Aesth Plast Surg

https://doi.org/10.1007/s00266-023-03722-3

ORIGINAL ARTICLES FAT INJECTION

Updated Filler Emergency Kit: Next-Generation Emergency

Solution
Nabil Fakih-Gomez1 • Carmen Alejandra Porcar Plana1 • Alba Verano-Garcia1 •

Cristina Muñoz-Gonzalez1 • Jonathan Kadouch2

Received: 28 April 2023 / Accepted: 17 October 2023

Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2023

Abstract please refer to the Table of Contents or the online

Introduction: The rising popularity of facial filler injec- Instructions to Authors www.springer.com/00266.
tions has corresponded with an increase in reported com-
plications. While a filler emergency kit was previously Keywords Fillers
Filler complications
Complication
introduced, advancements in the field have highlighted protocol
Filler emergency kit
certain limitations, prompting the development of the
updated filler emergency kit (UFEK).
Methods: The authors conducted literature research up to Introduction
February 2023, focusing on PubMed and open web sear-
ches for articles referred to filler emergent complications: Cosmetic procedures are a worldwide trend, with botuli-
vascular occlusion, blindness and anaphylaxis. Approxi- num toxin and fillers being the most popular cosmetic
mately 1200 articles were obtained from PubMed and other procedures. The most commonly used fillers are hyaluronic
sources, and 45 articles were reviewed. acid (HA), followed by autologous fat [1]. Although these
Results: The developed UFEK protocol delineates specific procedures are generally considered safe, their increased
interventions meticulously tailored to address diverse frequency (increasing by 42% from 2020 to 2021) [2] is
emergent scenarios linked to soft tissue fillers complica- unfortunately accompanied by an increase in adverse
tions. This protocol emphasizes the urgent requirement for events [3]. In the literature, the frequencies of vascular
timely and personalized interventions. complications after fillers are unclear but estimated to be
Conclusion: The UFEK offers a standardized, compre- between 1:2000 and 1:10000 (0.05–0.01%) [4].
hensive and effective approach. This work contributes to Common complications include edema, erythema,
the responsible and informed progression of the field of granulomas, noninflammatory and inflammatory nodules,
aesthetic medicine, providing more value and safety, both pigmentation changes, infections, abscesses, abnormal
for clinicians and patients. scarring, and paresthesia [5]. While these reactions are
Level of Evidence IV This journal requires that authors usually transient, there are other complications that are
assign a level of evidence to each article. For a full considered emergencies due to their potential irreversibil-
description of these Evidence-Based Medicine ratings, ity, such as anaphylaxis and vascular occlusions [6–8].
These vascular complications have severe consequences,
potentially resulting in persistent skin necrosis, ophthal-
moplegia, permanent unilateral or bilateral vision loss, and
& Nabil Fakih-Gomez even stroke [7, 8].
[email protected]
The most important factor for avoiding serious com-
1
Department of Facial Plastic and Cranio-Maxillo-Facial plications is prevention, which includes three fundamental
Surgery, Fakih Hospital, Khaizaran, Lebanon pillars for the injector: (1) deep anatomical and product
2
Practice for Aesthetic Dermatology, ReSculpt Clinic, knowledge, (2) early detection, and (3) systematic action.
Amsterdam, The Netherlands Despite the importance of systematic action in these

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emergencies, there is little information in the literature [9]. Methods

