Ischemic complications of dermal fillers

Abstract

Dermal fillers have become increasingly popular as a cosmetic treatment for facial rejuvenation. Although these injections are generally considered to be safe, as the number of injections has increased, so has the rate of complications. Ischemic complications of fillers include vision loss, ophthalmoplegia, skin necrosis, and cerebral infarction. Knowing the anatomy well is critical to optimally prevent and manage these serious complications. Prevention includes knowledge of the vascular anatomy of the facial area, as well as certain injection techniques such as aspiration, use of a smaller needle, and adoption of a larger cannula. The use of ultrasound has been a recent innovation in preventing and treating filler complications as well. The reversibility of fillers should also be considered when choosing a filler. Some hyaluronic acid (HA) fillers, including the newer ones on the market, are difficult to reverse and non-HA fillers and fat are irreversible. This review aims to discuss facial anatomy, the various ischemic filler complications, the prevention and management of these complications, and the relatively recent use of imaging as an adjunct.

Keywords

Filler complications / soft tissue necrosis / blindness / ophthalmoplegia / cerebral infarction / ischemic complications

References

[1] ISAPS International Survey on Aesthetic/Cosmetic Procedures. Available from: https://www.isaps.org/wp-content/uploads/2020/12/Global-Survey-2019.pdf [Last accessed on 1 Sep 2022]

[2] FDA Executive Summary General Issues Panel Meeting on Dermal Fillers. Prepared for the meeting of the general and plastic surgery devices advisory panel. Available from: https://www.fda.gov/media/146870/download [Last accessed on 1 Sep 2022]

[3] Heitmiller K,Saedi N.Rheologic properties of soft tissue fillers and implications for clinical use.J Cosmet Dermatol2021;20:28-34

[4] Murthy R,Goldberg RA.Periocular hyaluronic acid fillers: applications, implications, complications.Curr Opin Ophthalmol2019;30:395-400

[5] Beleznay K,Humphrey S,Jones D.Update on avoiding and treating blindness from fillers: a recent review of the world literature.Aesthet Surg J2019;39:662-74

[6] Kim A,Kim HJ,Hwang JM.Ophthalmoplegia as a complication of cosmetic facial filler injection.Acta Ophthalmol2016;94:e377-9

[7] Beleznay K,Carruthers JDA.Vascular compromise from soft tissue augmentation: experience with 12 cases and recommendations for optimal outcomes.J Clin Aesthet Dermatol2014;7:37-43. PMCID:PMC4174919

[8] Chatrath V,Goodman GJ.Soft-tissue filler-associated blindness: a systematic review of case reports and case series.Plast Reconstr Surg Glob Open2019;7:e2173 PMCID:PMC6554164

[9] Kim YJ.Bilateral blindness after filler injection.Plast Reconstr Surg2013;131:298e-9e.

[10] Oranges CM,Schaefer DJ,Harder Y.Complications of nonpermanent facial fillers: a systematic review.Plast Reconstr Surg Glob Open2021;9:e3851 PMCID:PMC8542164

[11] Beleznay K,Humphrey S.Avoiding and treating blindness from fillers: a review of the world literature.Dermatol Surg2015;41:1097-117

[12] Rohrich RJ,Dayan E.Practical approach and safety of hyaluronic acid fillers.Plast Reconstr Surg Glob Open2019;7:e2172 PMCID:PMC6635180

[13] van Loghem J,Pavicic T.Managing intravascular complications following treatment with calcium hydroxylapatite: an expert consensus.J Cosmet Dermatol2020;19:2845-58 PMCID:PMC7687073

[14] Goodman GJ,Callan P.A consensus on minimizing the risk of hyaluronic acid embolic visual loss and suggestions for immediate bedside management.Aesthet Surg J2020;40:1009-21 PMCID:PMC7427155

[15] DeLorenzi C.Complications of injectable fillers, part 2: vascular complications.Aesthet Surg J2014;34:584-600

[16] Ten B,Kaya Tİ.Evaluation of facial artery course variations and depth by Doppler ultrasonography.J Cosmet Dermatol2021;20:2247-58

[17] Tseng FW,Frank K.Descriptive analysis of 213 positive blood aspiration cases when injecting facial soft tissue fillers.Aesthet Surg J2021;41:616-24

