniques as a possible explanation for the development of prolonged edema. Similarly, the rheological properties of the specific hyaluronic acid used during this procedure might be crucial in the development of this complication. [ABSTRACT FROM AUTHOR]

The injection of hyaluronic acid (HA), a naturally occurring biopolymer, is a common cosmetic procedure. Despite their effcacy and growing adaptation by the medical community, HA fillers occasionally give rise to adverse events. Adverse events from HA fillers range from temporary, such as edema and erythema, to more longterm effects, including granulomas or, in rare cases, sequelae from vascular occlusion. Here, we present a case of a 61-year-old Caucasian woman with prolonged infraorbital hollow edema after injection of HA filler for nasojugal groove correction. We review the anatomy of the nasojugal area and differing injection techniques as a possible explanation for the development of prolonged edema. Similarly, the rheological properties of the specific hyaluronic acid used during this procedure might be crucial in the development of this complication. [ABSTRACT FROM AUTHOR]

Injection of dermal fillers, like hyaluronic acid (HA), is a safe procedure, with few and transient side effects such as erythema, bruising and swelling etc. The aim of this report is to provide our protocol for the early treatment of necrotic complications after facial treatment with dermal fillers. We present two cases of skin suffering of the face after dermal infiltration of HA, treated successfully with our early protocol. Our protocol includes the early infiltration of hyaluronidase in the treated areas. We start with infiltration of hyaluronidase distributed over the area to be treated through micro-injections with dosage 40 IU per cm 2. Our protocol includes the use of systemic corticosteroids for 4 days, anti-aggregation therapy, oral antibiotic, topical cream with nitric oxide and compresses with gauze and warm water. In the skin complications after dermal filler treatment, marked pain and characteristic reticulated erythema in the skin distribution of the affected vessels is often developed. Due to the implementation of our protocol in these patients, we managed to avoid an irreversible necrotic complication of the face in both cases. In this report, our protocol was compared with results published in the literature and allowed us to avoid complications such as skin necrosis with permanent damage.

Background: The growing interest in filler injection requires a more comprehensive knowledge about the complications of this procedure. Methods: A total of 5 cases with debilitating chronic complications following filler injection referred to Al-Zahra hospital, Isfahan are presented in this report. Results: The outcome of treatment for two of the cases was satisfactory. In one case the treatment led to failure. A case committed suicide, the remaining case had received vitamin E injection which caused severe necrosis and scaring. Conclusions: All fillers are considered foreign bodies and may provoke the immune system to varying degrees. Most complications are, however, caused by the technique of injection not the filler itself. Experience of physicians along with adequate knowledge about fillers and their complications can definitely guarantee a better outcome.

Facial thread-lifting has more popularity, but the incidences of complications following thread-lifting remain controversial [1]. Represent case that demonstrates possibly of ultrasound in the assessment of complications after thread-lifting. A 44-year-old woman with pain and swelling in the left submandibular region, fever. Two weeks ago, thread lifting was performed. During ultrasound on the right in the subcutaneous adipose tissue of the submaxillary region, when scanning with a 18 MHz frequency transduser, a thread is determined in the form of two contour hyperechoic structures around which invariable adipose tissue. On the left the double-contours hyperechoic linear structure in the lateral part is surrounded by anechoic fluid accumulation, which extends to the angle of the lower jaw, with a total volume up to 20 ml. Around are the enlarged lymph nodes, the salivary glands are intact. A aspiration was performed, 15 ml was removed. Ultrasound is a quick, affordable and cheap way to assess the condition of soft tissues after face thread lifting, which can assess the position of the threads, as well as the presence of complications. [ABSTRACT FROM AUTHOR]

Six cases of vascular compromise after hyaluronic injection are reported. Clinical symptoms realized a Nicolau syndrome, which is characterized by immediate pain, livedoid pattern and a few days later by the appearance of scabs and skin necrosis. This type of complication is rare, but may be dramatic and injectors must be aware of that. A thorough knowledge of facial anatomy is mandatory to avoid the risky facial areas. The use of a flexible cannula instead of a sharp needle has much less risk of hurting vessels and must be preferred. The support of the patient is discussed and a treatment protocol is proposed. [ABSTRACT FROM PUBLISHER]

BACKGROUND: The growing interest in filler injection requires a more comprehensive knowledge about the complications of this procedure. METHODS: A total of 5 cases with debilitating chronic complications following filler injection referred to Al-Zahra hospital, Isfahan are presented in this report. RESULTS: The outcome of treatment for two of the cases was satisfactory. In one case the treatment led to failure. A case committed suicide, the remaining case had received vitamin E injection which caused severe necrosis and scaring. CONCLUSIONS: All fillers are considered foreign bodies and may provoke the immune system to varying degrees. Most complications are, however, caused by the technique of injection not the filler itself. Experience of physicians along with adequate knowledge about fillers and their complications can definitely guarantee a better outcome. [ABSTRACT FROM AUTHOR]