Previously published FEK emergency kits have some
limitations [10], such as differentiation between acute and Literature research was performed to gather information on
late occlusion and different approaches depending on the treatment of complications after the injection of soft
whether it is an embolism or vasospasm. In this work, we tissue fillers up to February 2023 and was limited to pub-
present an updated filler emergency kit (UFEK), which lications in English. The search was focused on PubMed
represents a new approach to emergencies associated with and open Web searches. Approximately 1200 articles were
fillers, with the goal of providing more value and safety, for obtained by using the terms ‘‘filler complications’’, ‘‘in-
both clinicians and patients. jectable filler complications’’ or ‘‘hyaluronic acid filler
Conventional classification suggests that complications complications.’’ We selected 45 papers based on the rele-
should be categorized as early (less than 14 days), late (14 vant, complication protocol-related content of the articles
days to 1 year), and delayed (more than 1 year) [11]. from PubMed and other sources.
However, the authors propose to classify emergency filler The authors focused on reports of complications arising
complications as early vascular occlusion (from immediate from emergent/urgent situations following the use of HA
onset during injection up to 6 h, when tissue is assumed to injectables for this review. This includes filler embolization
still being viable) [12], late vascular occlusion (after 6 h, resulting in impending skin necrosis, blindness, and
when skin viability is compromised) [12], blindness and anaphylaxis.
anaphylaxis.
The importance of prevention, early detection, and
systematic action is emphasized in this work. Existing Results
emergency kit limitations are discussed, leading to the
development of an advanced approach to filler emergencies The UFEK (Fig. 1) gathers the necessary material to
with the UFEK. address four different emergent scenarios: acute and late
vascular occlusion, blindness, and anaphylaxis, as sum-
marized in Table 1.

Figure 1 Updated filler emergency kit (UFEK)

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Table 1. The updated filler emergency kit (UFEK)

ACUTE VAE LATE VAE BLINDNESS ANAPHILAXIS

Hyaluronidase bole 1500 units
(minimum 4 boles)
0.9% NaCl 250 ml
Ultrasound scanner
Aspirin tablets 100 mg
Dexamethasone 8 mg IM
Prednisolone 20 mg
Hydrocorsone 100 mg IV
Ibuprofen 600 mg
Amoxicillin-clavulanate 875 mg/125 mg
Timolol drops
Brimonidine drops
Brinzolamide drops
Dilazem 30 mg
Pentoxifylline 400 mg
Mannitol 20% 250ML
Acetazolamide 250 mg
Clostripepdase An ointment
(collagenase)
Promethazine (25 mg/ml) 2 ml IV
Adrenaline 1 mg/ml 1:1000
Salbutamol 100 mcg/dose
Connectors
Angiocath 22-G x 25-mm
Syringes 1-cc, 3-cc, 5-cc
(2 of each)
Cannula 25-G x 38-mm
Cannula 25-G x 50-mm
Needles 33-G x 9-mm, 23G x 25 mm,
18-G x 38-mm (2 of each)
Sterile swab
Sterile gloves
Povidone-iodine prep pads
Lidocaine 2% 50 ml
Pulse oximeter

Included items in green, excluded items in red. VAE vascular adverse event

Discussion product used [13], timely identification of complications

[14], and consistent strategy implementation [10].
Nonsurgical cosmetic procedures are a growing trend Highlighting the need for a standardized approach to
worldwide. Fillers are becoming an increasingly common manage an emergency resulting from filler injection, the
practice in aesthetic medicine; therefore, their adverse authors propose an updated kit to enable prompt and safe
effects are also becoming more frequent. These compli- responses to this stressful event.
cations can range from mild swelling and bruising to vas- Hyaluronic acid (HA) is the most commonly used filler
cular occlusion, anaphylaxis, or blindness. due to its advantage that it can be dissolved with hyalur-
Critical factors for filler complications lie in preventive onidase (HYAL) [15]. Therefore, in the case of a vascular
measures, which comprise three fundamental principles for adverse event, the use of HA remains the first treatment to
the injector: proficient understanding of anatomy and the consider [7]. Even in occlusion due to non-HA filler,

