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Se viaggiate con un vostro mezzo di trasporto, dovrete servirvi di uno dei frequenti traghetti con trasporto veicoli motocicletta , Le strade ripide e tortuose di Ko Chang sono piuttosto pericolose v. Accademia delle scienze fisiche e matematiche, Naples, Reale Accademia delle scienze fisiche e matematiche di Napoli, Cocarde, s.
Jko-kard Fiocco ; nappa ; coccarda. CocU, g.
Carro coperto. Physicians performing facial filler injections should have a proficient knowledge of anatomy. Nonsurgical cosmetic procedures are a growing trend worldwide. Included among these minimally invasive techniques are botulinum toxin and soft-tissue augmentation with fillers, which are used to restore tissue loss and correct aging-related rhytides and folds.
In , dermal fillers were used in nearly 1. Hyaluronic acid HA fillers are the most commonly used injectable fillers, followed by autologous fat. According to the American Society for Aesthetic Plastic Surgery, nearly , soft- tissue augmentation procedures were performed with HA in While these adverse reactions are usually transient, the common use of three- dimensional facial volume restoration techniques, where the filler material can be injected at any depth, has brought about infrequent but serious and often irreversible vascular complications caused by symptomatic arterial occlusion.
Based on the available literature, some authors have suggested that the injection technique, site, and substance can have significant influence on the level of risk for an adverse vascular event. Therefore, we reviewed the literature regarding vascular complications and performed a meta-analysis of the variables that potentially affect the frequency and severity of adverse events. This meta-analysis included data from case reports and case series of patients experiencing any type of vascular complication after an aesthetic procedure published during the years to The main source for article retrieval was the PubMed.
Additional sources included Google Scholar, where the search was restricted to the article title, and a case series by Park et al,18 which provided details from 19 cases previously published as case reports. The database search, performed on December , combined the term filler with the following terms: injection or injected , blindness, visual loss, ophthalmoplegia, artery occlusion, embolism, ischemia or ischemic , necrosis, and complication.
Only full-text articles written in English were considered for eligibility. To be included in the analysis, cases had to report a vascular event occurring after an aesthetic procedure on the human face. Data for the meta-analysis were extracted from each case and transferred to a predefined form containing the following variables: case reference, age, sex, injected product, aesthetic procedure, needle diameter, injected volume, person who injected the product, injection site, blood vessel affected, main consequence s of the vascular event, concomitant symptoms, time to symptom onset, intervention performed to treat the vascular complication, and outcome.
Additionally, diagnostic tests performed to confirm the occurrence of vascular complications were recorded to address the quality of the articles included in our review. The main consequences of a vascular complication were blindness, visual loss, necrosis, and other. Blindness was only considered when explicitly stated in the text, whereas visual loss included a reduction in visual acuity, the perception of light only, and the perception of hand movement only.
Time-to-onset values were grouped into three categories: less than one hour postprocedure, 1 to 24 hours postprocedure, and more than 24 hours postprocedure. The final outcome was categorized as no change, partial recovery, or full recovery based on the progress of the main consequence of the vascular complication.
Categorical variables were described as frequency and percentage, whereas quantitative variables were described as means and standard deviations SDs. To assess the factors possibly influencing the outcome of vascular complications, the percentages of cases with no improvement and those showing partial or full recovery were compared using the chi- squared test.
For variables showing statistically significant differences, a post-hoc analysis was performed by computing the chi-squared values of the adjusted residuals and applying the Bonferroni correction, as described by Beasley et al. The multivariate analysis included all variables regarding events occurring prior to any vascular complication, which showed significant differences when comparing patients without improvement and those with partial or total recovery. The initial search including articles retrieved from additional sources yielded articles, published during the years to , on vascular events potentially associated with the use of injected fillers Figure 1.
After removing duplicates and excluding non-English articles and those without full-text availability, 86 were considered eligible. Of these, 56 either reported results at injection sites other than the face or did not report any vascular complication, and thus were discarded. The final selection included 30 full-text articles reporting 93 cases: 22 case reports i.
All cases had information regarding the injection site and main consequences of vascular complications. Other key variables, such as injected substance, outcome, and affected blood vessel were reported in 92 In 80 cases In six cases, the affected vessel was deduced from the signs e. Conversely, in four cases, the physician failed to identify the affected vessel despite performing imaging diagnostic tests. Needle diameter, injected volume, and the professional who performed the injection were only reported in 11, 17, and 13 cases, respectively; due to their low representation in the study sample, these variables were excluded from analysis.
Table 1 summarizes the main characteristics of the cases described in the selected articles. In five cases 5. Whereas blindness was typically assumed to be a consequence of a vascular embolization of the filler material, necrosis was sometimes attributed to compression Figure 2. Nine patients 9. Eight patients 8. One patient that was injected with autologous fat in the glabella experienced occlusion of the retinal artery with concomitant brain infarction, which resulted in hemiplegia and death.
Theoretically, multiple blood vessels and nerves can be reached by the needle during filler injection Figure 3. However, the paths of facial, nasal, temporal, and ophthalmic arteries define anatomical areas with increased risk of injury during filler injection Figure 4. In the case of the ophthalmic artery, the increased risk included occlusion of one of its most important branches: the retinal artery. In our analysis, the ophthalmic retinal arteries accounted for In addition to the nasociliary artery, other blood vessels affected by the aesthetic procedure were the choroid vessels, the internal carotid artery, the middle cerebral artery, and the facial vein and artery.
