Post‐rhinoplasty complications with previous hyaluronic acid injection history: Cerebral infarction and vision loss

Rhinoplasty is becoming increasingly frequent as the pursuit of aesthetics by people accelerates. In recent years, the proportion of people opting for rhinoplasty injections has gradually increased. This has led to numerous reports citing catastrophic postoperative complications such as skin necrosis, cerebral infarction, and visual impairment.


| INTRODUC TI ON
Rhinoplasty is a standard operation in plastic surgery performed by inserting different types of implants or injecting fillers.Hyaluronic acid (HA) has strong hydrophilic properties and is a commonly used nonsurgical filler. 1 HA injections are considered safe but, in rare cases, may lead to complications of vascular embolism, cerebral infarction, and visual impairment. 2 These complications usually occur immediately after the onset of vascular embolism.If complications do not appear immediately after injection, they are less likely to occur in the long term.We report a rare case wherein a patient with a history of HA injections developed permanent vision loss in the left eye and subacute cerebral infarction immediately after rhinoplasty.

| C A S E REP ORT
A healthy 19-year-old woman had previously (2 years earlier) undergone a nasal HA injection.She opted for a comprehensive rhinoplasty (ear cartilage + silicone prosthesis) under intravenous anesthesia 2 years after the initial session.Hyaluronidase was injected into the dorsal nostril.The technical details of the HA filling procedure are not known.Upon awakening from anesthesia, the patient complained of vision loss in the left eye, dizziness, nausea, vomiting, and weakness.At a local eye hospital, she received infusion to enhance blood circulation in her eyes, but her vision loss in the left eye remained unchanged.She arrived at our hospital 2 days later.
The patient mentioned undergoing a suture suspension treatment 7 months ago because she had not been satisfied with the shape of her nose.The patient had no history of systemic diseases.
Upon arrival at our hospital, we observed that the patient was in a poor mental state.The appearance of both eyes was normal (Figure 1A).The pupil of the left eye was round with a diameter of approximately 2 mm.In the left eye, there was no direct light reflex and light perception, and the indirect light reflex and eye movements were normal.Furthermore, the right eye was normal under examination.However, her nose was mildly swollen, and surgical incision scars and bruises were visible at the nasal roots.Head magnetic resonance imaging showed high diffusion-weighted imaging signals in the bilateral frontal lobe, left parietal lobe, and bilateral semioval center, indicating subacute cerebral infarction (Figure 2).Color fundus photographs revealed a left retinal artery occlusion (Figure 3).
All blood chemistry results were within normal ranges.
After obtaining written informed consent from the patient, digital subtraction angiography (DSA) and superselective intra-arterial thrombolysis were immediately performed.Under local anesthesia, a microcatheter was placed in the left femoral artery and DSA was performed at the left proximal ophthalmic artery, which revealed central retinal artery occlusion and distal vessel disappearance.

| DISCUSS ION
HA rhinoplasty is often the first choice for candidates who wish to improve nose shape and aesthetics owing to its simplicity and short duration, minimal postoperative swelling, and immediately visible change in appearance.Typically, HA can be retained in the tissues for 6-12 months. 3However, experienced practitioners believe that HA may persist in nasal tissues for much longer periods than in other facial tissues, sometimes 2-3 years. 4HA fillers have a significant advantage over other fillers: they are somewhat reversible and are readily soluble by hyaluronidase. 5 If patients In rhinoplasty, the manipulation of the contouring tool of the surgeon increases the local pressure, and when this pressure exceeds the systolic pressure, the embolus retrogrades into the ophthalmic artery, the anterior cerebral artery, middle cerebral artery, or the internal carotid artery.In this case, the patient did not present with clinical signs of cerebral infarction, but imaging changes signifying subacute embolism were seen in the bilateral frontal-occipital lobe.
Studies have shown that patients with a history of rhinoplasty may be at high risk of vascular damage because the natural vascular system is altered and collateral circulation is reduced. 8,9Our patient received HA nasal injections 2 years before presentation.HA fillers reportedly promote the proliferation of extracellular matrix components such as type I collagen and elastin and induce skin angiogenesis. 10,11Furthermore, our patient underwent suture suspension 7 months earlier to improve nasal appearance.The protein threads used for suture suspension are known to degrade slowly, thereby allowing fibroblast migration. 12Collagen production is promoted and stimulated, forming scar tissue at the surgical site.These tissues have an anchoring effect on blood vessels, making them more susceptible to puncture by sharp needles and providing an entry for HA Although the possibility that hyaluronidase also entered the with the embolus cannot be ruled out, we believe that the amount of hyaluronidase that entered the vessel was not sufficient to dissolve the embolus.Therefore, we treated the patient with intra-arterial thrombolytic therapy (IATT) and injected an adequate amount of hyaluronidase into the blood vessels.The poor postoperative recovery of vision in the left eye was associated with irreversible damage to retinal nerve cells after complete embolization of the central retinal artery. 13In another study, one patient with loss of vision after HA injection was administered topical hyaluronidase injection and symptomatic treatment and developed exotropia and ocular atrophy at long-term follow-up. 14At 3-year postoperative follow-up, the symptoms mentioned above did not occur in our patient, implying that although IATT treatment does not improve vision in patients with prolonged embolization, it is a therapy with a positive outcome and is effective for patients.Recanalization of other branches of the ophthalmic artery responsible for extraocular muscles and anterior ciliary muscle prevents exotropia and ocular atrophy, maintains the normal appearance of the eye, and reduces mental burden in daily social life.

