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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 39-42

Analysis of artery occlusion caused by facial autologous fat injections


1 Department of Laser and Plastic Surgery, Guangzhou General Hospital of Guangzhou Milltary Command, Guangzhou 510010, Guangdong Province, China
2 Center for Faculty Development, Southern Medical University, Guangzhou 510010, Guangdong Province, China

Date of Web Publication30-Sep-2015

Correspondence Address:
Jianzeng Qin
Center for Faculty Development, Southern Medical University, Guangzhou 510010, Guangdong Province
China
Xiangdong Qi
Department of Laser and Plastic Surgery, Guangzhou General Hospital of Guangzhou Milltary Command, No. 111, Liuhua Road, Guangzhou 510010, Guangdong Province
China
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Source of Support: The work was supported by the National Natural Science Foundation of China (Grant No. 41271153), the National High Technology Research and Development 863 Program of China (Grant No, 2012AA021105) and the Special Project on the Integration of Industry, Education and Research of Guangdong Province, China (Grant No. 2012B091100472), Conflict of Interest: None declared.


DOI: 10.4103/2226-8561.166362

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  Abstract 

Objective: To investigate the causes for retinal artery occlusion and cerebral infarction resulting from cosmetic facial autologous fat injections. Materials and Methods: Twenty-seven retrospective, noncomparative cases with artery occlusion caused by facial autologous fat injections were included. Injection sites, basic demographic information (age, sex, and laterality of the involved eyes), best-corrected visual acuities (BVCAs), fundus fluorescein angiography, optical coherence tomography findings, brain magnetic resonance imaging, and associated ocular and systemic manifestations were collected as study information. Twenty-seven cases were classified according to artery occlusion, which led to blindness and brain infarction, as relationship between blindness and brain infarction may provide clues to help us figure out the process of arterial blockage. Results: Of the 27 cases, 13 patients had ophthalmic artery occlusion (OAO), 6 had central retinal artery occlusion (CRAO), and 3 had branch retinal artery occlusion (BRAO). Injection sites were the glabellar area (9 cases), nasolabial area (5 cases), forehead area (4 cases), periocular area (2 cases), nose area and nasal area (2 cases), multiple places (2 cases), and other areas (3 cases). Injection at different injection sites may lead to blindness, which means that emboli went into the blood by different branches of the external carotid artery, and eventually blocked the ophthalmic artery and its branches. Concomitant brain infarction developed in 13 cases with retinal artery occlusion. The high probability of occurrence of cerebral infarction indicated that internal carotid artery could be a flow path of emboli. Conclusion: Cosmetic facial autologous fat injections may cause retinal artery occlusion. Under the pressure of injection, fat emboli go through the terminal artery of face into the ophthalmic artery counter currently. In some cases, retrograde arterial embolism also causes brain infarction. Middle cerebral artery occlusion is closely associated with OAO.

Keywords: Artery occlusion, autologous fat, complication, infarction, injection


How to cite this article:
Qi X, Zhou J, Ma L, Qin J. Analysis of artery occlusion caused by facial autologous fat injections. Digit Med 2015;1:39-42

How to cite this URL:
Qi X, Zhou J, Ma L, Qin J. Analysis of artery occlusion caused by facial autologous fat injections. Digit Med [serial online] 2015 [cited 2019 May 21];1:39-42. Available from: http://www.digitmedicine.com/text.asp?2015/1/1/39/166362


  Introduction Top


As cosmetic facial filler injections become increasingly popular in recent years, severe complications have been more and more frequently reported. Autologous fat injection for cosmetic facial augmentation is considered safer than other filler materials. However, retinal artery occlusion after autologous fat injections has been reported. All cases of facial autologous fat injection resulted in blindness, and in some patients severe systemic manifestations occurred. The causes for artery occlusion remain unclear. In this study, we aimed to investigate the reason for retinal artery occlusion and brain infarction resulting from cosmetic facial autologous fat injections.