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HYAL can be advantageous due to its edema-reducing not included because of secondary effects but may be
effects, decreasing occluding vessel pressure [16]. considered [34]. Pentoxifylline is also included because of
The estimated dose of HYAL varies depending on the its beneficial effect on improving ischemic symptoms [35].
thickness and number of areas involved; based on the old In late vascular occlusion, application of clostridium A
treatment protocol, proper HYAL dose is approximately collagenase ointment once daily has been demonstrated to
300–600 units of HYAL, whereas if we base it on the new enhance wound healing by selectively removing necrotic
modality of ‘‘high-dose pulsed HYAL’’, it is approximately tissue without affecting healthy skin [36].
500 units, every hour, for each localized affected area as Occlusion of the ophthalmic artery occurs because of
described by deLorenzi [17]. Reevaluation and reinjection HA embolism via retrograde from the supratrochlear,
are performed until perfusion returns to normal. Ultrasound supraorbital, and dorsal nasal artery [37]. In this case,
(US)-guided HYAL injection has been shown to be more vasodilators could be useful since they could move the
effective [18, 19]. embolus to a more distal branch, causing less ischemic
Two variations to this posology are the nose, where 900 damage [38], although this is not proven. To improve
units are used, and in the case of blindness, where retrob- ocular perfusion and dislodge the embolus, it is important
ulbar HYAL injection should be considered. However, there to decrease intraocular pressure [8, 39]. With this purpose,
is no consensus about retrobulbar HYAL injection in cases triple topical hypotensive therapy (timolol, brimonidine,
of blindness, with some articles in favor [20–23] and some and brinzolamide), oral acetazolamide, and intravenous
articles against it [24–26]. Proper retrobulbar HYAL injec- mannitol are included.
tion dosage is estimated to be approximately 800 units [26], Vascular occlusion can compromise blood flow and
although more units have been applied in some cases [27]. nutrient supply to the affected area, which weakens the
Regarding antiplatelet and anticoagulant treatment, it is immune system and increases invasive infection [40].
important to consider terminal artery embolization and Polymicrobial (staphylococci, streptococci, enterococci,
vascular tree vasospasm as the causative agents of arterial E. coli, and other gram-negative bacteria) infections are
occlusion [28]. The skin does not contain terminal arteries; common, with Staphylococcus aureus being the most fre-
instead, the flow is controlled by compensation mechanisms quently implicated pathogen in vascular occlusion-related
of small vessels that are closed or have low flow in the basal infections [40]. Based on its broad spectrum coverage,
state and increase their flow according to the needs of the amoxicillin-clavulanate would be indicated for empiric
supplied territory [29]. These vessels are called choke ves- treatment, and in cases of suspected methicillin-resistant S.
sels [28] and provide double protection against arterial filler aureus (MRSA), vancomycin should be considered [41]. In
occlusion: (1) some choke vessels of the ischemic area will early vascular occlusion, which is considered to be diag-
dilate, compensating for the blood supply, and (2) vasos- nosed and resolved at the moment of intervention, no
pasm occurs in vessels acting as a barrier and preventing the ambulatory antibiotic is needed.
embolus from arriving at a terminal artery [18]. What trig- Decreasing the inflammatory component with systemic
gers vasospasm in choke vessels is unknown [30], but HA corticosteroids is recommended in emergent cases
has been shown to be a strong inflammatory response [16, 42, 43]. Intramuscular (IM) administration is supposed
inductor within blood vessels [31]. This new concept of to result in fast and complete absorption with high absolute
choke vessel spasm is the major determinant of the location bioavailability [44], so it is indicated for emergent com-
and extent of tissue necrosis following inadvertent hya- plications. Intravenous (IV) hydrocortisone will be added
luronic acid intraarterial injection [29]. in anaphylaxis [45]. For ambulatory treatment in late
As the choke vessel mechanism causes ischemia within occlusion, we included prednisolone tablets [9].
the vascular territory but also blocks HA embolus, pre- Anaphylaxis is a life-threatening type I hypersensitivity
venting irritation spread to other territories, the use of reaction [45]. The first step in anaphylaxis cases is to
vasodilators such as nitroglycerin, phosphodiesterase inhi- administer IM adrenaline. Apart from the IV corticos-
bitors or prostaglandin analogs is not included in early teroids mentioned, antihistamines and salbutamol should
occlusion treatment [29]. However, an antiplatelet agent be considered [45].
such as acetylsalicylic acid (AAS) is included in the kit, as We present a revised application kit protocol, specifying
blood fluidization improves perfusion in the affected each scenario: acute vascular occlusion, late vascular
territory. occlusion, blindness, and anaphylaxis:
In late occlusions, vasodilators should be considered
after HYAL treatment and positive pinprick test results or Acute Vascular Occlusion
HA embolus dilution confirmed by ultrasound [32, 33]. In
the UFEK, calcium channel blockers, such as diltiazem, are Stop the injection immediately once signs of vascular
considered vasodilators. Phosphodiesterase inhibitors are occlusion appear, which include pain, pallor, or blanching

