We read with great interest and fear the article by Dr. Lazzeri et al. entitled “Blindness following Cosmetic Injections of the Face” published in the April 2012 issue of Plastic and Reconstructive Surgery.1 In their well-prepared article, they reviewed 29 articles that include data of 32 patients who developed blindness after facial fat grafting or cosmetic filler injections. We agree with the authors on many points. However, we would like to offer our views and recommendations on several topics.
Lipofilling is simply a procedure with many unknowns. It is evident from this article that the cause of embolism development after facial fat injection is still not fully understood. The most probable mechanism is considered retrograde access of filling material into the ophthalmic artery system following an accidental injection into the vessel or entry into a damaged vessel during a high-pressure injection. In our opinion, massage in the region of fat grafting can be another possible mechanism contributing to an embolism. A hand massage is frequently applied to the region after injection for the purpose of shaping the material. In the interim, the fat or any other material that could cause embolism may enter the damaged vessel.
In addition, a review of selected references revealed that there is no evidence that occlusion or embolism of the central retinal artery is a consequence of fat particles.2,3 The material causing embolism may be high-density liquid fat or clots in the injection field, and fat particles.
After reviewing all 29 references, we think it is inappropriate to make clinical recommendations, such as using smaller needles and syringes during fat grafting. In only three articles was information given regarding the size of needle and syringe (all are in different sizes) used for injection.
We frequently use the fat injection technique, and have performed fat grafting in the same session to one or more areas of the forehead, lips, nasolabial sulcus, or malar areas in more than 200 rhinoplasty patients.4 Here are some suggestions based on our experience: In all patients, we apply a local anesthetic around the arteries that might be involved during the operation. Another technique we find useful is the application of pressure with the fingers to both the medial canthal regions during the injection. By applying pressure on the arteries and the subsequent increase in intravascular pressure, the risk of introducing fat or other filling materials into the vessels may be reduced.
Given that the diameter of arteries in the facial region is 1 mm or less, we respectfully disagree with the authors and advocate the use of a large needle, as suggested by Coleman.5 We also use a 16-gauge needle with a sharp curved tip, and a 10-cc epidural needle. In the periorbital region, we inject the fat under the periosteum by directly accessing the bone with the tip of the injection needle and dissecting the periosteum. This technique avoids complications such as embolism or irregularities caused by fat in the thin skin of the eyelid.
Ismail Sahin, M.D.
Selcuk Isik, M.D.
Department of Plastic Reconstructive and Aesthetic
Gulhane Military Medical Academy
The authors have no financial interest to declare in relation to the content of this communication.
1. 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.
2. Park SH, Sun HJ, Choi KS. Sudden unilateral visual loss after autologous fat injection into the nasolabial fold. Clin Ophthalmol. 2008;2:679–683.
3. Lee YJ, Kim HJ, Choi KD, Choi HY. MRI restricted diffusion in optic nerve infarction after autologous fat transplantation. J Neuroophthalmol. 2010;30:216–218.
4. Isik S, Sahin I. Contour restoration of the forehead by lipofilling: Our experience. Aesthetic Plast Surg. 2012;36:761–766.
5. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthet Surg J. 2002;22:555–557.
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