In 12 cases Two of these were associated with ophthalmic artery occlusion, whereas eight were associated with retinal artery occlusion. Full recovery was reported in seven cases 8. Temporary blindness was caused by an HA injection in the eyebrow. The patient reported foggy and hazy vision immediately after the filler injection; 10 days later, the filler was successfully removed by irrigation and aspiration after creating a temporal limbal incision in the affected eye.
Eight days after removal, visual acuity was restored. Hyaluronidase was used only in 10 of 40 cases in which HA was the cause of vascular occlusion. The time between symptom onset and hyaluronidase injection exceeded three hours in all cases. The dose of hyaluronidase injected, reported only in five cases, ranged from 1, to 9, units.
In five of these cases, blindness was the main consequence of the vascular event; only one patient experienced partial recovery,25 whereas the rest remained blind despite attempts to remove the HA obstruction by injecting hyaluronidase. To explore possible baseline factors influencing the outcome, cases with either visual loss or blindness as the main consequence were grouped into two categories based on the outcome: total or partial recovery and no improvement Table 2.
A chi-squared test revealed significant differences in the injected substance, the affected blood vessel, and the time to symptom onset.ehricrirest.cf
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A post-hoc analysis of time-to-onset did not reveal significant differences in any of the three categories. The injected substance, the affected blood vessel, and the time to symptoms onset were included in a logistic regression analysis. However, only the affected blood vessel significantly contributed to the overall model Table 3. In this systematic review and meta-analysis of patients with vascular complications occurring after aesthetic procedures, we found that unilateral blindness was the most frequent vascular adverse event associated with cosmetic fillers for facial tissue augmentation.
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Of these, autologous fat tended to cause more cases of permanent vascular damage. Among all blood vessels affected, the ophthalmic artery was significantly associated with irreversible blindness. The risk of vascular complications associated with facial aesthetic procedures has been addressed previously in case reports, case series, and literature reviews. In an attempt to further understand the factors influencing the risks and outcomes of vascular complications, we extracted data from individual cases to provide a quantitative approach. Moreover, considering that the number of products available for soft- tissue augmentation has been progressively and continuously increasing for the last 10 years, our review aimed to present an updated picture of vascular complications associated with these fillers.
All analyses based on case reports are constrained by the amount and accuracy of the information published. Eighty-six percent of cases reported using imaging diagnostic techniques to verify the diagnosis of vascular occlusion, and most of them provided details regarding key variables such as the injected substance, the blood vessel affected, the outcome of the vascular complication, and the time to symptom onset. In terms of clinical correlation, one of the most relevant variables was the filler injected. In our study selection, the absolute number of cases with vascular complications after the use of HA and autologous fat was similar.
However, considering that HA is, by far, the most used filler in the world for aesthetic procedures,4,5 this observation suggests that autologous fat is more often associated with vascular complications than HA. Regarding the recovery rate of vascular complications, both HA and autologous fat were significantly associated with a lower frequency of improvement, but the latter showed a stronger trend towards more severe outcomes. This result is consistent with that of previous reviews, which concluded that autologous fat is the filler material that most frequently causes permanent blindness.
The increased risk of major vascular complications associated with autologous fat injections could be explained by its large particle size, enabling it to occlude relatively large vessels, such as the ophthalmic artery. Regarding safety, one of the advantages of HA is the availability of an effective rescue procedure i. Furthermore, although the reduced number of cases limited our statistical analysis, it is worth mentioning that only half of these cases resulted in the total recovery of the main outcome related to vascular occlusion. The low recovery rate despite the use of hyaluronidase could be partially explained by the excessive time gap between symptoms onset and hyaluronidase injection, ranging from 3 to 24 hours, with five over seven cases exceeding the four-hour threshold, below which significant differences are seen.
Furthermore, various authors have proposed that, when exerting too much pressure on the plunger, even during the injection of small amounts of filler, arterial pressure can easily be overcome, with the filler reaching deeper arteries. Motorized injectors have been proposed as a means to reduce injection risks, as they provide a comfortable flow rate and allow physicians to keep their attention on the patient.
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In addition to its metabolic effect, lack of adipose tissue may have a major impact on appearance and cause distressing physical changes. While global research has focused on diagnosis and management, there is no published work investigating the psychological effects of lipodystrophy on body image. Following ethical approval, participants with lipodystrophy were purposively sampled from the National Severe Insulin Resistance Service in Cambridge, UK, and invited to take part in a semi-structured interview.
Eleven 10 female, one male interviews were conducted and digitally recorded. Data were analysed using an inductive thematic approach. Four main themes were identified in the data set; "Always feeling appearance was different," "a better understanding of lipodystrophy is needed," "feeling accepted" and "there's more to lipodystrophy than managing symptoms. For some, negative body image led to feelings of worthlessness impacting daily life and adherence to treatment.
Meaning of "k.o." in the Italian dictionary
Psychological support was lacking but desired by participants. Lipodystrophy contributes to negative body image affecting patients' daily lives.
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Patients wanted psychological support alongside medical management. Further research is needed to determine how best to deliver psychological support and to evaluate its impact on well-being and metabolic management. The effects of rare diseases such as lipodystrophy on appearance can be distressing for patients.