This lecture was given the Gulf and Middle East Plastic Surgery and Aesthetic Medicine conference in Kuwait in 20/02/2020 .

1. Periocular Hyaloronic Acid
Filler Complications
Raed Behbehani , MD FCSC

2. Introduction
• Growing interest in HA dermal fillers.
• Over $11 billion annually by 2020 .
• 40% increase in the number of injectable procedures over 10 years .
• Safe , versatile , effective .
• Increased interest in non-surgical methods (Less is more ).
• Complications are rare but some can be devastating .

3. Early Fillers
• Late 1800s-early 1900s : autologous fat , Paraffin
• 1960s – Silicone
• 1980s – Collagen
• 1990s – Hyaloronic Acid
• 2003- HA became FDA-approved (Restylane , Juvederm , Hylaform,
Perlane , Evolence ).

4. Early Filler Complications
• Parafiin was the filler of choice
in the early 1900 but was
associated with infection ,
inflammation and embolism.
• “Parfiinoma"
Gladys Spencer-Churchill (1881–1977),
second
wife of the 9th Duke of Marlborough

5. Silicone

6. Aging Face

7. Bruising
• NSAID / oral anti-coagulants .
• Prophylaxis: To use arnica with vitamin K creams for 3 to 4 days.
• Treatment: To use arnica and vitamin K creams/photoprotection.

8. Swelling and Edema
• Common in the eyelids and periorbital region.
• Cold compressor , NSAID (mild – moderate)
• Oral steroids 3 days – 3 weeks (severe)
• Immediate swelling : IgE-mediated- immune response (Type I
hypersensitivity reaction) – Anti-histamine
• Swelling after day 1 : Delayed hypersensitivity – does not respond
well to anti-histamine , hyaluronidase.

9. Tyndall Effect
• Injection into superficial dermis or
epidermis they cause a “bluish hue” .
• Hyaluronidase should be the initial
approach to treatment.

10. Skin Necrosis
In Ho Bae at al. Internrational J Cosmetic Derm 2017

11. Skin Necrosis Treatment
• Warm gauze, tapping the area to facilitate vasodilatation, and
massage of the area.
• Topical nitroglycerin (1 or 2%) paste 2 or 3 times/daily in the office
and at home by the patient.
• Nitroglycerin sublingual tablets can be used.
• Hyaluronidase injection (200–400 IU/ 1–2 mL)

12. Nodules
• Can occur with any filler .
• Can last for years .
• Excess filler .
• Unsuitable product .
• Non-inflammatory , inflammatory , infectious .

13. Nodules

14. Pathophysiology of Nodules
• Coincide with systemic or , local infectious or immune trigger, such as
local trauma.
• Seasonal variation (winter)
• More common in low molecular weight hyaluronic acid
(immunogenic)
• HA manufactured by bacterial fermentation (antigenic)
• HA provides a ”shield” to diffusion of antibiotics .

15. Nodules

16. Nodules

17. Inflammatory nodules

18. Infectious nodules
• Most are culture-negative .
• Painful and red nodules.
• Can get worse in dehydration or following Botox injections .
• Treat with Hyloronidase +- oral steroids.

19. Non-infectious Nodules – Treatment
• Observation .
• Hyaluronidase 150U/mL .
• Surgical excision .
• For post-inflammatory hyperpigmentation: intense pulsed light/laser;
photo-protection; or depigment cream.

20. Infection
• Delayed chronic inflammation .
• Atypical micro-organisms (Mycobacteria , E.coli)
• Need to distinguish infection from delayed hypersensitivity .
• Culture and swabs
• Appropriate antibiotic therapy .

21. Blindness

22. Autologous Fat vs HA Filler
Autologous Fat HA Filler
Diffuse vascular occlusions -
Worse visual outcome -
Higher rate of Cerebral lesions -
- High rate of Anterior Segment Ischemia (corneal
edema and AC inflammation )

23. Vascular Occlusion
Park et al. JAMA Ophthalmology June
2014

24. Retinal Artery Occlusion
• Glabella (38.8%), nasal region (25.5%), nasolabial , fold (13.3%), and
forehead (12.2%).
• Retrograde flow of filler through distal branch of ophthalmic artery
( smaller particulate size )
• Vision loss is immediate .
• Painless or associated with headache.
• Treatment window is 60-90 minutes.

25. OA occlusion with HA Filler
Shi et al. JAMA Ophthalmol. 2018;

26. Retinal Artery Occlusion

27. Retinal Artery Occlusion
• Topical beta-blocker.
• IV Manitol .
• Digital message ( firm pressure on the eyeball through the closed
eyelids ).
• Apply firm pressure for 5–15 s and quickly release.
• Repeat this cycle for at least 5 min
• If no improvement in the first 15-20 min – referral for ophthalmology
for AC paracentesis .
• Spontaneous improvement has been seen in 15%.

28. Retrobulbar Hyaloronidase
• Literarture review 2001 – 2019 of all cases treated of HA-induced blindness treated with
Hyaloronidase.

29. Retrobulbar Hyaloronidase
• Retrobulbar 450 units injection.
• No clear evidence of efficacy.
• Secondary thrombus formation will not be affected by Hyaloronidase.
• Attempt to canalize the ophthalmic artery and injection of
Hyaloronidase was not effective in restoring vision.

30. Retrobulbar Hyaloronidase
• Two of the nine documented cases treated showed visual
improvement was demonstrated ,
• Inconsistent pretreatment ophthalmic assessment and
documentation .
• Improvement in some cases due to natural history of disease.

31. Case Report
Thanasarnaksorn et al. J Cosmet Dermatol. 2018;1–7.

32. Case Reports

33. Complications of Retrobulbar Injection
• Retrobulbar hemorrhage
• Globe perforation
• Vascular retinal occlusion
• Exacerbate vision loss (compartment syndrome) .

34. Preventive Strategy
• Understanding the facial anatomy and the warning signs of occlusion
• Minimal pressure, slow, low-volume injections.
• Small syringe, large (22 G) micro-cannula injections.
• Mixing of filler with injectable vasoconstrictors (low-concentration
epinephrine)
• Avoidance of high-risk zones especially in high-risk patients with multiple
risk factors
• Occlusive pressure in the area of the supraorbital notch while performing
injections in the glabellar region
• Aspiration prior to injection

35. Treatment of HA-induced blindness
• Ocular massage
• Anterior chamber paracentesis
• Intraocular pressure lowering with Timolol drops
• Aspirin
• IV Diamox or Mannitol
• CO2 rebreathing
• Hyperbaric oxygen
• Topical and systemic steroids

36. Summary
• HA fillers are safe and effective device for restoring volume.
• Understanding of the facial and vascular anatomy is important to
prevent complications.
• Complications can occur with any HA (nodules , edema).
• Most complications can be managed with appropriate medical
treatment .
• Vascular occlusion of the ophthalmic or central retinal artery is a
devastating complication of HA dermal filler injection .
• Appropriate ophthalmic referral .