[18] Lee JG,Hu KS.Frontal branch of the superficial temporal artery: anatomical study and clinical implications regarding injectable treatments.Surg Radiol Anat2015;37:61-8

[19] Maio M, DeBoulle K, Braz A, Rohrich RJ; Alliance for the Future of Aesthetics Consensus Committee. Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fillers: focus on the midface.Plast Reconstr Surg2017;140:540e-50e

[20] Hufschmidt K,Foissac R.The infraorbital artery: clinical relevance in esthetic medicine and identification of danger zones of the midface.J Plast Reconstr Aesthet Surg2019;72:131-6

[21] Zhang-Nunes S,Cahill K.Prospective in vivo evaluation of three different hyaluronic acid gels to varying doses of hyaluronidase with long-term follow-up.J Plast Reconstr Aesthet Surg2021;74:874-80

[22] Ryu C,Zhang-Nunes S.Response of twelve different hyaluronic acid gels to varying doses of recombinant human hyaluronidase.J Plast Reconstr Aesthet Surg2021;74:881-9

[23] Zhang-Nunes S,Ryu C. Response of five different hyaluronic acid gels to varying doses of recombinant human hyaluronidase. In: American Society of Ophthalmic Plastic & Reconstructive Surgery Spring Meeting 2022. Available from: https://asoprsconf.memberclicks.net/assets/docs/ASOPRS_2022_Spring_Program.pdf [Last accessed on 1 Sep 2022]

[24] Vrcek IM,Gilliland GD.A novel solution for superficially placed calcium hydroxylapatite (Radiesse) in the inferior eyelid.Orbit2012;31:431-2

[25] Vu PQ,Tao JP.Light perception vision recovery after treatment for calcium hydroxylapatite cosmetic filler-induced blindness.Ophthalmic Plast Reconstr Surg2018;34:e189-92

[26] Danysz W,Hengl T.Can sodium thiosulfate act as a reversal agent for calcium hydroxylapatite filler?.Clin Cosmet Investig Dermatol2020;13:1059-73 PMCID:PMC7781022

[27] Rivkin AZ.Volume correction in the aging hand: role of dermal fillers.Clin Cosmet Investig Dermatol2016;9:225-32 PMCID:PMC5012627

[28] Aguilera SB,Reed A.Successful treatment of calcium hydroxylapatite nodules with intralesional 5-fluorouracil, dexamethasone, and triamcinolone.J Drugs Dermatol2016;15:1142-3

[29] Kapoor KM,Heydenrych I.Vision loss associated with hyaluronic acid fillers: a systematic review of literature.Aesthetic Plast Surg2020;44:929-44

[30] Sito G,Sommariva R.Vascular complications after facial filler injection: a literature review and meta-analysis.J Clin Aesthet Dermatol2019;12:E65-E72 PMCID:PMC6624005

[31] Samizadeh S,Bertossi D.Anatomical variations in the course of labial arteries: a literature review.Aesthet Surg J2019;39:1225-35

[32] Toure G,Vlavonou S.Transverse facial artery: its role in blindness after cosmetic filler and botulinum toxin injections.J Plast Reconstr Aesthet Surg2021;74:1862-9

[33] Tansatit T,Jitaree B,Sahraoui YME.Investigation of the presence and variation of the ascending mental artery: Conventional dissections and ultrasonographic study.J Cosmet Dermatol2019;18:1821-9

[34] Myung Y,Jeong JH.The classification and prognosis of periocular complications related to blindness following cosmetic filler injection.Plast Reconstr Surg2017;140:61-4.

[35] Coleman SR.Avoidance of arterial occlusion from injection of soft tissue fillers.Aesthet Surg J2002;22:555-7

[36] Carruthers JDA,Rohrich RJ,Carruthers A.Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg2014;134:1197-201

[37] Cho KH,Toth G,Zins JE.Pathophysiology study of filler-induced blindness.Aesthet Surg J2019;39:96-106

[38] Tran AQ.vision loss and blindness following fillers.J dermatology Ski Sci2021;3:1-4 PMCID:PMC8294333

[39] Sorensen EP.Update in soft-tissue filler-associated blindness.Dermatol Surg2020;46:671-7.

