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Cosmetic Treatment Abstract Most popular fillers in cosmetic medicine are hyaluronic acid based. These comprise over 90% of the market and come with the advantage to be soluble in case of complications. Other fillers are contained in the group of bio-stimulatory fillers. They exert a secondary volumizing effect by provoking a low-grade inflammatory response that produces extra collagen. Examples are calcium-hydroxyapatite and L-poly-lactid acid. Finally autologous fat is being used as a filling substance (lipofilling). The gravest complications with fillers are intravascular injections. In particular when injected in arteries fillers can block blood flow and lead to skin necrosis or vison loss in case the material occludes the Central Retinal Artery (CRAO). Two opposing theories about the nature of arterial occlusion exist. One based on Ian Taylor idea of choke anastomoses assume vasoconstriction induced by the filler, both of the primary offended artery and its anastomosing vasosomes. In this case resolving the hyaluronic acid filler with the enzyme hyaluronidase at the primary occluding location would suffice. This is done under ultrasound guidance. The other theory assumes displacement of parts of the filler to end arterioles. Then, the whole affected area has to be flooded with large dosages of hyaluronidase. Obstructions with fillers based on other materials cannot be resolved. It seems logical to prevent intra-arterial filler injection by duplex sonography detection of the course of arteries prior to injection. Ultrasound has additional advantages for cosmetic doctors such as recognizing remains of previously injected filler. It also can give feedback on a physician’s ability to inject filler in the correct subdermal location. Citation: Velthuis PJ, Schelke LW (2021) Fillers and Vessels: The Story of Arterial Obstruction after Cosmetic Treatment. J Angiol Vasc Surg 6: 069. • Page 2 of 3 • J Angiol Vasc Surg ISSN: 2572-7397, Open Access Journal DOI: 10.24966/AVS-7397/100069 Volume 6 • Issue 2 • 100069 transverse facial artery branches from the ECA just caudal to the zygomatic bone and courses medially. Arterial supply for the lateral upper face stems from the superficial temporal artery, that in the parietal region bifurcates medially becoming the frontal branch that runs medially to the forehead. A large part of the mid-forehead receives its blood supply from branches of the ophthalmic artery, in particular the supra-orbital and supratrochlear artery. Some of the arterial supply in the lower and midface may stems from the maxillary artery who gives off branches named the mental artery (entering the chin area through mental foramen) and the infraorbital artery(entering the midface area through the infraorbital foramen). These arteries anastomose with branches of the facial artery. The most important and most dangerous anastomoses with regard of vision loss are those between facial (angular) and ophthalmic artery. There are also small interconnection between the intra-orbital / infra-trochlear arteries and the facial (angular) artery. These have proven to be the major sources of the central retinal artery occlusion. Arterial Occlusion Vascular occlusion in the face after filler injection leads to the so-called Nicolau syndrome. By and large it is a clinical diagnosis consisting of skin blanching, reticular bluish erythema, and slow capillary refill as immediate symptoms, followed a few days later by pustules and finally crusts with subsequent atrophic scars. Complete skin necrosis may appear in severe cases. The initial symptoms are immediate and accompanied by pain and edema [7]. In the first 1-2 days after occlusion an artery with increased lumen is seen on duplex ultrasound. At days 2 and later, rays of collateral arteries surrounding the obstructed vessel become visible. This is a very specific pattern that we tentatively named Medusa Head. On sonography hyaluronic acid filler is depicted as an anechoic pocket. It is impossible to determine whether the filler is actually inside a vessel. Since there are usually more than one filler deposits, we customary inject all HA filler deposits around the occluded artery with hyaluronidase (usually 50-100 units in total). This is best done under ultrasound guidance. In most cases
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