| CON CLUS ION
It is advisable for patient safety to maintain a long interval of time between hyaluronidase injection and repeat rhinoplasty.When performing rhinoplasty on patients with a history of HA injections, surgeons must become familiar with the anatomical peculiarities of the patient and be gentle during the rhinoplasty procedure.For patients with a history of nasal injections, block anesthesia of the maxillary branch of the trigeminal nerve may be considered in rhinoplasty to provide a more comfortable experience, 15 and the surgeon will be

F
I G U R E 1 Appearance of eyes before and after admission.(A) Appearance on admission.(B) Appearance 3 years after surgery.are not satisfied with the results of the nasal fillers, they can undergo rhinoplasty again after HA dissolution.is a relatively safe operation: patients with a history of HA injections and no immediate postoperative vascular embolism complications generally do not develop vascular embolism complications when undergoing rhinoplasty again.However, after undergoing rhinoplasty, our patient developed vision loss in the left eye and foci of subacute cerebral infarction in the bilateral, frontoparietal, and left temporo-occipital lobes.We hypothesize that a vascular embolism developed after the hyaluronidase injection, and the incompletely dissolved HA was the source of the embolus for visual impairment.A vascular embolism may occur by various mechanisms, and the retrograde embolization theory is now widely accepted.The ophthalmic artery enters the orbit via the optic nerve canal and divides into the central retinal artery, supraorbital artery, superior gliding artery, dorsal nasal artery, ciliary artery, and branches of the extraocular muscular artery.The ophthalmic artery supplies blood to the ipsilateral eye and orbital tissues.The facial artery branches off from the external carotid artery, reaches the face after tracing the lower edge of the mandible, extends upward anteriorly, and branches into the inferior labial artery, superior labial artery, external nasal artery, and internal canthal artery. 6There are a large number of branches interconnecting the ophthalmic and facial arteries, especially in the posterior aspect of the nose and between the eyebrows.These branches include the posterior nasal artery connected to the external nasal artery and internal canthal artery; the supratrochlear artery connects to the internal canthal artery.It is because of these arterial connections that the dorsal nasal and inter-brow regions are at a high risk of causing visual impairment after HA injection. 7Hyaluronidase injected into the patient may have incompletely dissolved the HA remaining in the original filler site into smaller fragments.We speculate that the needle used to inject hyaluronidase or surgical manipulation during rhinoplasty caused a disconnection or injury to the dorsal nasal arterial connections, creating an entry point for the incompletely dissolved HA embolus to enter the vessel.

F I G U R E 2
Magnetic resonance imaging indicates subacute cerebral infarction in the bilateral frontal lobe, left parietal lobe, and bilateral semioval center (white arrows).F I G U R E 3 Fundus photographs on admission.Fundus photographs revealed pale optic disc with blurred boundary, retina with large patchy whiteness and edema involving the macular; several arteries were segmented or absent.emboli to enter the vessels, thus increasing the chances of vascular embolic complications.
able to detect any complications in time.If patients show abnormal symptoms, remedial measures should be implemented immediately to minimize trauma.F I G U R E 4 Intravascular intervention radiation angiography of the left eye.(A) Digital subtraction angiography (DSA) images show that the ophthalmic artery and its branches were decreased, and the choroid filling ring (white arrow) was attenuated before the IATT.(B) DSA imaging reveals numerous branches of an enlarged ophthalmic artery and a clearer ring (white arrow) around the eye after the patient received intra-arterial thrombolysis of 30 mg papaverine and 1500 U hyaluronidase.