  Materials and Methods Top


Cases from August 1996 through March 2014 meeting the following criteria were reviewed retrospectively: (i) Nonarteritic retinal artery occlusion newly diagnosed by fundus fluorescein angiography; (ii) no history of intraocular surgery or vascular interventions for retinal artery occlusion before symptom development; and (iii) a history of cosmetic facial filler injection immediately before retinal artery occlusion.[1] Twenty-seven cases were classified according to occlusion artery, which led to blindness and brain infarction. And the relationship between blindness and brain infarction may provide clues to help us figure out the process of arterial blockage.

Cases of artery occlusion caused by facial autologous fat injections were rarely reported, which may lead to a lack of data. The collected data included information concerning underlying diseases, demographics, injection sites, injected substances, basic demographic information (age, sex, and laterality of the involved eyes), initial and final best-corrected visual acuities (BCVAs), associated ocular symptoms and systemic problems, duration of follow-up,[1] and treatment management intra-arterial thrombolysis or conservative therapy), optical coherence tomography (OCT), fundus fluorescein angiography, and brain magnetic resonance imaging (MRI).

The cases of iatrogenic retinal artery occlusion were divided according to the affected arteries as follows: (i) Ophthalmic artery occlusion (OAO), (ii) central retinal artery occlusion (CRAO), and (iii) branch retinal artery occlusion (BRAO). OAO was defined as CRAO with evidence of choroidal ischemia and definite embolic occlusion of the ophthalmic artery on cerebral angiography. CRAO applied to cases without evidence of choroidal ischemia and definite embolic occlusion of the ophthalmic artery on cerebral angiography.[1]


  Results Top


Twenty-seven consecutive patients with cosmetic facial filler injection-associated retinal artery occlusion were included in the study [Table 1]. Of these, 13, 6, and 3 patients had OAO, CRAO, and BRAO, respectively. All the patients had a history of sudden visual loss immediately after the injections. Almost all the patients were healthy without hypertension, diabetes, or other underlying diseases, except patient 21 who had hypertension.
Table 1: Characteristics and clinical data of 27 patients with retinal arterial occlusion after autologous fat injection in the literature

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The clinical characteristics of the 27 patients with iatrogenic retinal artery occlusion are described in [Table 1]. Most of the patients with the retinal artery occlusion after cosmetic facial autologous fat injections were middle-aged women (mean age, 37.7 ± 2.7 years; 82% [18 of 22] female). The injection sites included the glabellar region (9 cases, 33.3%), the nasolabial fold (5 cases, 18.5%), the forehead region (4 cases, 14.8%), nose area and nasal area (2 cases, 7.4%), the periorbital region (2 cases, 7.4%), and other places (5 cases, 18.5%). Conservative treatment including ocular massage, oxygen and carbon dioxide therapy, hyperbaric oxygen therapy, steroid therapy, topical antibiotics, and anticoagulant were executed in most of the patients.

OAO (13 cases)

Most of the cases with OAO complained of severe ocular pain in the affected eye immediately after the injection. Fundus examination showed cherry red spot, ischemia of the retina, and papilloedema. Fundus fluorescein angiography showed no retinal perfusion and attenuated choroidal perfusion in the patients with this condition. Selective angiography of carotid artery and cerebral angiography showed OAO and attenuated choroidal perfusion. Six patients patients 1, 2, 4, 11, 20, and 24) experienced brain infarction, and five patients 1, 2, 11, 20, and 24) had middle cerebral artery (MCA) infarction.

CRAO (6 cases)

The initial presentation of iatrogenic CRAO was decreased vision without ocular pain. Fundus examination showed cherry red spots, ischemia of the retina, and papilloedema. Fundus fluorescein angiography showed no retinal perfusion, but intact choroidal perfusion. Two patients (patients 17 and 18) had necrosis, and one (patient 27) experienced MCA and anterior cerebral artery (ACA) infarction.