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of the skin. Dilute 1500 U HYAL in 5 ml of NaCl, Conclusion

obtaining 30 U HYAL per 0.1 ml. Inject 500 U HYAL
ultrasound guided subcutaneously per area of vascular The increasing popularity of cosmetic procedures, partic-
occlusion. Reevaluation and HYAL reinjection were per- ularly fillers, has led to a corresponding increase in adverse
formed each hour until perfusion returned to normal. events, including severe complications such as anaphylaxis
Embolus dilution is confirmed by the pinprick test or and vascular occlusions. Prevention, early detection, and
ultrasound. Administer aspirin 300 mg sublingual and 100 systematic action are critical factors in managing these
mg every 24 h. Administer IM dexamethasone. Give emergencies. It is imperative to develop individualized
ibuprofen 600 mg every 8 h. Monitor the patient for protocols for each situation, providing enhanced value and
24–48 h to ensure that the occlusion was resolved. safety to both clinicians and patients. Limitations of
existing emergency kits have led to the development of
Late Vascular Occlusion UFEK, which provides a standardized approach to
managing emergencies associated with fillers. The UFEK
Dilute 1500 U HYAL in 5 ml of NaCl, obtaining 30 U represents a valuable tool for clinicians and patients in the
HYAL per 0.1 ml. Inject 500 U HYAL US guided sub- management of emergencies associated with fillers. With
cutaneously per area of vascular occlusion. Administer this work, it is hoped that the field of aesthetic medicine
aspirin 300 mg sublingual and 100 mg every 24 h. will be able to continue to evolve in a positive and
Administer IM dexamethasone. Prednisolone 20 mg daily, responsible manner.
ibuprofen 600 mg, and amoxicillin-clavulanate 875 mg/
125 mg every 12 h are given. Reevaluation and HYAL Acknowledgements N.F.G., C.A.P.P., C.M.G., and J.K. were
involved in the hypothesis/clinical observation. N.F.G., C.A.P.P.,
reinjection are to be done each hour until perfusion returns
A.V.G., C.M.G., and J.K contributed to the study design/methodol-
to normal. Embolus dilution is confirmed by the pinprick ogy. N.F.G., C.A.P.P., A.V.G., and C.M.G. contributed to the
test or ultrasound. Once embolus dilution is confirmed, research/data assessment. N.F.G., C.A.P.P., A.V.G., and C.M.G.
diltiazem 30 mg and pentoxifylline 400 mg can be used. analyzed the data. N.F.G., C.A.P.P., A.V.G., C.M.G., and J.K. wrote
the paper.
Collagenase ointment should be applied daily. Hyperbaric
oxygen chamber therapy at 2–3 atm (1:30 h/7–10 days) is Funding None of the authors received any funding or financial
recommended. Patient care wound and revision should be support for the content of this article.
daily.
Declarations
Blindness
Conflict of interest The authors N.F. and J.K. are both consultants
for Merz Aesthetics (Frankfurt, Germany).
Once visual acuity is affected, there are 90 min to act with
the minimum sequelae. Ocular hypo tensors are given: Human or Animal Rights This article does not contain any studies
mannitol IV 250 ml in 1 h, acetazolamide orally, and with human participants or animals performed by any of the authors.
timolol, brimonidine, and brinzolamide drops are applied. Informed Consent For this type of study, formal consent is not
Ocular massage may decrease intraocular pressure. If the needed.
doctor is experienced in retrobulbar injection, retrobulbar
800 U HYAL injection can be performed slowly in the
lower temporal third of the orbit, although there is no References
evidence of its effectiveness. Administer aspirin 300 mg
sublingual every 24 h, IM dexamethasone, ibuprofen 1. Sito G, Manzoni V, Sommariva R (2019) Vascular complications
after facial filler injection. J Clin Aesthet Dermatol 12(6):E65–
600 mg every 8 h are given. Vasodilators can be consid- E72. https://doi.org/10.1111/ijcp.14675
ered, although there is no evidence of their effectiveness. 2. Databank N (2022) Aesthetic plastic surgery national databank
Refer to ophthalmologist for more specialized maneuvers statistics 2020–2021. Aesthet Surg J 42(1):1–18. https://doi.org/
to decompress the anterior chamber. 10.1093/asj/sjac116
3. Bellew S, Del Rosso JQ (2011) The spectrum of adverse reac-
tions after treatment with injectable fillers in the glabellar region:
Anaphylaxis results from the injectable filler safety study. Dermatol Dermatol
Surg 2011:451–452. https://doi.org/10.1016/j.yder.2010.12.019
The objective is to stabilize the patient and refer them to 4. Schelke L, Decates T, Kadouch J, Velthuis P (2020) Incidence of
vascular obstruction after filler injections. Aesthet Surg J
the emergency department. IM adrenaline 1 mg/ml 40(8):NP457–NP460. https://doi.org/10.1093/asj/sjaa086
(1:1000), IM dexamethasone and IV hydrocortisone were 5. Lemperle G, Duffy DM (2006) Treatment options for dermal
administered. Administer inhaled salbutamol and promet- filler complications. Aesthet Surg J 26(3):356–364. https://doi.
hazine (25 mg/ml) 2 ml by IV. org/10.1016/j.asj.2006.04.002

