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Background
Hyaluronic acid fillers have a satisfactory safety profile. However, adverse reactions do occur, and rarely intravascular injection may lead to blindness. Currently there is no internationally recognized consensus on the prevention or management of blindness from hyaluronic acid filler.
Objectives
The authors sought to give guidance on how to minimize the risk and optimize the management of this rare but catastrophic adverse reaction.
Methods
A multinational group of experts in cosmetic injectables from multiple disciplines convened to review current best practice and develop updated consensus recommendations for prevention and bedside intervention if visual loss occurs after cosmetic injection of hyaluronic acid filler.
Results
The consensus group provided specific recommendations focusing on the consenting process, prevention, and early management of visual impairment related to intravascular hyaluronic acid filler injection.
Conclusions
Although visual loss due to filler injections is rare, it is important that both patient and physician be aware of this risk. In this paper the authors describe methods and techniques available to reduce the risk and also document suggested initial management should a clinician find themselves in this situation.
Level of Evidence: 5
Little else is known about the optimal preparation of foamed sclerosants and the best technique for administering foam for sclerotherapy. Long-term studies are required to determine outcome for various techniques. There is an opportunity for many controlled trials to assess results.
Background
Aesthetic physicians rely upon certain anecdotal beliefs regarding the safe practice of filler injections. These include a presumed safety advantage of bolus injection after a negative aspiration.
Objectives
The article aims to review and summarize the published literature on inadvertent intravascular injection of hyaluronic acid and to investigate whether the technique of aspiration confers any safety to the practitioner and the patient.
Methods
Pertinent literature was analyzed and our understanding of the safety of negative and positive aspiration outlined.
Results
The available studies demonstrate that aspiration cannot be relied upon and should not be used as a safety measure. It is safer to adopt injection techniques that will avoid injecting an intravascular volume with embolic potential than use an unreliable test to permit a risky injection.
Conclusions
To prevent intravascular injection, understanding “injection anatomy” and injection plane and techniques such as slow, low-pressure injection are important safety measures. Assurance of safety when delivering a bolus after negative aspiration, does not appear to be borne out by the available literature. If there is any doubt about the sensitivity or reliability of a negative aspiration, then there is no role for its use. Achieving a positive aspiration would just defer the risk to the next injection location where a negative aspiration would then be relied upon.
Utilization of a 1-10 msec vascular laser to treat facial vessels to limit purpura has become available in recent years. Its efficacy and morbidity in the treatment of common vascular lesions require exploration. We have assessed the relative outcomes and morbidity from a single treatment session of two patterns of 'difficult to treat' facial telangiectasia - perialar vessels and spider naevi - with such a system. Two prospective clinical studies with long pulse 532 nm potassium tritanyl phosphate (KTP) laser were performed with subjective and independent objective assessment at 3 days, 1 week and 4 weeks in both studies. Perialar vessels showed good to excellent improvement subjectively at 4 weeks in 53% (8/15), spider naevi in 83% (20/24). Pain of treatment was substantially greater treating perialar telangiectasia than when treating spider naevi (P < 0.01). Morbidity was low in both groups with no long-term complications. Despite the clinical end-point of vessel disappearance at time of treatment and good early improvement in the appearance of perialar vessels, the failure rate was significant at 1 month follow up. It would appear that spider naevi behave more predictably, with vessel disappearance at time of treatment most often forecasting a successful outcome. Although not statistically significant, spider naevi probably respond better than perialar vessels to a single treatment with this laser.
The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30–90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6–12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.
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