Abstract
Graphical Abstract
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Figures and Tables
Fig. 1
Angiographic findings of an autologous fat-injected patient. A 40-yr-old woman after autologous fat injection in the glabella. (A) The fundus photograph shows an obstructed retinal artery with white infiltrations (arrow heads) and retinal edema at the corresponding area. Some whitish infiltration is observed at the end of arterioles (arrows). (B) Fluorescein angiography reveals markedly delayed retinal and choroidal perfusion. (C) There is abrupt cut off of some of the arteriolar ends (arrows), and demonstrates focal hyperfluorescence in the late phase, which suggests direct embolic obstruction of the arteriole. (D) The selective ophthalmic artery angiogram shows a large filling defect (arrow) in the proximal ophthalmic artery.
![jkms-30-1847-g001](/upload/SynapseData/ArticleImage/0063jkms/jkms-30-1847-g001.jpg)
Fig. 2
Angiographic findings of a hyaluronic acid-injected patient. A 39-yr-old woman after hyaluronic acid injection in the glabella and nasal dorsum. (A) Fundus photograph reveals segmented and attenuated retinal vessels. (B) Fundus fluorescein angiography shows markedly compromised retinal and choroidal perfusion. (C) Fundus photograph taken at the day after intra-arterial thrombolysis. The retinal vessels were still segmented and the margin was blurred due to retinal edema secondary to ischemic injury. (D) The choroidal perfusion was improved after intra-arterial thrombolysis, while retinal perfusion remained compromised.
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Fig. 3
Selective ophthalmic artery angiogram. (A-D) In hyaluronic acid-injected patients, no mechanical obstruction is visible in the supratrochlear or supraorbital branch, while blood flow to the retina and the choroid is compromised. (A and D) Obstruction was visible in two patients at small branches of the second segment of ophthalmic artery including the posterior ciliary branch (arrow). (B and C) However, it could not be clearly delineated in the other two patients. (E-G) In autologous fat-injected patients, a large filling defect is visible in the proximal part of ophthalmic artery (arrow). Blood flow is compromised thereafter. (H) Schematic drawings of the vascular anatomy in selective ophthalmic artery angiogram. The lighter lines indicate the optic nerve and the posterior wall of the eye ball. Presumed obstruction level is shown as dashed circle (autologous fat) or lined circle (hyaluronic acid). Case numbers are identical to those in Table 1.
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Fig. 4
Selective external carotid artery angiogram. (A-C) In hyaluronic acid-injected patients, the angiographic runoff is diminished in the distal branches of internal maxillary and/or facial arteries and contrast staining is decreased in the periorbital area (dashed circle). (C) Faint distal runoff of internal maxillary artery (arrows) is observed but periorbital contrast staining is diminished (dashed circle). (D-G) In hyaluronic acid-injected patient, who were also treated with subcutaneous hyaluronidase injection (D), and in autologous fat-injected patients (E-G), the distal angiographic runoff in the distal branches of internal maxillary and/or facial arteries (arrows) and contrast staining (arrow heads) are relatively preserved (dashed circle). Case numbers are identical to those in Table 1.
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Fig. 5
Skin changes after cosmetic facial filler injections on the glabella and/or nasal dorsum. (A-C) Hyaluronic acid-injected patients have skin necrosis. (D) Hyaluronic acid-injected patient, who were also treated with subcutaneous hyaluronidase injection showed mild erythema in the injected area. Autologous fat-injected patients also have (E) mild erythema or (F) normal appearance in the injected area. Case numbers are identical to those in Table 1.
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Fig. 6
Schematic drawing of vascular anatomy and the comparison of possible obstruction mechanism between hyaluronic acid and autologous fat. (A) Vascular anatomy of external and internal carotid artery and its ophthalmic and facial branches. (B) Hyaluronic acid (HA) molecules are small and uniform in size, compared to fat. HA may obstruct the central retinal artery, posterior ciliary arteries, and branch retinal arteries. In addition, the pressure gradient may be diminished between the ophthalmic artery and its distal ends because the distal intra-tissue pressure increases due to water absorption and volume expansion properties of HA, thereby decreasing blood flow. On the other hand, fat particles are composed of various sizes; thus, they can concomitantly obstruct from small arteries to the proximal part of the ophthalmic artery. Filler injected area and possible affected vascular area is drawn with yellow colored circle in A and B. BRA, branch retinal artery; CCA, common carotid artery; CRA, central retinal artery; DNA, dorsal nasal artery; ECA, external carotid artery; FA, facial artery; ICA, internal carotid artery; IMA, internal maxillary artery; IOA, infraorbital artery; OA, ophthalmic artery; PCA, posterior ciliary artery; SOA, supraorbital artery; STA, superficial temporal artery; STrA, supra-trochlear artery.
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Table 1
Demographic and cerebral angiographic findings of patients
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*This patient was treated with subcutaneous hyaluronidase injection immediately after the onset of visual symptom by the physician who performed cosmetic filler injection. CRAO, central retinal artery occlusion; ECA, external carotid artery; F, female; IAT, intra-arterial thrombolysis; L, left; HA, hyaluronic acid; HM, hand motion; MCA, middle cerebral artery; MRI, magnetic resonance imaging; NLP, no light perception; OAO, ophthalmic artery occlusion; OphA, Ophthalmic artery; R, right; UK, urokinase.