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Report CopyRight/DMCA Form For : Imaging Features Of Midface Injectable Fillers Review
Fig 1 Calcium hydroxyapatite Axial CT image A shows hyperattenuated material within the bilateral cheek subcutaneous tissues arrows Axial T1 B and T2 C MR images show that. the fillers have low to intermediate signal on both sequences arrows. The various brands have different concentrations of hyal. uronic acid and cross linking chemistries which impart dif. ferent viscosities The more viscous forms of hyaluronic acid. gel are appropriate for treating HIV lipoatrophy while the soft. and pliable consistency of the less viscous forms is particularly. suitable for use in the lips perioral and periocular regions 18. On CT hyaluronic acid fillers demonstrate nearly fluid atten. uation and the surrounding subcutaneous fat can appear in. filtrated Hyaluronic acid has a T2 relaxation time of approx. imately 600 ms which is much higher than that for dermal and. subdermal tissues Indeed hyaluronic acid gel fillers have an. MR imaging appearance similar to that of water Fig 6 In. addition the progressive diffusion and degradation of the. Fig 2 Calcium hydroxyapatite Coronal 18FDG PET image shows apparent hypermetabolism. filler can be observed over serial MRIs 20 On postcontrast. at the site of the fillers which can be a false positive finding for malignant disease. arrows T1 weighted sequences there is occasionally minimal periph. eral enhancement that can last up to 2 months In general. Hyaluronic Acid hyaluronic acid has a lower incidence of complications than. Hyaluronic acid based gel fillers Restylane Perlane Juve semipermanent and permanent agents 19 Furthermore hyal. derm are biocompatible biodegradable nonpermanent fill uronic acid fillers can be rapidly reversed by injection of. ers used for both facial rejuvenation and HIV lipoatrophy 17 19 hyaluronidase 19 21. Fig 3 Collagen Axial CT image A shows stranding in the. bilateral cheek subcutaneous tissues arrows Axial T1 B. postcontrast T1 C and fat saturated T2 D MR images. show that the filler has nearly fluid signal characteristics. 2 Ginat AJNR 2013 www ajnr org, Fig 4 Liquid silicone Axial CT image A shows numerous high attenuation foci within the bilateral cheeks arrows Axial T1 B and T2 C MR images show corresponding intermediate. signal on both sequences,Polyacrylamide Gel, Polyacrylamide Bio Alcamid is formed from polymeriza. tion of acrylamide monomers Polyacrylamide gel contains. 2 5 5 of polyacrylamide suspended in 95 97 5 water. and is biocompatible 25 Due to the high water content poly. acrylamide gel displays high signal intensity on T2 weighted. images and low signal intensity on T1 weighted images 3 sim. ilar to that of water on MR imaging Fig 8 Thus polyacryl. amide gel is best depicted by using a T2 weighted MR imaging. with or without fat suppression to delineate its location and. extent A thin low T2 signal rim surrounding the collections of. polyacrylamide gel is commonly identified and likely corre. sponds to fibrous capsules found at open surgery 25. Complications, All facial fillers can cause both early and late complications. Early complications days to weeks after injection include. immediate hypersensitivity reaction overcorrection infec. Fig 5 Polytetrafluoroethylene Coronal CT image shows linear hyperattenuation in the. bilateral nasolabial folds arrows tion skin necrosis and discoloration 26 Late complications. weeks to years after injection include infection filler migra. Poly L Lactic Acid tion delayed hypersensitivity reaction foreign body granu. Poly L lactic acid Sculptra is a synthetic biodegradable poly loma and scarring 26 Imaging with CT and or MR is war. mer that received FDA approval in August 2004 for treatment ranted for evaluating many of these complications. of facial lipoatrophy in patients with HIV but it is also used for Because there is some degree of skin trauma incurred dur. facial rejuvenation 22 23 The polymer is derived from corn ing facial filler injections micro organisms can be introduced. starch and is prepared in a solution of mannitol and carbome into the dermal tissues The incidence of infections appears to. thoxycellulose The filler is biostimulatory and promotes col be low if the procedure is performed in an appropriate setting. lagen formation which results in a gradual increase in dermal with proper sterile technique For example infections