【科普】透明质酸进行颏部填充诱导骨吸收:亚洲患者的回顾性队列研究

2020-08-14

As one of the most commonly used soft-tissue fillers, hyaluronic acid is generally considered safe and efficacious. However, evident bone resorption in mentum was observed. Compared with sliding genioplasty and implants, injectable fillers offer a safe and efficacious method of three-dimensional chin shaping for patients with mild and moderate microgenia. In 2018, we first reported nine cases of mental bone erosion after hyaluronic acid injection. With time, we found that this phenomenon was not sporadic. Therefore, a retrospective, comparative study was conducted to shed light on this complication and the possible pathogenesis, and to highlight the need for awareness and change in clinical practice.


透明质酸作为最常用的软组织填充剂之一,被普遍认为是安全有效的。但临床偶尔可见颏部明显的骨吸收。2018年,研究团队首次报道了9例注射透明质酸后的骨吸收。随着时间的推移,他们发现这种现象并不是偶发的。因此进行了一项回顾性的比较研究,以阐明这种并发症及其可能的发病机制,增加临床认知并采取积极的举措。

METHODS

方  法

We retrospectively reviewed the computed tomography database of patients with a medical history of chin augmentation with hyaluronic acid from January of 2014 to October of 2019 at the Maxillofacial Department of the Chinese Academy of Medical Science and Plastic Surgery Hospital. Information regarding demographics, complications, injection volume, injection interval, number of injections, and product brand was collected for analysis.

 

The semimandibular bone resorption index was calculated as the ratio of bone thickness in the incisive fossa compared with bone thickness in the mandibular symphysis (Figs. 1 through 3).  The bone thickness was measured three times by three independent authors, and the values were averaged. Patients were phoned and asked to rate their satisfaction with previous hyaluronic acid injection procedure (i.e., not satisfied, satisfied, or very satisfied) and the influence of bone erosion on aesthetics (i.e., does not realize, feels influenced, largely influenced) using a three-level scale.


本研究回顾性地回顾中国医学科学院整形外科医院颌面科2014年1月-2019年10月有透明质酸隆颏病史的患者的计算机断层扫描数据库。收集有关人口统计、并发症、注射量、注射间隔、注射次数和产品品牌的信息进行分析。


半下颌骨吸收指数计算为切牙窝骨厚度与下颌联合部骨厚度的比值(图1-图3)。骨厚度由三位独立作者测量三次,并取平均值。给患者打电话,要求他们用三级量表评估他们对先前透明质酸注射过程的满意度(即:不满意、满意或非常满意),以及骨骼侵蚀对美学的影响(即:没有意识到、感觉受到影响、很大程度上受到影响)。



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RESULTS

结   果

Eighty patients (160 semimandibular cases) met our inclusion criteria. All patients received hyaluronic acid injection in cosmetic clinics, and 33 patients could provide partial medical records. The bone resorption index in the hyaluronic acid injection cohort was significantly smaller than the controls (Table 1 and Fig. 4).


共招募患者80例【160例,对照组80例】符合研究的纳入标准,所有患者在住院前6个月均有在颏部注射透明质酸的病史,并在术前进行面部轮廓的计算机断层扫描。所有患者均在美容门诊注射透明质酸,33例患者可提供部分病历。透明质酸注射组的骨吸收指数明显小于对照组(表1)。



Twenty-one patients had hyaluronic acid injected multiple times; thus, hemimandibular data for 42 cases were compared with the remaining data (59 patients; 118 cases) were compared using an independent t test, and no significant difference was revealed. However, the bone resorption index in the multiple-injection group was smaller (72.80 ± 8.24 versus 76.11 ± 10.54; p = 0.068) (Table 2 and Fig. 5).

 

Thirteen patients reported largevolume injection per time; 10 of these patients received multiple injections. When compared with leftover data (67 patients; 134 cases), patients injected greater than or equal to 1 ml per time were more susceptible to bone erosion (68.89 ± 10.84 versus 76.49 ± 9.42; p = 0.000) (Table 2 and Fig. 6).


21例患者多次注射透明质酸,将连同对照组共42例患者的半下颌数据与其余数据进行独立t检验比较,无显著性差异。然而,多次注射组的骨吸收指数较小(72.80±8.24 vs 76.11±10.54;p=0.068)(表2)。


13例报告每次大容量注射,其中10例接受多次注射。与剩余数据相比,每次注射大于或等于1ml的患者更易发生骨侵蚀(68.89±10.84 vs 76.49±9.42;p=0.000)。



Six patients reported a short injection interval within 6 months, whereas 11 patients (22 cases) indicated a longer injection interval of greater than or equal to 6 months. Compared with the long-injection-interval group, although the bone resorption index in the short-injectioninterval group was less (69.57 ± 9.34 versus 72.95 ± 7.78; p = 0.267), there was no significant difference between these two groups (Table 2 and Fig. 7).


Furthermore, 70 patients (87.50 percent) in the hyaluronic acid injection group responded to the satisfaction survey: 32 patients (45.71 percent) felt very satisfied, 37 patients (52.86 percent) selected satisfied, and one patient (1.43 percent) reported being dissatisfied because of infection after the injection that was addressed by hyaluronidase injection. All patients stated that they did not realize any reduced aesthetic outcomes caused by bone erosion.


6例报告6个月内注射间隔较短,11例注射间隔≥6个月。与注射间隔长的组别相比,注射间隔短的组别骨吸收指数较小(69.57±9.34 vs 72.95±7.78;p=0.267),但两组之间无显著性差异(表2)。


此外,透明质酸注射组有70名患者(87.50%)对满意度调查作出回应:32名患者(45.71%)感到非常满意,37名患者(52.86%)选择满意,1例患者(1.43%)因注射透明质酸酶后感染而不满意。所有患者均表示,他们没有感受到骨骼侵蚀会降低美学效果。


>>更多结果请阅读原文<<


总   结

注射软组织填充物隆颏是一种创伤小、恢复快的手术,适用于小颏症患者或颏唇关系正常但希望颏部更尖的求美者。然而,与注射透明质酸有关的骨吸收却鲜有报道。本研究回顾性地比较了80例有透明质酸注射病史的患者与80例性别和体重指数相匹配但没有进行颏部填充的患者。本研究的结果证实了注射透明质酸会造成骨吸收。


这项研究的临床价值是至关重要的,因为现在是时候让我们重新思考以前关于透明质酸隆下巴的共识,尤其是对亚洲人而言。根据亚太共识小组的意见,亚洲人颏尖增大的推荐注射量为1-3ml,本发现表明,体积小而不是大体积更不容易受到骨侵蚀;因此,体积小可能更安全。另外,不同于皮肤下注射进行面部修复,最推荐的注射平面是骨膜上和真皮下。研究团队认为,将透明质酸直接作用于骨膜上可能会产生破骨细胞的聚集作用,也可能会受到上述产品和心理因素的直接或间接压力效应。


注射透明质酸可引起颏部骨吸收,其严重程度与每次注射量有关,但不影响美观效果。是时候重新思考一下之前关于颏部填充的共识。本研究表明小容量注射可能更安全。应避免6个月内的短间隔注射。


(来源: 中国整形与重建外科CJPRS )

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