The Unknown Risks of Facial Dermal Fillers

In 2011, total cosmetic procedures as reported to the American Society of Plastic Surgeons have increased by 5%. While the majority of that rise has been attributed to the increasing use of noninvasive treatments which include Botox, lasers and fillers, actual surgical procedures have decreased somewhat. This may be more reflective of a rather anemic economy than an actual trend per se. Soft tissue fillers like Hyaluronic acid (Restylane®, Juvederm Ultra®, etc.), calcium hydroxyapatite (Radiesse®), and fat injections experienced some of the largest growth in the minimally-invasive market during 2011. More than 1.3 million hylauronic acid procedures were performed in 2011, up 9 percent; 286,000 calcium hydroxyapatite procedures, up 36 percent; and 68,000 fat injections, up 19 percent. However, in my practice I have noticed a shift back towards surgical procedures such as facelifts-perhaps this is because seasoned, sophisticated patients have come to realize firsthand the limitations of noninvasive treatments.

With the ever expanding embrace of fillers by the population, people are increasingly equating them to a manicure and pedicure. Doctors, Nurses and patients alike rarely think twice about their application and often times are not aware of their potentially serious risks. However, even a recent study has shown that seven out of 10 British doctors have experienced complications with the use of fillers (http://www.inquisitr.com/432110/wrinkles-dermal-fillers-can-cause-blue-skin-and-blindness-report/).

Among the fillers approved for use within the United States include many hyaluronic acids-HA (Juvéderm®, Restyane®, Perlane®, etc.), calcium hydroxyapatite (Radiesse®), PMMA (Artefill®), Sculptra® and fat. The HA’s are associated with their own unique side effects such as the Tyndall effect (a bluish gray swelling that imparts a puffy look to the lower eyes) while Radiesse®, Sculptra® and Artefill® can induce granulomas. However, all of these fillers have been associated with a few extremely rare but potentially devastating complications. Among these are skin necrosis (death of soft tissue) and vision loss. These problems result from a highly unlikely, unforeseen introduction of a minuscule amount of material into a microscopic branch of a facial blood vessel. A very small amount of filler injected into a peripheral vessel around the forehead, nose, nasolabial fold and even lip can result in these aforementioned complications. It is important to note that not only filler, but fat from a facial fat transfer and even a simple steroid injection have been implicated in both tissue and vision loss.

Once in the bloodstream, the filler in turn can travel downstream through the labyrinth of interconnecting blood vessels and if, in the highly unlikely event, it makes a wrong turn, it can end up in one of the blood vessels supplying the retina of the eye. Recently, I was devastated to discover that a patient of mine suffered one sided vision loss because of this very issue. Ironically, she showed no signs of external injury and still appears as a beautiful woman. A few ways for doctors to diminish the chances of such terrible occurrences are to use blunt tip cannulas instead of sharp-tipped needles whenever possible and to inject small amounts while withdrawing the syringe. Though I employ these two techniques routinely even under magnification, there is no absolute guarantee that these complications can be avoided. It is important that patients are made aware of these risks, albeit fleetingly small, in order that they can make an informed decision as to whether to proceed.

“We cannot estimate the incidence of these devastating complications among recipients to filler injections. It must be extremely rare, but it does happen,” Dr. Woo from Seoul National University’s Bundang Hospital told Medscape Medical News. The likelihood of such a devastating event is probably less than being struck by lightning

Odds of being struck by lightning in a given year (reported deaths + injuries)              1/1,000,000
Odds of being struck by lightning in a given year (estimated total deaths + injuries)      1/775,000
Odds of being struck in your lifetime (Est. 80 years)                                                           1/10,000
and certainly less than being injured in a car accident. Even though we are aware of the risks of driving and probably know a few people may have been seriously injured or even killed in a motor vehicle accident, few of us think twice about getting into a an automobile, turning on its ignition and driving.

A good summary of this tragic problem written from an objective standpoint can be accessed here http://www.lipostructure.com/wp-content/uploads/2012/08/Avoidence.pdf

R.D. Haworth M.D., F.A.C.S.

Ironically, two weeks after I wrote this blog, I was involved in a motor vehicle accident  (1 week ago, today being March 12, 2013). Fortunately, no one was seriously injured.

This New Blunt-Tip Needle Screws the Bruise! Dermasculpt

What is Beverly Hills Plastic Surgeon, Dr Randal Haworth’s, latest tool to minimize bruising with injections?