were. volume 24 On CT poly L lactic acid appears as soft tissue at reported in 0 2 of cases in a series of 1300 patients treated. tenuation foci surrounded by stranding of the subcutaneous with polyacrylamide injections 27 Staphylococcus aureus is the. fat that may represent collagen formation Fig 7 most common organism responsible for facial filler infections. Fig 6 Hyaluronic acid gel Axial T1 A and fat suppressed postcontrast T1 B and T2 C MR images show bilateral fluid intensity collections in the nasolabial folds right greater than. left arrows,AJNR Am J Neuroradiol 2013 www ajnr org 3. This complication occurs in 0 2 8 of cases 28 Imaging can. be useful for delineating the extent of the excess material. which can be identified by contour deformity of the overlying. skin Fig 10 Patients who present for imaging evaluation of. skin bulges may be reluctant to disclose a history of facial aug. mentation making the diagnosis somewhat less straight. forward Nevertheless if material with any of the imaging. characteristics described in the previous sections is identified. at the affected site overfilling should be included in the differ. ential diagnosis Conversely what appears to be an asymmet. ric distribution of filler agent on imaging does not imply that. the patient is necessarily displeased with the cosmetic out. come Overfilling can be treated via needle aspiration hyal. uronidase in the case of hyaluronic acid or surgical excision of. permanent fillers, Fig 7 Poly L lactic acid Axial CT image shows bilateral irregular soft tissue attenuation. Filler migration consists of spontaneous displacement of. with surrounding stranding in the subcutaneous tissues of the cheeks the material away from the intended site of injection and has. been reported to occur in 3 of cases with polyacrylamide 27. though there is also an increased incidence of mycobacterial This complication is not only cosmetically displeasing but can. infections with cosmetic fillers 26 On imaging infection in be uncomfortable and debilitating particularly if the filler mi. the form of cellulitis can appear as stranding and enhancement grates to sensitive areas such as the eyelids Fig 11 The use of. of the subcutaneous tissues in the vicinity of the filler resem smaller droplets of filler material tends to decrease the risk of. bling inflammatory reactions or as rim enhancing collections migration Treatment options include local corticosteroid in. if abscesses develop Fig 9 Abscess can be difficult to differ jections hyaluronidase injection for hyaluronic acid or re. entiate from focal deposits of filler materials such as hyal moval of the filler. uronic acid which resembles fluid on CT and MR imaging A mild degree of inflammation occurs with most fillers and. However abscesses tend to display a greater degree of sur is usually transient 29 However filler agents can occasionally. rounding enhancement elicit a more severe chronic inflammatory response within. Overfilling overcorrection consists of injecting excess the subcutaneous tissues that can present with swelling This. filler agent which can lead to lumpiness and conspicuity of the complication is mainly encountered with long term and per. material under the skin surface and patient dissatisfaction manent fillers such as silicone and is predisposed by under. Fig 8 Polyacrylamide gel Axial T1 A and T2 B MR images. show a cluster of fluid intensity collections surrounded by. thin hypointense capsules within the left buccal space. 4 Ginat AJNR 2013 www ajnr org, Fig 9 Abscess The patient presented with painful swelling of right cheek after hyaluronic acid injection 2 months earlier Axial A and coronal B T2 axial T1 C and coronal fat saturated. postcontrast T1 D MR images show deposits of hyaluronic acid in the bilateral oral commissures and upper lip arrowheads Posterior to the filler on the right there is a multiloculated. rim enhancing fluid collection arrows, Fig 10 Overfilling The patient presented with a facial lump and did not initially disclose a history of facial augmentation which prompted imaging evaluation A metallic marker was placed. over the affected site Axial CT images A and B show asymmetric contour deformity of the right nasolabial fold where there is a prominent deposit of filler agent Courtesy of Gul Moonis. lying inflammatory diseases such allergies as well as regional Scarring can develop many years after injection of the filler 27. infectious processes such as