123
 Aesth Plast Surg

6. Carruthers A, Carruthers J (2007) Non-animal-based hyaluronic 24. Zhu GZ, Sun ZS, Liao WX et al (2017) Efficacy of retrobulbar
acid fillers: scientific and technical considerations. Plast Reconstr hyaluronidase injection for vision loss resulting from hyaluronic
Surg 120(6S):33–40. https://doi.org/10.1097/01.prs.0000248808. acid filler embolization. Aesthet Surg J 38(1):12–22. https://doi.
75700.5f org/10.1093/asj/sjw216
7. Sahin I, Isik S (2012) Blindness following cosmetic injections of 25. Hwang CJ, Mustak H, Gupta AA, Ramos RM, Goldberg RA,
the face. Plast Reconstr Surg 130(5):2012. https://doi.org/10. Duckwiler GR (2019) Role of retrobulbar hyaluronidase in filler-
1097/PRS.0b013e318267d740 associated blindness: evaluation of fundus perfusion and elec-
8. Beleznay K, Carruthers JDA, Humphrey S, Jones D (2015) troretinogram readings in an animal model. Ophthal Plast
Avoiding and treating blindness from fillers: a review of the Reconstr Surg 35(1):33–37. https://doi.org/10.1097/IOP.
world literature. Dermatol Surg 41(10):1097–1117. https://doi. 0000000000001132
org/10.1097/DSS.0000000000000486 26. Tansatit T, Apinuntrum P, Phetudom T (2015) A cadaveric fea-
9. Lemperle G, Rullan PP, Gauthier-Hazan N (2006) Avoiding and sibility study of the intraorbital cannula injections of hyalur-
treating dermal filler complications. Plast Reconstr Surg 118(3 onidase for initial salvation of the ophthalmic artery occlusion.
SUPPL.):92–107. https://doi.org/10.1097/01.prs.0000234672. Aesthet Plast Surg 39(2):252–261. https://doi.org/10.1007/
69287.77 s00266-015-0456-1
10. Fakih-Gomez N, Orte-Aldea MC, Poonja K, Khanna D (2019) 27. Ramesh S, Fiaschetti D, Goldberg RA (2018) Orbital and ocular
Hyaluronic acid filler emergency kit. Am J Cosmet Surg ischemic syndrome with blindness after facial filler injection.
36(4):183–190. https://doi.org/10.1177/0748806818825214 Ophthal Plast Reconstr Surg 34(4):E108–E110. https://doi.org/
11. Rohrich RJ, Nguyen AT, Kenkel JM (2009) Lexicon for soft 10.1097/IOP.0000000000001104
tissue implants. Dermatol Surg 35(SUPPL. 2):1605–1611. https:// 28. Jajoria H, Venkataram A, Mysore V (2020) Importance of choke
doi.org/10.1111/j.1524-4725.2009.01337.x vessels in injectable fillers. J Cutan Aesthet Surg 13(3):185–190
12. Kreidstein ML, Pang CY, Levine RH, Knowlton RJ (1991) The 29. Ashton MW, Taylor GI, Corlett RJ (2018) The role of anasto-
isolated perfused human skin flap: design, perfusion technique, motic vessels in controlling tissue viability and defining tissue
metabolism, and vascular reactivity. Plast Reconstr Surg necrosis with special reference to complications following
87(4):741–749 injection of hyaluronic acid fillers. Plast Reconstr Surg 141:818e–
13. Delorenzi C (2014) Complications of injectable fillers, part 2: 830e. https://doi.org/10.1097/PRS.0000000000004287
vascular complications. Aesthet Surg J 34(4):584–600. https:// 30. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ
doi.org/10.1177/1090820X14525035 (2009) The perforasome theory: vascular anatomy and clinical
14. Rzany B, DeLorenzi C (2015) Understanding, avoiding, and implications. Plast Reconstr Surg 124(5):1529–1544. https://doi.
managing severe filler complications. Plast Reconstr Surg org/10.1097/PRS.0b013e3181b98a6c
136(5):196S-203S. https://doi.org/10.1097/PRS. 31. Taylor GI, Corlett RJ, Ashton MW (2017) The functional
0000000000001760 angiosome: clinical implications of the anatomical concept. Plast