[40] Ugradar S,Hoenig J.Generation of filler emboli as a mechanism for filler-related blindness.Dermatol Surg2021;47:235-7

[41] Ramesh S,Katsev B.The force required to inject a column of filler through facial arteries.Dermatol Surg2020;46:e32-7

[42] Khan TT,Mettu P,Woodward JA.An anatomical analysis of the supratrochlear artery: considerations in facial filler injections and preventing vision loss.Aesthet Surg J2017;37:203-8

[43] Karam EZ,Muci Mendoza R,Perez E.Visual loss after platelet-rich plasma injection into the face.Neuroophthalmology2020;44:371-8 PMCID:PMC7722697

[44] Roberts SA.Severe visual loss and orbital infarction following periorbital aesthetic poly-(L)-lactic acid (PLLA) injection.Ophthalmic Plast Reconstr Surg2012;28:e68-70

[45] Hayreh SS.Experimental occlusion of the central artery of the retina. IV: retinal tolerance time to acute ischaemia.Br J Ophthalmol1980;64:818-25 PMCID:PMC1043826

[46] Tobalem S,Chronopoulos A.Central retinal artery occlusion - rethinking retinal survival time.BMC Ophthalmol2018;18:101 PMCID:PMC5907384

[47] Graue G,Plata Palazuelos C.The M.A.STE.R.S algorithm for acute visual loss management after facial filler injection.J Cosmet Dermatol2020;19:2859-66

[48] Paap MK,Ugradar S,Silkiss RZ.Examining the role of retrobulbar hyaluronidase in reversing filler-induced blindness: a systematic Review.Ophthalmic Plast Reconstr Surg2020;36:231-8

[49] Heydenrych I,Kapoor KM.The 10-point plan 2021: updated concepts for improved procedural safety during facial filler treatments.Clin Cosmet Investig Dermatol2021;14:779-814 PMCID:PMC8279269

[50] Butler FK Jr,Murphy-Lavoie H.Hyperbaric oxygen therapy and the eye.Undersea Hyperb Med2008;35:333-87

[51] Hwang CJ,Pimentel A,Goldberg RA.Rethinking the role of nitroglycerin ointment in ischemic vascular filler complications: an animal model with ICG imaging.Ophthalmic Plast Reconstr Surg2016;32:118-22

[52] Shah J.Hyperbaric oxygen therapy.J Am Col Certif Wound Spec2010;2:9-13 PMCID:PMC3601859

[53] Uittenbogaard D,Bauland CG.Hyperbaric oxygen therapy for dermal ischemia after dermal filler injection with calcium hydroxylapatite: a case report.Undersea Hyperb Med2019;46:207-10.

[54] Hung JH,Lee CN.Unilateral vision loss after hyaluronic acid injection: a case report.Ann Plast Surg2021;86:S127-31

[55] Wu CW.Retinal artery occlusion following cosmetic injection of poly-L-lactic acid.Taiwan J Ophthalmol2021;11:317-20 PMCID:PMC8493991

[56] Hu XZ,Wu PS,Kikkawa DO.Posterior ciliary artery occlusion caused by hyaluronic acid injections into the forehead: a case report.Medicine (Baltimore)2016;95:e3124 PMCID:PMC4839944

[57] Celebi ARC,Altiparmak UE,Ozkiris A.Hyperbaric oxygen for the treatment of the rare combination of central retinal vein occlusion and cilioretinal artery occlusion.Diving Hyperb Med2016;46:50-3.

[58] Kim YS,Park EJ.The effect of adjunctive hyperbaric oxygen therapy in patients with central retinal artery occlusion.Undersea Hyperb Med2020;47:57-64

[59] Kim SH,Lee Y,Yoon IN.Successful treatment of central retinal artery occlusion using hyperbaric oxygen therapy.Clin Exp Emerg Med2018;5:278-81 PMCID:PMC6301864

[60] Lemos JA,Carvalho R.Combined central retinal artery and vein occlusion associated with factor V leiden mutation and treated with hyperbaric oxygen.Case Rep Ophthalmol2015;6:462-8 PMCID:PMC4777962

[61] Chesnut C.Restoration of visual loss with retrobulbar hyaluronidase injection after hyaluronic acid filler.Dermatol Surg2018;44:435-7