dental caries and sinusitis 30 31 On Particularly severe fibrotic reactions have been reported with. imaging chronic inflammatory reactions can appear as diffuse liquid silicone 30 32 33 Scarring related to silicone injection. swelling and enhancement of the tissues surrounding the filler consists of subcutaneous fibrotic masses that can appear as. material Fig 12 thick bands of soft tissue attenuation on CT Fig 13 Retrac. Chronic inflammation and perhaps lymphatic obstruction tion of the overlying skin can also be observed This compli. caused by the filler materials can lead to scar formation 30 32 cation is often disfiguring with limited mobility of the mi. AJNR Am J Neuroradiol 2013 www ajnr org 5, Fig 11 Migration The patient presented with an eyelid mass after hyaluronic acid injection in the cheeks Axial A sagittal B and coronal C T1 and axial fat suppressed T2 D MR. images show a globular collection of hyaluronic acid within the inferior eyelid arrow which extends superiorly from large deposits of filler in the cheeks arrowheads. Fig 12 Chronic inflammation The patient presented with right greater than left facial swelling approximately 5 years after silicone injection Axial T2 A T1 B and fat saturated. postcontrast T1 C MR images show an external marker overlying the lower right cheek arrows where there is diffuse swelling and enhancement surrounding the filler material Milder. involvement is also noted in the left side, metic muscles and is difficult to treat even via steroid the classic giant cell granuloma type associated with most. injections and surgical excision 28 new fillers and cystic and macrophagic types associated with. Foreign body granulomas are considered rare complica liquid silicone 37 Consequently the imaging features of for. tions of FDA approved injectable facial fillers with incidences eign body granulomas are variable ranging from solid to. ranging from 0 02 to 1 and tend to develop several cystic round or ovoid foci with associated irregular micro. months to years after injection 34 35 Silicone oil has a relatively calcifications or small ringlike or large eggshell calcifications. high incidence of foreign body granuloma formation though and surrounding fibrosis Fig 14 38 Granulomas can grow. this adverse reaction most commonly results from the use to several millimeters If diagnosed early the lesions can re. of preparations that are not medical grade silicone 13 32 36 gress with corticosteroid injections 34 Otherwise foreign. Several histologic types of foreign body granulomas can oc body granulomas can become disfiguring and are difficult to. cur depending on the type of filler agent used including treat surgically. 6 Ginat AJNR 2013 www ajnr org, ated facial lipoatrophy and correction of nasolabial folds Dermatol Surg 2008. 34 suppl 1 S78 84, 6 Bass LS Smith S Busso M et al Calcium hydroxylapatite Radiesse for treat. ment of nasolabial folds long term safety and efficacy results Aesthet Surg J. 2010 30 235 38, 7 Saray A Porcine dermal collagen Permacol for facial contour augmentation. preliminary report Aesthetic Plast Surg 2003 27 368 75. 8 Fagien S Elson ML Facial soft tissue augmentation with allogeneic human. tissue collagen matrix Dermalogen and Dermaplant Clin Plast Surg. 2001 2 63 81, 9 Homicz MR Watson D Review of injectable materials for soft tissue augmen. tation Facial Plast Surg 2004 20 21 29, 10 Lemperle G Romano JJ Busso M Soft tissue augmentation with artecoll 10. year history indications techniques and complications Dermatol Surg 2003. 29 573 87 discussion 587, 11 Duffy DM Liquid silicone for soft tissue augmentation Dermatol Surg. 2005 31 1530 41, 12 Mathews VP Elster AD Barker PB et al Intraocular silicone oil in vitro and in. vivo MR and CT characteristics AJNR Am J Neuroradiol 1994 15 343 47. 13 Chasan PE The history of injectable silicone fluids for soft tissue augmenta. tion Reconstr Surg 2007 120 2034 40 discussion 2041 43. 14 Sherris DA Larrabee WF Jr Expanded polytetrafluoroethylene augmentation. of the lower face Laryngoscope 1996 106 658 63, Fig 13 Scarring The patient has a remote history of liquid silicone injection Axial CT 15 Cisneros JL Singla R Intradermal augmentation with expanded polytetra. image shows fibrotic bands in the bilateral cheek subcutaneous tissues arrows fluoroethylene Gore Tex for facial lines and wrinkles J Dermatol Surg Oncol. 