BRAO (3 cases)

The initial presentation of iatrogenic BRAO was also decreased vision without ocular pain. Fundus examination showed diffuse whitening of the retina. Fundus fluorescein angiography showed filling defects in the branch and retrograde retinal artery fillings. Two of the cases (patients 3 and 6) experienced MCA infarction.


  Discussion Top


In this study, we summarized clinical and angiographic characteristics of 27 patients experiencing iatrogenic occlusion of the ophthalmic artery and its branches after cosmetic facial autologous fat injections. Of the 27 patients, we detected several fat embolisms in the retinal vessels, including the ophthalmic artery and multiple branches of the ophthalmic arteries, and ACA, MCA infarction with ischemic and infarction in its supply area, by fundus photography, fundus fluorescein angiography, transfemoral cerebral angiography, and OCT. Patients showed no improvement after treatment of ocular massage, oxygen and carbon dioxide therapy, hyperbaric oxygen therapy, steroid therapy, topical antibiotics, anticoagulant, intraarterial thrombolysis, and anterior chamber paracentesis. Clinical manifestations of cerebral infarction mitigated or disappeared, and computed tomography (CT) and MRI scan showed cortical calcifications in the infarcted area.

Many researchers have proposed that retrograde embolic mechanisms are responsible for the development of arterial occlusion. At first, there must be perforation of an arterial wall. Second, the force of injection for the product delivery exerted on the plunger of a syringe can significantly expand these arterioles many times their normal caliber and can cause retrograde flow.[19] A needle or cannula used to inject a soft tissue filler can accidentally perforate the wall of one of the distal branches and enter the lumen of artery. If the tip of the needle or cannula is in the lumen of an artery when the plunger of the syringe is pressed to propel the injectable filler out of the syringe, the filler may be injected into the lumen of the cannulated artery. As more pressure is applied to the plunger, the filler displaces the arterial blood and travels as a column proximally past the origin of the retinal artery.[20] Once the surgeon stops placing pressure on the plunger, the forced injection ceases and the arterial systolic pressure propels the filler into the branches of the ophthalmic artery.[17] Autologous fat or lipid droplets that cause arterial occlusion are injected into peripheral vessels accidentally, and fat emboli retrograde into the upper level artery under the force of injection. The rich vascular anastomosis between the distal branches of the facial and the ophthalmic arteries makes it easy to cause retinal artery occlusion when there is perforation of facial arterial wall. The supratrochlear and supraorbital arteries are the possible inlets for retrograded flow in the glabellar region.[21] The anastomosis of the dorsal nasal artery from the ophthalmic artery, angular artery, and lateral nasal artery from the facial artery is the possible inlet for retrograded flow in the nasolabial fold.[1] This severe complication can be prevented by avoiding sharp needles. Instead, we should use a smaller syringe to minimize delivery pressure, avoid facial arteries and use proper injection technique.[22]

Five of eight MCA infarction cases were associated with OAO. To our knowledge, the middle cerebral artery is the thickest branch of the internal carotid artery within the skull. Chances are that fat emboli, which block the ophthalmic artery, may be retrograded into the internal carotid artery when the vascular wall is impaired and the force of injection is too great. We also suspect that traffic branch may exist between middle cerebral artery and ophthalmic artery. When the force of injection is great, the traffic branch is open, giving rise to MCA infarction.


  Conclusion Top


In conclusion, cosmetic facial autologous fat injection may cause retinal artery occlusion. The injections are associated with a great incidence of combined cerebral infarction. This possible complication should be discussed with patients before injection into the face. Most importantly, surgeons should know the method of autologous fat grafting and how to avoid arterial occlusion from facial autologous fat injection.

