Pinch Anatomy of Forehead: An Injection Guide for Forehead Filler Treatment

With the popularity of filler injections globally, more and more injectors are using them for facial shaping and reversing the aging changes of the face. Detailed knowledge of facial anatomy, especially of important vessels and tissue planes is essential for injectors. While performing filler injections, injectors tend to pinch the tissue layers with their non-dominant hand for ease of doing the procedure. Such deformational forces cause some changes in the anatomy of tissue layers held in a pinch. During a deep pinch, the important arteries in that area can get pulled up in the pinch's tissue layers, or they can stay in their position being unaffected by pinching. The ‘pinch and pull’ can also improve the tissue space for injections, by pulling away the mobile tissue layers from the fixed ones. Knowledge of the ‘pinch anatomy’ in the forehead can be used to the injector's advantage to avoid important arteries and place filler in the correct plane. By knowing the anatomical changes during the pinched state of tissue layers, filler injections in the forehead can be performed with relative safety in the correct tissue plane.

Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review

Tear trough deformity is a popular target for the treatment with filler injections. The side effects are generally mild and transient. However, delayed complications may occur. We aim to perform a thorough systematic review of the published literature related to delayed complications after tear trough filler injections. A search of published literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in June 2021 and included PubMed, ScienceDirect, and Embase databases. The Medical Subject Headings (MeSH) terms used included the following terms: delayed complications, nodules, granulomas, swelling, discoloration, dermal filler, hyaluronic acid (HA), polyacrylamide, calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), eyelid, periorbital, periocular, and tear trough. Twenty-eight articles consisting of 52 individual cases were included in the final analysis. 98% (51/52) of patients were female and had an average age of 48.3 years. HA was the most reported product (71.2%, 37/52), followed by PLLA (4/52, 7.7%), and CaHA (4/52, 7.7%). The most common delayed complication with any dermal filler was swelling (42.3%, 22/52) followed by lumps or nodules (25.0%, 13/52). Xanthelasma-like reaction (17.3%, 9/52), migration (7.7%, 4/52), discoloration (3%, 3/52) also occurred. The average time of onset of any complication was 16.8 months with xanthelasma-like reaction appearing soonest (mean: 10 months) and discoloration appearing latest (mean: 52 months). Most swelling cases were caused by HA. Semi-permanent fillers such as PMMA and synthetic fillers such as PLLA were more likely to be associated with lumps and nodules than other complications. It is important that clinicians who perform tear trough augmentation with dermal fillers have a thorough understanding of the risks of the procedure to diagnose and manage them promptly as well as provide patients with accurate information regarding the potential adverse effects.

Evaluation of Neurotoxin and Filler Injection Training in Otolaryngology Residency

Introduction: Residency training courses are fundamental to an Otolaryngology (ENT) residency curriculum. Neurotoxin and filler injections have become common during ENT residency, and the outcomes of training courses have not been previously evaluated. We hypothesize that after participating in the course, resident knowledge, skill, and likelihood of using neurotoxin and filler injections in future practice will significantly improve. Materials and Methods: A prospective study was designed among ENT residents undergoing neurotoxin and filler injection educational training courses from April 2019 to November 2020. After the completion of the course and injections, residents completed a self-evaluation to assess their level of knowledge and skill level with neurotoxin and filler injections. Results: The mean number of neurotoxin and filler injections besides within the course was 1.67 and 0.33, whereas during the course was 3.39 ( P = .008) and 1.39 ( P = .0009), respectively. Resident knowledge, skill, and likelihood of using neurotoxin and filler injections in future practice all significantly improved ( P < .05). This study found that a biannual training course for neurotoxin and injectable fillers was an effective strategy at improving resident knowledge, skill, and likelihood of use in future practice.

Laser Doppler Imaging for Treating Vascular Complications from Procedures Involving Dermal Fillers: Case Series and Literature Review

Vascular occlusion is a rare but severe complication of dermal filler injections. Early treatment of this complication produces better outcomes. Current diagnostic methods for vascular occlusion in the skin are subjective and imprecise; these include capillary refill time, skin color, and reports of pain. This study aimed to assess the use of laser Doppler imaging (LDI) in the evaluation and treatment of vascular complications caused by dermal filler injections. This retrospective study used laser Doppler imaging (LDI) in 13 patients who developed vascular occlusion after facial dermal filler injections, with subsequent follow-up. The precise areas of perfusion observed on LDI were compared with the findings of clinical and photographic evaluation. The results showed that LDI accurately identified areas of vascular occlusion and improved treatment precision among these thirteen patients. The procedure was more precise than visual inspection or photographic evidence. Satisfactory outcomes were achieved for all patients, and no procedure-related complications were reported. Collectively, LDI provides fast, noninvasive, and accurate delineation of areas of vascular occlusion caused by complications of dermal filler injections and avoids several subjective shortcomings of visual and photographic evaluations. Thus, LDI effectively tracks treatment outcomes. However, large-scale studies are required to confirm the present findings.

452 Dermal Filler Injection Leading to Facial Cellulitis: A Case Report

Background Aesthetic medicine is a rapidly expanding field that is progressively becoming a normal part of society’s health and beauty regime. Hyaluronic Acid dermal filler injections are the second most widely performed aesthetic procedure, following Botulinum Toxin type A. Although serious complications are rare, they can have a detrimental impact on aesthetic outcome and general health. Infections following dermal fillers can be difficult to treat and have the potential to require hospital admission, intravenous antibiotics and surgical intervention. Case description We present a case of a 41-year-old female who suffered from facial cellulitis as a consequence of palpebro-malar groove dermal filler injections. The patient had 0.1ml of Monalisa dermal filler injected over her right malar prominence and suffered complications 6 days later, which eventually lead to the need for hospital admission on day 12 following the procedure for intravenous antibiotics. The management of this aesthetic procedure complication is outlined to highlight the risks and serious complications of these procedures. Conclusions Facial cellulitis is a rare adverse event following facial filler injection; however, it is an important risk factor to discuss during the consent process for these procedures. In addition, it is important that a highly trained and skilled professional performs these injections using a sterile non-touch technique due to the potential for serious complications and the anatomical proximity to vital structures.

Deformation of Needle Tips during Facial Soft Tissue Filler Injections: An Electron-Microscopic Study

Background Injectable soft tissue fillers are used on a global scale for a variety of aesthetic indications. Despite their widespread use, there is a dearth of information regarding the potential repeated injections into tissue have to cause needle deformation. Repeated injections with the same needle result in an increase in force used by the injector to achieve dermal penetration, potentially resulting in decreased precision and increased patient discomfort. Objectives The objective of this study is to quantify the magnitude of needle tip deformation utilizing Scanning Electron Microscopy (SEM) image analysis. Methods An observational study was performed evaluating four differently sized needles following soft tissue filler injections for five different aesthetic indications (zygomatic arch, infraorbital, mid cheek, nasolabial sulcus and perioral) in patients aged 36-64 years old. Following treatment, each needle was visualized and imaged through SEM, and the percentage of deformation in relation to the total amount of needle tip surface was calculated. Results The most influencing factor for needle tip damage was revealed to be the number of injection passes, ie, dermal transitions. Per injection procedure, an increase in needle tip damage of 4.7% occurred. Touching the bone deformed the needle tip by 9.6% and the increase in needle size allowed for 0.13% more damage. Conclusions To the authors’ knowledge, this is the first SEM investigation to provide objective evidence for the deformation of needle tips after repeated facial soft tissue filler injections. This data may help improve patient safety and comfort during these minimally invasive procedures.