steve yoelin md private practice newport beach, california · steve yoelin md private practice...
TRANSCRIPT
Steve Yoelin MDPrivate Practice
Newport Beach, California
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Disclosures–Allergan: Consultant, Paid Research
–Galderma: Consultant
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Treatment Goals for Botulinum Toxin Therapy
Effacement of hyperfunctional rhytides
Recontour facial proportions and achieve symmetry
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Injectable Botulinum Toxins
Produced by various strains of Clostridium botulinum
Serotype A
– onabotulinumtoxinA = BOTOX® Cosmetic
– abobotulinumtoxinA = Dysport®
– incobotulinumtoxinA = Xeomin®
onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA are FDA-approved for
cosmetic use (glabellar lines); onabotulinumtoxinA approved for crow’s feet
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Know
Your Anatomy!
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Complications
Brow Ptosis
Eyelid Ptosis
HeadacheBruising
(Hematonia)
Asymmetry
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Video
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Video
DERMAL FILLERS
TREATMENT GOALS FOR DERMAL FILLERS
Volume restoration
Recontour facial proportions and achieve symmetry
WHICH DERMAL FILLER TO USE
Videos
Videos
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Vascular Complications
Background Mechanisms Findings Prevention & Treatment Personal Experience Blindness
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Background
Soft-Tissue Fillers Widespread use in the 1980s with advent of bovine
collagen In North America, second-most popular nonsurgical
aesthetic procedure behind botulinum toxins (Botox) The popularity of soft-tissue fillers in part due to their
favorable side effect profile Adverse effects from soft-tissue filler injection are
generally mild and self-limited
“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.
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Injection site reactions
– Bruising
– Swelling
– Erythema
Infections
Nodules / asymmetry
Hypersensitivity
Vascular compromise
Delayed (Can Be Years Later)
Infection
Granuloma formation
Biofilm formation
Adverse Events from Soft-Tissue Augmentation
Early (Within 1 Week)
Adapted from Glashofer MD, Flynn TC. Complications of temporary fillers. In: Carruthers J, Carruthers A. Soft
Tissue Augmentation. Toronto: Elsevier Saunders; 2013:179-187.
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Vascular Compromise
Most ominous adverse event
Partial or complete interruption of vascular supply by extravascular compression
Complete occlusion of vascular supply from intravascular injection
– Subsequent necrosis and scarring are potentially permanent sequelae
“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.
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Vascular Compromise
All soft-tissue fillers can lead to vascular compromise, including:
– Hyaluronic acids
– Calcium hydroxylapatite
– PMMA
– PLLA
– Collagen
– Fat
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Mechanisms
Not completely understood
Extravascular– Results from vessel compression due to injectable filler
– Secondary inflammation and edema can further put pressure on vessels
Intravascular– Results from direct injection of the filler into the vasculature causing
obstruction and damage to the wall of the blood vessels
– This presentation may be immediate and has also been reported with a delayed presentation at 6 hours post-injection
“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.
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Findings
Typically, the first indication of vascular damage after filler injection is painless blanching
– This can be subtle and may go unnoticed
Over the next couple of days, progression to a painful, violaceous, reticulated patch may occur
A necrotic eshar may develop on top of an ulcer with subsequent scar formation
Treatment should be instituted at first sign of this complication to prevent necrosis and scarring
“Vascular Compromise from Soft Tissue Augmentation”, J Clin Aesthetic Dermatol. 2014 Sep; 7 (9) 37-43.
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Incidence
Presented as 0.001% in the literature, but believed to be higher (the “elephant in the room”)
– Underreported
– Fillers are now being injected into deeper planes of the face, which poses greater risk of vascular occlusive events
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Prevention
There are a number of preventative strategies that can reduce the risk of occlusion
– Choose a reversible hyaluronic acid filler
– Exercise caution when injecting high-risk areas
– Aspirating before injecting
– Use low volumes of product
– Use a cannula technique
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Personal Experience
Before After
• Age: 28
• Date of Incident: May 2016
• Treatment Area: Tear Trough
• Product: Biphasic HA
• Findings:
• Blanching to right cheek
• Violaceous reticulated patch
• Treatment
• Hyaluronidase
• Aspirin
• Massage
• Warm packs
• Nitroglycerine paste
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Blindness
Mechanism
– Arterial pressure can be overcome and retrograde movement of material into the more proximal arterial network can occur
– Then embolization of the ophthalmic artery can deprive the retina of oxygen and lead to blindness
“Dermal fillers in aesthetics: an overview of adverse events and treatment approaches” Clin Cosmet Investig
Dermatol. 2013 Dec 12;6:295-316
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Blindness
Angiographic findings of a hyaluronic acid-injected
patient. A 39-yr-old woman after hyaluronic acid
injection in the glabella and nasal dorsum. (A)
Fundus photograph reveals segmented and
attenuated retinal vessels. (B) Fundus fluorescein
angiography shows markedly compromised retinal
and choroidal perfusion.
“Cerebral Angiographic Findings of Cosmetic Facial Filler-related Ophthalmic and Retinal Artery Occlusion” J Korean Med Sci. 2015 Dec;
30(12): 1847–1855.
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Blindness
High-risk areas
– The glabella
– The forehead
– The nose
– The periorbita
“Complications Following Injection of Soft-Tissue Fillers” Cemile Nurdan Ozturk MD, Yumeng
Li BS, Rebecca Tung MD, Lydia Parker MD, Melissa Peck Piliang MD, James E. Zins MD
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Blindness
Treatment
– Document vision
– Evaluate pupils
– Retro or PeriBulbar High-Dose Hyaluronidase Injection
– Oral aspirin
“Retro or PeriBulbar Injection Techniques to Reverse Visual Loss After Filler Injections.” Dermatol Surg. 2015 Dec;41 Suppl
1:S354-7. doi: 10.1097/DSS.0000000000000558.
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Final Thoughts
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Thank you!