The availability of dermal fillers for multiple cosmetic indications has led to a dramatic increase in their application. Although fillers are generally regarded as safe tools for soft tissue augmentation, complications can occur. Therefore, to describe and review the complications associated with the currently- available dermal filling agents, the authors conducted a literature review in peer-reviewed journals and present the reported complication rates. They also describe current strategies to avoid, diagnose, and manage complications if they do occur. [ABSTRACT FROM AUTHOR]

Background Hyaluronic acid is generally accepted today as the “gold standard” filler agent, and its use has subsequently grown enormously. In addition, newer facial volume augmentation indications are constantly evolving. Rare adverse events, such as granulomas, have been described. However, complications are more commonly due to product misplacement or overcorrection leading to unsightly lumps and masses. Hyaluronidase treatment of these latter adverse effects can be both effective and rapid. Objective This paper aims to confirm the efficacy of hyaluronidase injections in dissolving unsightly hyaluronic acid overcorrection. Methods A case of hyaluronic acid overcorrection is described with evaluation of the effects of hyaluronidase. Results The use of hyaluronidase, injected intracutaneously permits the elimination of patient discomfort and inaesthetic lumps within a few hours. Conclusions Hyaluronidase is highly effective in eliminating HA volume overcorrection. [ABSTRACT FROM AUTHOR]

Summary Background Facial lipoatrophies are rare disfiguring syndromes, most commonly characterized by loss of buccal fat pads. Aims To demonstrate a relationship between facial lipoatrophy and a new synthetic filler device (Profill) used to correct naso-labial folds. Methods Five cases of lipoatrophy, appeared 9 months or later after Profill injections. No systematic abnormalities were found. In one case biopsy reported a destruction of adipocytes with intense fibrosis in the hypodermis. Discussion The culpability of this new biodegradable product is highlighted. To our knowledge, this is the first time this adverse reaction has been reported. Conclusion Serious adverse reactions may appear months after Profill injection, skin testing is not always predictive or sufficient. Clinical studies with long-term follow-up need to be carried out before new filler devices are launched on the market. [ABSTRACT FROM AUTHOR]

Dermal fillers remain popular for facial rejuvenation but with its increasing use, the potential for more complications including blindness is present. This article focuses on the mechanism of filler-associated blindness, possible treatments, and future directions. Unfortunately, to date there is no proven treatment to reverse filler-induced blindness or visual compromise. It is essential for all injectors to discuss the potential ocular risks including blindness with their patients and obtain informed consent before filler injection., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: The nasolabial fold (NLF) causes particular concern during aging in the middle face region. However, arterial complications of filler injections at this site have been continually reported during recent years. The aim of this study was to investigate the arterial locations and their anastomotic pathways related to filler injection sites in the NLF., Materials and Methods: Thirty hemi-faces of 15 embalmed Thai cadavers were dissected. Three anatomical landmarks of NLFs were assigned: the inferior margin level (NLF1), the mid-philtral horizontal line level (NLF2), and the inferior alar level (NLF3). Ten hemi-faces of five soft embalmed Thai cadavers underwent a modified Sihler's staining procedure to investigate the arterial anastomoses., Results: The artery closest to all of the landmarks was the facial artery. It was located inferomedial to NLF1 in 28%, and the mean distances along the X- and Y-axes were 3.53 ± 2.11 mm and 3.53 ± 1.75 mm, respectively. It was also located medial to NLF2 in 52.1% with an X-axis distance of 4.93 ± 1.53 mm. Several arteries were located close to NLF3, including the facial (33.3%), lateral nasal (33.3%), and infraorbital (30.0%) arteries. Anastomoses of the nasolabial arteries served to connect both the external-external and internal-external carotid systems., Conclusions: Several arteries are located close to NLF1-NLF3. To prevent arterial injury, the locations and anastomotic pathways, as possible sources of severe complications, should be recognized prior to NLF filler injection., (© 2020 Wiley Periodicals LLC.)

Facial aging associated with volume loss can be addressed with soft tissue fillers. This minimally invasive technique has quickly gained popularity and is commonly performed in many outpatient settings. The composition of injectable dermal fillers includes marketed hyaluronic acid, calcium hydroxyapatite, polylactic acid, silicone and polymethylmethacrylate. Complications, such as vision loss, are rare, but can result in a devastating and irreversible sequala from iatrogenic vascular occlusion. Understanding the facial anatomy, specific filler characteristics, and having a safe injection technique is crucial to assure optimal aesthetics results while avoiding complications. Injectors need to be able to recognize early complications and treat them appropriately, especially if vision loss is encountered. This review will focus on vision loss from fillers, techniques to prevent such complications and possible treatment strategies., Competing Interests: Proprietary Interests The authors have no conflicts of interest.