[62] Wibowo A,Philipp-Dormston WG.Reversal of post-filler vision loss and skin ischaemia with high-dose pulsed hyaluronidase injections.Aesthetic Plast Surg2019;43:1337-44

[63] Thanasarnaksorn W,Rudolph C,Chanasumon N.Severe vision loss caused by cosmetic filler augmentation: case series with review of cause and therapy.J Cosmet Dermatol2018;17:712-8

[64] Zhu GZ,Liao WX.Efficacy of retrobulbar hyaluronidase injection for vision loss resulting from hyaluronic acid filler embolization.Aesthet Surg J2017;38:12-22

[65] Zhang L,Shi H,Wu S.Blindness after facial filler injections: the role of extravascular hyaluronidase on intravascular hyaluronic acid embolism in the rabbit experimental model.Aesthet Surg J2020;40:319-26

[66] Hwang CJ,Gupta AA,Goldberg RA.Role of retrobulbar hyaluronidase in filler-associated blindness: evaluation of fundus perfusion and electroretinogram readings in an animal model.Ophthalmic Plast Reconstr Surg2019;35:33-7

[67] Lee W,Ko HS,Kim KW.Effectiveness of retrobulbar hyaluronidase injection in an iatrogenic blindness rabbit model using hyaluronic acid filler injection.Plast Reconstr Surg2019;144:137-43

[68] Hwang CJ.Effectiveness of retrobulbar hyaluronidase injection in an iatrogenic blindness rabbit model using hyaluronic acid filler injection.Plast Reconstr Surg2020;145:658e-60e

[69] Paap MK,Ugradar S.Assessing retrobulbar hyaluronidase as a treatment for filler-induced blindness in a cadaver model.Plast Reconstr Surg2019;144:315-20

[70] Ugradar S.Quantifying the digestion of cross-linked hyaluronic acid fillers with hyaluronidase.Dermatol Surg2021;47:1233-6

[71] Burns PB,Chung KC.The levels of evidence and their role in evidence-based medicine.Plast Reconstr Surg2011;128:305-10 PMCID:PMC3124652

[72] Baley-Spindel I,Márquez-Espriella C,Dávila-Díaz R.Perivascular hyaluronidase with alteplase as treatment for hyaluronic acid thrombosis.Aesthet Surg J2020;40:551-9

[73] Park KH,Woo SJ.Korean Retina SocietyIatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections: a national survey by the Korean Retina Society.JAMA Ophthalmol2014;132:714-23

[74] Yang HK,Woo SJ,Kim JS.Natural course of ophthalmoplegia after iatrogenic ophthalmic artery occlusion caused by cosmetic filler injections.Plast Reconstr Surg2019;144:28e-34e

[75] Zimmerman CF,Golnik KC,Anand R.Orbital infarction syndrome after surgery for intracranial aneurysms.Ophthalmology1995;102:594-8

[76] Downie EM,Lucarelli MJ.Isolated ophthalmoplegia following filler injections to the upper face.Ophthalmic Plast Reconstr Surg2020;36:e152-4. PMCID:PMC8791630

[77] Bae IH,Choi H,Shin BS.Ischemic oculomotor nerve palsy due to hyaluronic acid filler injection.J Cosmet Dermatol2018;17:1016-8

[78] Sclafani AP.Treatment of injectable soft tissue filler complications.Dermatol Surg2009;35 Suppl 2:1672-80

[79] Loh KTD,Phua V.Successfully managing impending skin necrosis following hyaluronic acid filler injection, using high-dose pulsed hyaluronidase.Plast Reconstr Surg Glob Open2018;6:e1639. PMCID:PMC5865919

[80] Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: prevention, assessment, and treatment.Clin Cosmet Investig Dermatol2015;8:205-14 PMCID:PMC4404720

[81] Goodman GJ,Callan P.Experience and management of intravascular injection with facial fillers: results of a multinational survey of experienced injectors.Aesthetic Plast Surg2016;40:549-55

[82] Silva MT.Blindness and total ophthalmoplegia after aesthetic polymethylmethacrylate injection: case report.Arq Neuropsiquiatr2004;62:873-4

[83] Figueiredo JC, Naufal RR, Zampar AG, Mélega JM. Expanded median forehead flap and abbé flap for nasal and upper lip reconstruction after complications of polymethylmethacrylate.Aesthetic Plast Surg2010;34:385-7

