LAUSR

Dear Editor, We read with great interest the article by Dr. Stefura et al. entitled ‘‘Tissue Fillers for the Nasolabial Fold Area: A Systematic Review and Meta-Analysis of Randomized Clinical Trials’’ [1]. The authors aimed to evaluate the most recent literature on aesthetic outcomes and safety of tissue fillers for nasolabial folds. The authors concluded that the use of tissue fillers in the nasolabial folds achieved a satisfying and sustainable improvement. They recognized potential complications, including tenderness, lumpiness, swelling, and bruising. The nasolabial fold results from the interaction between underlying anatomical factors, such as bony structure and adjacent adipose, fascial, and muscular tissues. The nasolabial fold has been recognized among the danger zones of filler injections due to complications [2]. We respectfully attempt to enhance the discussion of available evidence regarding arterial supplies, anastomotic territories, injection techniques, and incidence of vascular obstruction. In our opinion, anatomical changes that occur in the nasolabial sulcus with aging should be discussed with the intention of decreasing the rate of vascular occlusion complications. Gelezhe et al. demonstrated that the angular artery is not located strictly subdermal in the nasolabial sulcus, but at a variable depth that is greater at the oral commissure than at the nasal ala [3]. They revealed that the artery is located lateral to the nasolabial sulcus at a variable distance, with a greater distance at the nasal ala. With aging, the angular artery travels deeper, while the lateral distance between the nasolabial sulcus and the artery reduces significantly. The dimensional and distributional change of the adipose tissue with age could render the nasolabial fold deeper by increasing the depth of the subcutaneous layer lateral to the fold [4]. Thus, to ameliorate the fold, adipose tissue lateral to the fold or muscle traction medial to the fold can be altered. The authors state that most patients tend to overlook the risks associated with fillers and those with a history of cosmetic rhinoplasty are at higher risk of adverse events [1]. They also describe how blunt cannulas may be more amenable to injection in high-risk areas. We intend to enhance the discussion on the risk factors for and methods to avoid vascular complications from hyaluronic acid fillers. The reasoning for increased risk of accidental intraarterial injection with previous cosmetic rhinoplasty was not discussed, but may be due to deep tissue scars stabilizing and fixing arteries in place making them easier to puncture, similar to when arteries are passing through bony foramina [2]. Operator technique has been shown to be more important than any single injection technique for maximizing patient safety [5]. According to the Global Aesthetics Consensus recommendations, in addition to aspiration prior to injection, the needle should be kept moving continuously. Finally, we appreciate the authors’ thorough discussion on the effectiveness and safety of various types of tissue & Payam Sadeghi [email protected]