15. Cavallini M, Gazzola R, Metalla M, Vaienti L (2013) The role of Reconstr Surg 140(4):721–733. https://doi.org/10.1097/PRS.
hyaluronidase in the treatment of complications from hyaluronic 0000000000003694
acid dermal fillers. Aesthet Surg J 33(8):1167–1174. https://doi. 32. Pafitanis G, Hung-Chi C (2019) The pinprick test: key consid-
org/10.1177/1090820X13511970 erations in execution of skin flap perfusion testing. Plast Reconstr
16. Dayan SH, Arkins JP, Brindise R (2011) Soft tissue fillers and Surg Glob Open 7(9):e2370
biofilms. Facial Plast Surg 27(1):23–28. https://doi.org/10.1055/s- 33. Mishra S (2011) A simple method for predicting survival of
0030-1270415 pedicled skin flaps before completely raising them. Indian J Plast
17. DeLorenzi C (2017) New high dose pulsed hyaluronidase pro- Surg 44(3):453–457. https://doi.org/10.4103/0970-0358.90821
tocol for hyaluronic acid filler vascular adverse events. Aesthet 34. Galiè N (2009) Phosphodiesterase type 5 inhibitors. Pulm
Surg J 37(7):814–825. https://doi.org/10.1093/asj/sjw251 Hypertens 5(August):350–354. https://doi.org/10.2165/
18. Schelke LW, Velthuis P, Kadouch J, Swift A (2023) Early 00063030-200013020-00002
ultrasound for diagnosis and treatment of vascular adverse events 35. Samlaska CP, Winfield EA (1994) Pentoxifylline. J Am Acad
with hyaluronic acid fillers. J Am Acad Dermatol 88(1):79–85. Dermatol 30(4):603–621. https://doi.org/10.1016/S0190-
https://doi.org/10.1016/j.jaad.2019.07.032 9622(94)70069-9
19. Schelke LW, Velthuis PJ, Decates T et al (2023) Ultrasound- 36. Shi L, Carson D (2009) Collagenase santyl ointment: a selective
guided targeted vs regional flooding: a comparative study for agent for wound debridement. J Wound Ostomy Cont Nurs
improving the clinical outcome in soft tissue filler vascular 36(SUPPL. 6):3–7. https://doi.org/10.1097/WON.
adverse event management. Aesthet Surg J 43(1):86–96 0b013e3181bfdd1a
20. Carruthers J, Fagien S, Dolman P (2015) Retro or peribulbar 37. Carle MV, Roe R, Novack R, Boyer DS (2014) Cosmetic facial
injection techniques to reverse visual loss after filler injections. fillers and severe vision loss. JAMA Ophthalmol 132(5):637–639.
Dermatol Surg 41:S354–S357. https://doi.org/10.1097/DSS. https://doi.org/10.1001/jamaophthalmol.2014.498
0000000000000558 38. Shin H, Lemke BN, Stevens T, Lim MJ (1988) Posterior ciliary-
21. Carruthers JDA, Fagien S, Rohrich RJ, Weinkle S, Carruthers A artery occlusion after subcutaneous silicone-oil injection. Ann
(2014) Blindness caused by cosmetic filler injection: a review of Ophthalmol 20(9):342–344
cause and therapy. Plast Reconstr Surg 134(6):1197–1201. 39. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S
https://doi.org/10.1097/PRS.0000000000000754 (2012) Blindness following cosmetic injections of the face. Plast
22. Chesnut C (2018) Restoration of visual loss with retrobulbar Reconstr Surg 129(4):995–1012. https://doi.org/10.1097/PRS.
hyaluronidase injection after hyaluronic acid filler. Dermatol Surg 0b013e3182442363
44(3):435–437. https://doi.org/10.1097/DSS.0000000000001237 40. Bandyk DF (2018) The diabetic foot: Pathophysiology, evalua-
23. Fagien S, Carruthers J (2018) Commentary on restoration of tion, and treatment. Semin Vasc Surg 31(2–4):43–48. https://doi.
visual loss with retrobulbar hyaluronidase injection after hya- org/10.1053/j.semvascsurg.2019.02.001
luronic acid filler. Dermatol Surg 44(3):437–443. https://doi.org/ 41. Smith J, Jones L, Garcia M (2022) Antibiotic selection for the
10.1097/DSS.0000000000001372 empiric treatment of Staphylococcus aureus infections:

123
Aesth Plast Surg

considerations for methicillin-resistant strains. J Infect Dis 45. Tupper J, Visser S, Em C (2010) Emergency files a review and
215(3):432–439 update. Can Fam Phys 56:1009–1011
42. Ramamoorthy S, Cidlowski JA (2016) Corticosteroids: mecha-
nisms of action in health and disease. Rheum Dis Clin North Am Publisher’s Note Springer Nature remains neutral with regard to
42(1):15–31. https://doi.org/10.1016/j.rdc.2015.08.002 jurisdictional claims in published maps and institutional affiliations.
43. Alam M, Dover JS (2007) Management of complications and
sequelae with temporary injectable fillers. Plast Reconstr Surg
120(6S):98–105. https://doi.org/10.1097/01.prs.0000248859. Springer Nature or its licensor (e.g. a society or other partner) holds
14788.60 exclusive rights to this article under a publishing agreement with the
44. Wyns H, Meyer E, Watteyn A et al (2013) Pharmacokinetics of author(s) or other rightsholder(s); author self-archiving of the
dexamethasone after intravenous and intramuscular administra- accepted manuscript version of this article is solely governed by the
tion in pigs. Vet J 198(1):286–288. https://doi.org/10.1016/j.tvjl. terms of such publishing agreement and applicable law.
2013.06.015

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