[84] Cohen JL.Understanding, avoiding, and managing dermal filler complications.Dermatol Surg2008;34 Suppl 1:S92-9

[85] Ortiz AE,Song SS.Analysis of U.S. food and drug administration data on soft-tissue filler complications.Dermatol Surg2020;46:958-61

[86] Tansatit T,Phetudom T.Facing the worst risk: confronting the dorsal nasal artery, implication for non-surgical procedures of nasal augmentation.Aesthetic Plast Surg2017;41:191-8

[87] Rauso R,Rugge L.Unusual intraoral necrosis after hyaluronic acid injections.Dermatol Surg2021;47:1158-60

[88] Chuchvara N,John AM.Dermal filler-induced vascular occlusion successfully treated with tadalafil, hyaluronidase, and aspirin.Dermatol Surg2021;47:1160-2

[89] Tansatit T,MCCabe H.Translucent and ultrasonographic studies of the inferior labial artery for improvement of filler injection techniques.Plast Reconstr Surg Glob Open2019;7:e2399 PMCID:PMC6908380

[90] Wang Q,Li H,Wang J.Vascular complications after chin augmentation using hyaluronic acid.Aesthetic Plast Surg2018;42:553-9

[91] Fang M,Kapoor KM.Managing complications of submental artery involvement after hyaluronic acid filler injection in chin region.Plast Reconstr Surg Glob Open2018;6:e1789 PMCID:PMC5999422

[92] Murray G,Walker L.Guideline for the management of hyaluronic acid filler-induced vascular occlusion.J Clin Aesthet Dermatol2021;14:E61-9. PMCID:PMC8211329

[93] Dayan SH.Complications from toxins and fillers in the dermatology clinic: recognition, prevention, and treatment.Facial Plast Surg Clin North Am2013;21:663-73

[94] Darling MD,Fabi SG.Impending necrosis after injection of hyaluronic acid and calcium hydroxylapatite fillers: report of 2 cases treated with hyperbaric oxygen therapy.Dermatol Surg2014;40:1049-52

[95] Avci P,Sadasivam M,Pam Z,Hamblin MR.Low-level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring.Semin Cutan Med Surg2013;32:41-52. PMCID:PMC4126803

[96] Nishioka MA,Sheliga TR,Gomes HC.LED (660 nm) and laser (670 nm) use on skin flap viability: angiogenesis and mast cells on transition line.Lasers Med Sci2012;27:1045-50

[97] Beer K,Beer J.A treatment protocol for vascular occlusion from particulate soft tissue augmentation.J Clin Aesthet Dermatol2012;5:44-7. PMCID:PMC3366448

[98] Oley MH,Mawu FO,Faruk M.Hyperbaric oxygen therapy in managing minimally invasive aesthetic procedure complications: a report of three cases.Clin Cosmet Investig Dermatol2022;15:63-8 PMCID:PMC8765711

[99] Henderson R,Cooper JS.Hyperbaric oxygen for ischemia due to injection of cosmetic fillers: case report and issues.Plast Reconstr Surg Glob Open2018;6:e1618 PMCID:PMC5811288

[100] DeLorenzi C.New high dose pulsed hyaluronidase protocol for hyaluronic acid filler vascular adverse events.Aesthet Surg J2017;37:814-25

[101] Ansari ZA,Rong AJ,Tse DT.Ocular and cerebral infarction from periocular filler injection.Orbit2019;38:322-4

[102] Lee JS,Woo SJ.Unilateral blindness with bilateral brain infarction after cosmetic facial filler injection.J Neuroophthalmol2021;41:e566-71

[103] Yang Q,Guo N.Fatal cerebral infarction and ophthalmic artery occlusion after nasal augmentation with hyaluronic acid-a case report and review of literature.Aesthetic Plast Surg2020;44:543-8

[104] Lee W,Oh W.Ocular complications of soft tissue filler injections: A review of literature.J Cosmet Dermatol2020;19:772-81

[105] Ozturk CN,Tung R,Piliang MP.Complications following injection of soft-tissue fillers.Aesthet Surg J2013;33:862-77

[106] Alam M,Dover JS.Rates of vascular occlusion associated with using needles vs. cannulas for filler injection.JAMA Dermatol2021;157:174-80 PMCID:PMC7774041