 
  References Top

1.
Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol 2012;154:653-662.e1.  Back to cited text no. 1
    
2.
Lee CM, Hong IH, Park SP. Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat. Korean J Ophthalmol 2011;25:358-61.  Back to cited text no. 2
    
3.
Park SH, Sun HJ, Choi KS. Sudden unilateral visual loss after autologous fat injection into the nasolabial fold. Clin Ophthalmol 2008;2:679-83.  Back to cited text no. 3
    
4.
Feinendegen DL, Baumgartner RW, Vuadens P, Schroth G, Mattle HP, Regli F, et al. Autologous fat injection for soft tissue augmentation in the face: A safe procedure? Aesthetic Plast Surg 1998;22:163-7.  Back to cited text no. 4
    
5.
Thaunat O, Thaler F, Loirat P, Decroix JP, Boulin A. Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg 2004;113:2235-6.  Back to cited text no. 5
    
6.
Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral arteryocclusion AND ocular fat embolism after autologous fat injection in the face. J Neurol 1998;245:53-4.  Back to cited text no. 6
    
7.
Yoon SS, Chang DI, Chung KC. Acute fatal stroke immediately following autologous fat injection into the face. Neurology 2003;61;1151-2.  Back to cited text no. 7
    
8.
Lee KM, Kim EJ, Jahng GH, Chang DI. Magnetic resonance findings in two episodes of repeated cerebral fat embolisms in a patient with autologous fat injection into the face. J Korean Neurosurg Soc 2012;51:312-5.  Back to cited text no. 8
    
9.
Carle MV, Roe R, Novack R, Boyer DS. Cosmetic facial fillers and severe vision loss. JAMA Ophthalmol 2014;132:637-9.  Back to cited text no. 9
    
10.
Mori K, Ohta K, Nagano S, Toshinori M, Yago T, Ichinose Y. A case of ophthalmic artery obstruction following autologous fat injection in the glabellar area. Nihon Ganka Gakkai Zasshi. 2007;111:22-5.  Back to cited text no. 10
    
11.
Egido JA, Arroyo R, Marcos A, Jiménez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993;24:615-6.  Back to cited text no. 11
    
12.
Lee DH, Yang HN, Kim JC, Shyn KH. Sudden unilateral visual loss and brain infarction after autologous fat injection into nasolabial groove. Br J Ophthalmol 1996;80:1026-7.  Back to cited text no. 12
    
13.
Allali J, Bernard A, Assaraf E, Bourges JL, Renard G. Multiple embolizations of the branches of the ophthalmic artery: An unknown serious complication of facial surgeries. J Fr Ophtalmol 2006;29:51-7.  Back to cited text no. 13
    
14.
Lee YJ, Kim HJ, Choi KD, Choi HY. MRI restricted diffusion in optic nerve infarction after autologous fat transplantation. J Neuroophthalmol 2010;30:216-8.  Back to cited text no. 14
    
15.
Park SJ, Woo SJ, Park KH, Hwang JM, Hwang GJ, Jung C, et al. Partial recovery after intraarterial pharmacomechanical thrombolysis in ophthalmic artery occlusion following nasal autologous fat injection. J Vasc Interv Radiol 2011;22:251-4.  Back to cited text no. 15
    
16.
Kim SK, Hwang K. A surgeon's legal liability of compensation for blindness after periorbital fat grafts. J Craniofac Surg 2013;24:970-1.  Back to cited text no. 16
    
17.
Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthet Surg J 2002;22:555-7.  Back to cited text no. 17
    
18.
Teimourian B. Blindness following fat injections. Plast Reconstr Surg 1988;82:361.  Back to cited text no. 18
    
19.
Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S. Blindness following cosmetic injections of the face. Plast Reconstr Surg 2012;129:995-1012.  Back to cited text no. 19
    
20.
Chen Y, Wang W, Li J, Yu Y, Li L, Lu N. Fundus artery occlusion caused by cosmetic facial injections. Chin Med J (Engl) 2014;127:1434-7.  Back to cited text no. 20
    
21.
Lee JH, Kirkham JC, McCormack MC, Nicholls AM, Randolph MA, Austen WG Jr. The effect of pressure and shear on autologous fat grafting. Plast Reconstr Surg 2013;131:1125-36.  Back to cited text no. 21
    
22.
Coleman SR. Structural fat grafting. Aesthet Surg J 1998;18:386-8.  Back to cited text no. 22
    



 
 
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