Every year, the number of aesthetic procedures for the face is growing rapidly. Despite the high safety profile of most minimally invasive techniques, the problem of complications after correction of the periocular region remains extremely relevant.
Many practitioners do not have sufficient knowledge to work safely in the periorbital area, minimize risk, and manage complications in a timely manner.
Dr. Daniel Ezra describes the problems that can occur in the periocular region after botulinum toxin therapy, filler injections and skin chemical treatments, and talks about how to prevent them and solutions.
Complications after correction of the periorbital area with botulinum toxin preparations
Correction of the periocular region is often performed with botulinum toxin preparations. Work with target muscles – the muscle wrinkling the eyebrow and the circular muscle of the eye – allows you to reduce the severity or smooth out wrinkles between the eyebrows and crow's feet, respectively. The most common side effects of toxin injections in this area – ptosis and diplopia.
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Ptosis
Risk factors: anatomical features, dose and dilution drug.
To avoid ptosis, the needle should not be placed near the attachment of the orbital septum.
When injecting a toxin into the eye socket, always inject the drug subcutaneously to protect deeper structures. It is important to remember that dry eyes can occur due to a violation of the closing of the eyelids.
Injection of high doses of botulinum toxin into the orbital septum is associated with an increased risk of ptosis, which can be minimized by volume reduction.
The most common side effects of botulinum toxin injections in the periorbital area – ptosis and diplopia.
Ptosis occurs in about 5% of patients and is usually treated with apraclonidine (eye drops). However, it must be remembered that long-term use of this drug can cause skin irritation in the form of chronic or acute allergic dermatitis, pupillomotor changes, lacrimation, discomfort, dry mouth and changes in taste. Apraclonidine is not intended for the treatment of other forms of ptosis.
Read also: How to solve the problem of ptosis of the upper eyelid after the introduction of botulinum toxin preparations
Diplopia
Diplopia after botulinum therapy occurs less frequently than ptosis, and is almost always caused by the injection of high doses of botulinum toxin too close to the orbital septum.
Temporary supportive measures for patients with transient post-procedural diplopia may include prisms and occlusive contact lenses, so patients with these complications should be referred to an ophthalmologist.
Complications after injections of HA fillers into the periocular region
HA-based fillers are associated with some pretty serious complications, especially if they are misplaced. Thin and delicate tissues of the periorbital region cause a high incidence of complications in this area.
Puffiness
The most common problem associated with fillers, especially in the area of the nasolacrimal trough.
Ways to minimize the risk of swelling:
• correct choice of drug (it is better to use gels with fewer cross-links);
• Introduction of small amounts of filler (0.2-0.3 ml for each nasolacrimal groove).
Infections
Reactions to foreign bodies and infections can occur months or even years after injection correction.
Granulomas and reactions to foreign bodies – one of the most common complications that should be differentiated from nodules and tubercles resulting from overcorrection or improper administration of the drug.
Granuloma – discrete nodules characterized by specific inflammatory reactions. They are often well-defined, painful, and red in color. It is believed that infectious processes are triggered either due to infection during filler injection, or as a result of the formation of a biofilm around the gel.
Difficulties in the treatment of infections are due to the isolation and low vascular permeability of the filler injection site. Therefore, after antibiotic therapy, infections often recur.
Prevention of bacterial contamination during filler injection – a very important precaution that dictates the need for aseptic conditions during the procedure: wearing sterile gloves and pre-treatment of the skin with chlorhexidine or povidone-iodine.
Combination therapy with antibiotics, steroids, surgical drainage, and hyaluronidase is indicated for infections following HA fillers.
Vascular Occlusion
The most dangerous complication of hyaluronic acid fillers is vascular occlusion. There are known cases of loss of vision after injection of HA into the periocular region. This phenomenon is explained by occlusion of the central retinal artery caused by the ingress of the filler into the internal branches of the carotid artery through the system of the external carotid artery.
Vision loss occurs suddenly and is often accompanied by ptosis, ophthalmoplegia, and pain.
Other forms of vascular occlusion can cause localized necrosis, which is more common around the medial structures of the face, particularly at the terminal supraorbital or labial arteries. Sometimes necrosis in these areas is sometimes mistaken for an infection.
Read also: Bypassing Dangerous Zones: Filler Injection Points
Characteristic signs of vascular occlusion – sudden blanching and discoloration of the skin, accompanied by pain and paresthesia.
If the above symptoms occur, stop the administration of the drug immediately and apply a warm compress to the treated area. It is also recommended to inject 300 units of hyaluronidase into the affected area. If necessary, 300 units of enzyme can be re-introduced every other day. Higher doses of hyaluronidase are not recommended as they may cause significant soft tissue changes. The patient is also prescribed a course of oral antibiotics.
If the above symptoms occur, it is necessary to immediately stop the administration of the drug and apply a warm compress to the treated area. It is also recommended to inject 300 units of hyaluronidase into the affected area. If necessary, 300 units of enzyme can be re-introduced every other day. Higher doses of hyaluronidase are not recommended as they may cause significant soft tissue changes. The patient is also prescribed a course of oral antibiotics.
Characteristic signs of vascular occlusion – sudden blanching and discoloration of the skin, accompanied by pain and paresthesia.
Fig. 1: retinal artery occlusion use the correct filler injection technique;
• have a good understanding of the anatomy of the periocular region;
• apply slight pressure on the plunger of the syringe when injecting the drug;
• Use larger diameter needles or cannulas to reduce the hydrostatic pressure of the filler;
• aspirate before injecting the product;
• Use cold vasoconstriction compresses prior to filler injection.
Hyaluronidase therapy is the main treatment for complications following HA fillers. However, too high doses of this enzyme can lead to the destruction of the extracellular matrix's own glycosaminoglycans, resulting in a emaciated appearance of the face and deterioration of the skin texture.
Read also:Hyaluronidase enzyme in cosmetology: elimination of side effects of fillers
Complications after the use of chemicals in the periocular region
Different types of chemicals and preparations are often used for aesthetic correction in the periocular region. Eyelash coloring, acid peels, retinoid therapy – all of these procedures can cause chemical burns and damage to the cornea. The protective layer of the cornea is predominantly a form of barrier immunity, and any damage to the epithelium can lead to infection and pain.
In the event of chemical contact with the eyes, eye baths or sterile saline should be used to immediately flush the eyes. Then it is necessary to measure the pH level of the tear film with universal indicator paper – The pH must be neutral. The patient should then be referred to an ophthalmologist.
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