PRIME Journal Vol. 11 Issue 4

References 1. BeleznayK,CarruthersJD,etal. UpdateonAvoidingandTreating BlindnessFromFillers:ARecentReview oftheWorldLiterature.AesthetSurgJ. 2019May16;39(6):662-674. 2. CasabonaG,BernardiniFP,Skippen B,RosamiliaG,HamadeH,FrankK, FreytagDL,SykesJ,OnishiEC,Cotofana S.Howtobestutilisethe lineof ligamentsandthesurfacevolume coefficient infacialsofttissue filler injections. JCosmetDermatol 2020Feb;19(2):303-311. 3. SkippenB,Baldelli I,HartsteinM, CasabonaG,MontesJR,BernardiniF. RehabilitationoftheDysmorphicLower EyelidFromHyaluronicAcidFiller:What toDoAfteraGoodPeriocularTreatment GoesBadAesthetSurgJ2020Jan 29;40(2):197-205. 4. Dubinsky-PertzovB,BernardiniFP, OrL,Gazit I,HartsteinME. Late-Onset UpperEyelidandBrowEdemaasa Long-TermComplicationofHyaluronic AcidFiller Injection.AesthetSurgJ.2021 May18;41(6) Chronic upper and lower eyelid oedema causes a clinical dysmorphism that is pathognomonic of delayed-onset HA filler complication Injectors are the first line specialists to recognise and treat this complication Radiologic studies usually are, in most instances, unyielding and are not necessary as the clinical exam is sufficient The treatment of infra-orbital oedema consists of old filler dissolution followed by secondary HA filler treatment, while in the upper eyelid dissolution alone Key points defects after HYAL, cannot be happy with the result unless they have a valid secondary treatment. This is the reason why for me, it is important to offer a secondary HA filler treatment to be performed two weeks after HYAL, before dissolving the oedema; in our reported series, all patients who opted for secondary filler treatment were satisfied with the final result and didn’t experience any recurrent episode of oedema during the follow-up period ( Figures 5–7 ). This is very similar to what happens when managing lip filler complications, such as filler migration or over- injection, for example, where filler dissolution is routinely followed by secondary filler treatment. In both cases for eyes and lips, a correct injection technique combined with the choice of adequate filler material is necessary to grant a satisfactory result ( Figure 8–10 ). Relative to upper lid complications, the treatment with HYAL is more straightforward and resolutive in most cases, without the need for secondary treatment in most circumstances. I found that the diagnosis in these circumstances is what is most challenging. Periocular DON (Delayed Onset Nodules) Finally, the last long-term complication that needs to be mentioned and that we will have to familiarise ourselves with a lot in the near future is represented by the occurrence of delayed onset nodules (DON) in the infra- orbital region. The indurated nodules potential underlying diagnoses include product redistribution, delayed hypersensitivity reaction, biofilm, and granuloma and occur late after the injection. They are considered to occur following a Type 4 delayed hypersensitivity reaction, which is T-cell mediated and can progress to a specific granulomatous reaction to the filler, with some fillers being more prone to their occurrence, according to the literature. They can occur several months after the original injection with or without associated inflammatory reaction ( Figure 11 ). The occurrence of DON during the Covid vaccinations seems tohave increased their occurrence. Their reported treatment consists of administration of intralesional HYAL and may require multiple injections to fully dissolve the nodule. Declaration of interest None Figures 1-11 © Dr Bernardini It is important to offer a secondary HA filler treatment to be performed twoweeks after HYAL, before dissolving the oedema; in our reported series, all patients who opted for secondary filler treatment were satisfied with the final result and didn’t experience any recurrent episode of oedema during the follow- up period. AESTHETIC FEATURE | PERIOCULAR INJECTIONS | 30 September/October 2021 | prime-journal.com

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