1993 19 539 42, 16 Kumar VA Lewin JS Ginsberg LE CT assessment of vocal cord medialization. AJNR Am J Neuroradiol 2006 27 1643 46, 17 Carruthers J Carruthers A Hyaluronic acid gel in skin rejuvenation J Drugs. Dermatol 2006 5 959 64, 18 Smith KC Reversible vs nonreversible fillers in facial aesthetics concerns. and considerations Dermatol Online J 2008 14 3, 19 Gensanne D Josse G Schmitt AM et al In vivo visualization of hyaluronic acid. injection by high spatial resolution T2 parametric magnetic resonance im. ages Skin Res Technol 2007 13 385 89, 20 Lupo MP Hyaluronic acid fillers in facial rejuvenation Semin Cutan Med Surg. 2006 25 122 26, 21 Fitzgerald R Vleggaar D Facial volume restoration of the aging face with poly. l lactic acid Dermatol Ther 2011 24 2 27, 22 Sterling JB Hanke CW Poly L lactic acid as a facial filler Skin Therapy Lett. 2005 10 9 11, 23 Perry CM Poly L lactic acid Am J Clin Dermatol 2004 5 361 66 discussion. 24 Lacombe V Sculptra a stimulatory filler Facial Plast Surg 2009 25 95 99. 25 Teo SY Wang SC Radiologic features of polyacrylamide gel mammoplasty. AJR Am J Roentgenol 2008 191 W89 95, 26 Verpaele A Strand A Restylane SubQ a non animal stabilized hyaluronic. acid gel for soft tissue augmentation of the mid and lower face Aesthet Surg J. 2006 26 S10 17, 27 Reda Lari A Augmentation of the malar area with polyacrylamide hydrogel. experience with more than 1300 patients Aesthet Surg J 2008 28 131 38. 28 Sturm LP Cooter RD Mutimer KL et al A systematic review of dermal fillers. for age related lines and wrinkles ANZ J Surg 2011 81 9 17. 29 Judodihardjo H Dykes P Objective and subjective measurements of cutane. Fig 14 Foreign body granuloma The patient underwent silicone injection 50 years before ous inflammation after a novel hyaluronic acid injection Dermatol Surg 2008. Axial CT image shows a nodule with eggshell calcification in the right cheek arrow 34 suppl 1 S110 14. 30 Rapaport MJ Vinnik C Zarem H Injectable silicone cause of facial nodules. Disclosures Charles Schatz UNRELATED Employment Beverly Radiology Medical Group cellulitis ulceration and migration Aesthetic Plast Surg 1996 20 267 76. Comments I am a full time diagnostic radiologist specializing in head and neck radiology 31 Narins RS Beer K Liquid injectable silicone a review of its history immunol. for this company Payment for Lectures including service on Speakers Bureau I gave a ogy technical considerations complications and potential Plast Reconstr. lecture at the 2012 Los Angeles Radiological Society meeting entitled Cosmesis The Surg 2006 118 3 suppl 77S 84S. Good The Bad and the Ugly I was given a 400 honorarium I was an invited speaker 32 Mastruserio M Pesqueira MJ Cobb MW Severe granulomatous reaction and. Travel Accommodations Meeting Expenses Unrelated to Activities Listed Two night hotel facial ulceration occurring after subcutaneous silicone injection J Am Acad. stay at the aforementioned meeting Dermatol 1996 34 849 52. 33 Raszewski R Guyuron B Lash RH et al A severe fibrotic reaction after cos. metic liquid silicone injection J Craniomaxillofac Surg 1990 18 225 28. References 34 Lemperle G Gauthier Hazan N Wolters M et al Foreign body granulomas. 1 Kontis TC Rivkin A The history of injectable facial fillers Facial Plast Surg after all injectable dermal fillers Part 1 Possible causes Plast Reconstr Surg. 2009 25 67 72 2009 123 1842 63, 2 Ridenour B Kontis TC Injectable calcium hydroxylapatite microspheres 35 Lemperle G Rullan PP Gauthier Hazan N Avoiding and treating dermal filler. Radiesse Facial Plast Surg 2009 25 100 05 complications Plast Reconstr Surg 2006 118 3 suppl 92S 107S. 3 Schatz CJ Ginat DT Imaging of facial cosmesis In Ginat DT Westesson PL 36 Christensen L Breiting V Janssen M et al Adverse reactions to injectable soft. eds Atlas of Postsurgical Neuroradiology Berlin Germany Springer Verlag tissue permanent fillers Aesthetic Plast Surg 2005 29 34 48. 2012 In press 37 Lombardi T Samson J Plantier F et al Orofacial granulomas after injection of. 4 Feeney JN Fox JJ Akhurst T Radiological impact of the use of calcium hy cosmetic fillers histopathologic and clinical study of 11 cases J Oral Pathol. droxylapatite dermal fillers Clin Radiol 2009 64 897 902 Med 2004 33 115 20. 5 Carruthers A Liebeskind M Carruthers J et al Radiographic and computed 38 Hirsch RJ Stier M Complications of soft tissue augmentation J Drugs Derma. tomographic studies of calcium hydroxylapatite for treatment of HIV associ tol 2008 7 841 45.
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