Injection techniques to place filler into the face to correct lines, folds and wrinkles have became even more advanced with the use of blunt tip cannulae, such as Dermasculpt. These are similar to needles except that they are not sharp and therefore are less prone to cut the tiny diameter blood vessels in and below the skin.

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What does this mean for the patient?

-Markedly less bruising

-Generally significant less discomfort

-Greater safety profile

I don’t employ them to treat all areas of the face, since certain anatomical facial features require extremely precise placement of filler not afforded by blunt tip cannulae. They are ideal to inject larger areas which require generalized plumping or filling such as the temples, cheek hollows, brows and jawline.

I have injected most types of filler through them including Juvederm, Restylane, Belotero, Artefill, Aquamid and Radiesse.

Be prepared to hear some minor crackling noise, however, for the first minute or so similar to lettuce being cut!

The Bulbous Nasal Tip In Rhinoplasty

Dr. Haworth of Beverly Hills gained much of his advanced experience as both a primary and revision rhinoplasty specialist back in the Middle East. He performed literally hundreds of nose jobs there on patients from all walks of life. One of the most common complaints there are boxy and bulbous nasal tips.

What constitutes a bulbous nasal tip?

The bulbous nasal tip is most likely caused by thick alar cartilages (see accompanying diagram)and/or alar cartilages that are splayed out instead of shaped in a neat triangular formation.

beverly hills nosejob, beverly hills rhinoplasty

This anatomic situation can be exacerbated by a thick layer of oily, sebaceous nasal tip skin. Think of the latter as a sleeping bag as opposed to a thin silk sheet., draped over delicate structures

How does an experienced plastic surgeon correct the thick bulbous nasal tip during a nose job?



In my hands, I prefer performing a rhinoplasty utilizing an “open” approach because it affords me vital binocular vision so I can assess up to half-a-millimeter asymmetries that otherwise I would would be unable to appreciate utilizing a closed approach. The closed approach is one where the incisions are solely confined to the inner rims of the nostril, whereas an open approach utilizes the same aforementioned incisions in addition to a small hidden incision below the columella (that fleshy partition that separate the left and right nostril). The open approach allows me to see both the left and right nasal tip cartilages simultaneously so that any maneuver I would perform on the other can be immediately assessed with its opposite counterpart. Sutures are meticulously placed in a strategic fashion in order to change the shape of the cartilages from a round convex shape into more of a triangular one which, in turn, will translate to a more refined, elegant nasal tip. Think of assembling a ship in a bottle via strings, so to speak. The rhinoplasty surgeon cannot just bend cartridges, he must utilize sutures in order to shape them. This is part of the stock-in-trade of nasal tip/nasal cartilage manipulation.

beverly hills nosejob, beverly hills rhinoplasty beverly hills nosejob, beverly hills rhinoplasty
Of course, some cartilage is removed as the surgeon sees fit. The importance of not being too aggressive cannot be overemphasized since doing so could result in an unsightly “pinched tip”. Finally, it is more often than not necessary to “defat” the under surface of the thick sebaceous nasal skin that would accompany such a bulbous tip. This allows the thick “sleeping bag” to redrape more fluidly over the newly reconstructed nasal cartilages.

Swelling of the nose may take many months to even a couple of years to fully disappear. This does not mean that the patient would not enjoy the effects of a rhinoplasty before then. It is just that the skin can remain slightly swollen for prolonged periods of time. The last area for swelling to dissipate is at the nasal tip area. So even though great of a 95% of my patients love their nose at the 21st day postoperatively, some will say that they would like their nasal tip to become further defined. I may either inject some Cortizone underneath the skin to turbocharge the swelling to go away quicker or just recommend patients. Sometimes that’s the hardest thing for inpatient to digest.

For more information, click here and here

See the following example:

beverly hills nosejob, beverly hills rhinoplasty
BEFORE AFTER
beverly hills nosejob, beverly hills rhinoplasty
Bulbous nasal tip with long upper lip and facial atrophy After a rhinoplasty (tip plasty), upper lip lift and complex facial fat transfer

Another example of an isolated bulbous tip with thin skin:

beverly hills nosejob, beverly hills rhinoplasty
A classic bulbous tip with rather thin skinAfter a tip plasty utilizing suture cartilage molding as well as cartilage reduction. After a tip plasty utilizing suture cartilage molding as well as cartilage reduction, Note the smooth nasal tip contour without any distracting shadowing.
beverly hills nosejob, beverly hills rhinoplasty
Patient with a Bulbous tip and thin skin coverage After tip plasty/rhinoplasty 5 years after rhinoplasty, facial fat transfer and upper lip lift