[107] Ugradar S.Measurement of the force required by blunt-tipped microcannulas to perforate the facial artery.Ophthalmic Plast Reconstr Surg2019;35:444-6

[108] Halepas S,Goldsmith JL.Vascular compromise after soft tissue facial fillers: case report and review of current treatment protocols.J Oral Maxillofac Surg2020;78:440-5

[109] Lee W,Moon HJ.A safe doppler ultrasound-guided method for nasolabial fold correction with hyaluronic acid filler.Aesthet Surg J2021;41:NP486-92

[110] Mespreuve M,Hendrickx B.Visualization techniques of the facial arteries.J Cosmet Dermatol2021;20:386-90 PMCID:PMC7891589

[111] Rocha PS,Teixeira DA.Description of a safe doppler ultrasound-guided technique for hyaluronic acid filler in the face-A method to avoid adverse vascular events.J Cosmet Dermatol2022;21:2783-7

[112] Schelke LW,Velthuis PJ.Ultrasound to improve the safety of hyaluronic acid filler treatments.J Cosmet Dermatol2018;17:1019-24

[113] Lee AL,Yao WT.Laser doppler imaging for treating vascular complications from procedures involving dermal fillers: case series and literature review.Diagnostics (Basel)2021;11:1640 PMCID:PMC8468831

[114] Huang P,Ren H.Color doppler flow imaging of retrobulbar ocular blood flow changes in retinal artery occlusions caused by cosmetic facial filler injections.Ophthalmic Plast Reconstr Surg2019;35:227-31

[115] AlGhadeer H,Al-Muhaylib A,Elkhamary SM.Acute unilateral vision loss and bilateral cerebral infarction following cosmetic filler injection.Orbit2021;

[116] Mundada P,Boudabbous S,Platon A.Injectable facial fillers: imaging features, complications, and diagnostic pitfalls at MRI and PET CT.Insights Imaging2017;8:557-72 PMCID:PMC5707222

[117] Davidova P,Wenner Y,Kenikstul N.Ophthalmic artery occlusion after glabellar hyaluronic acid filler injection.Am J Ophthalmol Case Rep2022;26:101407 PMCID:PMC8858863

[118] Danks JJ,Ayton T.Cosmetic filler blindness: recovery after repeated hyaluronidase injections.Aesthet Surg J2022;42:411-6

[119] Nguyen HH,Duong QH,Dao HX.Significant vision recovery from filler-induced complete blindness with combined intra-arterial injection of hyaluronidase and thrombolytic agents.Aesthetic Plast Surg2022;46:907-11

[120] Moore RM,Hu AC.Asymptomatic stroke after hyaluronic acid filler injection: case report and literature review.Aesthet Surg J2021;41:NP602-8

[121] Eldweik L.Orbital infarction syndrome following hyaluronic acid filler rhinoplasty.Am J Ophthalmol Case Rep2021;22:101063 PMCID:PMC8020441

[122] Jolly R,Zakir R.Visual loss from dermal fillers.Eur J Ophthalmol2021;31:NP102-5

[123] Zhang L,Li J.Endovascular hyaluronidase application through superselective angiography to rescue blindness caused by hyaluronic acid injection.Aesthet Surg J2021;41:344-55

[124] Liu H,Zhang J.Ophthalmic artery occlusion after forehead autologous fat injection.Retin Cases Brief Rep2020;14:271-4

[125] Conovaloff J,Hasso A.Vanishing beauty: a case of a 59-year-old woman with iatrogenic central retinal artery occlusion after cosmetic facial augmentation with filler injections (2694).Neurology2020;94(15 Supplement).

[126] Ramesh S,Goldberg RA.Orbital and ocular ischemic syndrome with blindness after facial filler injection.Ophthalmic Plast Reconstr Surg2018;34:e108-10

[127] Chen H,Yang Z.A case of hyaluronic acid induced blindness with ophthalmoplegia and ptosis.Ophthalmic Plast Reconstr Surg2018;34:e184-6.

[128] Kalyam K,Ehrlich M.Irreversible blindness following periocular autologous platelet-rich plasma skin rejuvenation treatment.Ophthalmic Plast Reconstr Surg2017;33:S12-6