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Eyelid-associated complications after autogenous fat injection for cosmetic forehead augmentation
© Paik et al.; licensee BioMed Central Ltd. 2013
Received: 12 October 2012
Accepted: 3 July 2013
Published: 10 July 2013
We report two cases of unilateral upper eyelid swelling with multiple small lumps as an unusual complication of autogenous fat injection for cosmetic forehead augmentation.
Two female patients were referred to our clinic for unusual unilateral eyelid swelling, with multiple small lumps. The duration of symptoms differed in each case, but both patients had a history of autogenous fat injection for cosmetic forehead augmentation at a local plastic surgery clinic. The lumps were small (diameter 5 mm~10 mm), palpable, hard, and nonmobile, and were evaluated by magnetic resonance imaging (MRI). Lumps from the eyelids of two patients were excised under general anesthesia. All of the masses were located deeply and found near the superior orbital rim or lateral orbital rim. The lumps exhibited chronic inflammation with fibrosis. Some of the lumps showed foamy histiocytic aggregation and foreign body lipogranuloma, resulting from iatrogenic fat injection. After excision, all masses and swelling disappeared, and moderate ptotic eyelid or lagophthalmos of affected eyes also improved.
To our knowledge, eyelid swelling with multiple lumps in the eyelid is a very rare complication of autogenous fat injection for cosmetic forehead augmentation. This report should be helpful for ophthalmic clinicians who encounter these unusual symptoms.
Autogenous fat is an easily accessible, renewable resource that can be harvested from multiple sites with little or no morbidity. After transfer to other locations, autogenous fat serves as non-allergenic, well-tolerated, supple, and versatile implant material. Therefore, autogenous fat injection into the periorbital or mid-face region is a common type of cosmetic surgery for rejuvenation in middle-aged and older Western subjects. In Asians, autogenous fat injection has become increasingly popular for forehead augmentation in relatively young people to enhance the esthetics of the typical flat Asian forehead. Although autogenous fat has good long-term safety and no severe adverse reactions, we encountered a case series of eyelid swelling with multiple mass-like lesions after dermal injection of autogenous fat. These complications are reported in order to assist clinicians in future diagnoses of patients after autogenous fat injection.
The clinical characteristics of two patients
Surgery at plastic surgery / Symptom onset after 1st injection/ visit our clinic
Additional fat inection
Forehead augmentation / 7 months/ 13 months after 1st inection
Chronic inflammation with foamy histiocytic aggregation
No lid lag
Forehead augmentation with rhinoplsty / 9 monnths / 12months after 1st injection
Chronic inflammation with foreign body lipogranuloma
No recur Still remained lagophthalmos, lid lag
Autogenous fat is an excellent material for filling spot defects, such as depressed scars, and area defects, such as trough and sulcus deformities. Autogenous fat is easily accessible for harvesting and is available in adequate quantities for injection, even in lean patients. The fat is readily accepted at the implantation site due to its autogenous nature . Facial injections, including periocular and paranasal injections of various substances, are becoming common as more procedures are performed under local anesthesia [2–4]. In young Asian subjects, autogenous fat injection for forehead augmentation is becoming increasingly popular to improve facial esthetics.
Complications of autogenous fat injection include a visible lump, the collection of fat at the injection site, an uneven skin surface, and allergic reactions to albumin or anesthetic agents. A rare, but potentially devastating, complication is embolization with loss of vision or stroke, which has been recently reported. The visual loss can result from retinal ischemia caused by occlusion of the ophthalmic and central arteries by fat emboli [5, 6]. To our knowledge, however, there have been no previous reports of eyelid swelling with multiple lumps with or without blepharoptosis that regressed after surgical removal. The pathogenesis of eyelid swelling with small masses after autogenous fat injection for forehead augmentation could be explained by incorrect injection and/or anatomical variations of the forehead. One patient in this report received two injections of autogenous fat. The relatively short period between injections (in this patient, 4 weeks) suggest that overcorrection may have played a role in the development of complications. Furthermore, repeat injections generally used previously harvested fat stored in a freezer; and it is possible that this fat was less vital, less oxygenated, and did not survive well. The other patients who received a single injection received a relatively large volume of fat (0.3~0.5 ml), which may have been injected into the same area. This could become necrotic in less oxygenated areas and descend along the musculoaponeurotic system of the forehead to reach the superior orbital rim or lateral orbital rim, developing adhesions, fibrosis, and chronic inflammation, to ultimately form a cicatrix.
Frequent eyelid swelling and multiple lumps with or without blepharoptosis are rare but potentially serious complications resulting from autogenous fat injection of the forehead. Here, we present the first report describing such adverse reactions and their treatment. Although blepharoptosis was not severe, if it progresses and does not improve with systemic anti-inflammatory medications, surgical intervention might be necessary, as it was in Case 1. Two patients were no longer suffered from frequent eyelid swelling after the masses were completely removed. Finally, if non-absorbable fatty tissue remains at the forehead, at the first injection site, it could move inferiorly and cause upper eyelid complications.
Written informed consent was obtained from both patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor in Chief of this journal.
Both cases reviewed followed approval from the institutional review board of the Catholic Medical Center at Seoul St. Mary’s Hospital.
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