We read with great interest the report by Rohrich et al. regarding complications when using soft-tissue fillers.1 Given the enormous increase in the use of soft-tissue filler injections, the complication rate is likely to increase. Besides biofilms, which are comprehensively addressed in Rohrich et al.'s stimulating special topic report, we believe that other patient-related risk factors should be highlighted in this regard as well. Dr. Rees and colleagues have reported in the Journal the detrimental effect of cigarette smoking on skin flap survival in the face lift patient.2 They reported on 1186 face lift procedures performed between 1975 and 1981, with a 10.2 percent total complication rate. Active smokers had a 12.5-fold increased risk for skin flap complications compared with nonsmokers. Notably, active smoking for more than 10 years leads to facial aging by 2.5 years, according to a comprehensive twin study from the Twins Day Festival in Twinsburg, Ohio, published in the Journal in 2009.3 In May of 2008, the Journal again reported four late infections after New-Fill injections in the cheek and lips in four female patients aged 48 years.4 All suffered late infections 2 to 6 months after filler injection, and all four women were active smokers. Notably, a recent case series with three female patients with alar necrosis following dermal filler injection did not comment on any smoking history that might have interfered with an altered nasal perfusion.5 Therefore, we would suggest physicians evaluate the smoking status of a given cosmetic customer before performing soft-tissue filler injections and, when in doubt, perform quantitative cotinine assays to estimate the risk for potential malperfusion. This is especially important among patients who have had previous surgical interventions, such as rhinoplasty or face lifts, with potentially altered vasculature.
Karsten Knobloch, M.D.
Peter M. Vogt, M.D., Ph.D.
Plastic, Hand, and Reconstructive Surgery
Hannover Medical School
1. Rohrich R, Monheit G, Nguyen AT, Brown SA, Fagien S. Soft-tissue filler complications: The important role of biofilms. Plast Reconstr Surg
2. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg.
3. Guyuron B, Rowe DJ, Weinfeld AB, Eshraghi Y, Fathi A, Iamphongsai S. Factors contributing to the facial aging of identical twins. Plast Reconstr Surg.
4. Goldan O, Garbov-Nardini G, Regev E, Orenstein A, Winkler E. Late-onset infections and granuloma formation after facial polylactic acid (New-Fill) injections in women who are heavy smokers. Plast Reconstr Surg.
5. Grunebaum LD, Bogdan Allemann I, Dayan S, Mandy S, Baumann L. The risk of alar necrosis associated with dermal filler injection. Dermatol Surg.
2009;35(Suppl 2):1635– 1640.
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