Complications in orofacial harmonization procedures: a systematic review

204-217


INTRODUCTION
Facial aesthetic changes and dissatisfaction with self-image are increasingly present in today's society [1][2][3] and facial beauty parameters have a considerable influence on the population 2,4 . The appearance, especially of the female figure, is mentioned beauty and youth' imposing a cosmetic standard that fights fatigue and aging 5 . Patients have been looking for quick, nonsurgical and less invasive procedures' where we can
Facial applicators and fillers are the most widely used non-surgical resources for cosmetic procedures that seek to prevent or adjust the signs of aging 9 through substances injected under the skin, which, although are effective and have favorable safety margins, early and late complications with various levels of severity can occur 9 . The increase in the performance of these dermal aesthetic procedures may be accompanied by factors that compromise patient safety and the reputation of professionals 10 .
In view of the consolidated medical practice in the cosmetic area and with the possibility of clinical practice by dentists on certain cosmetic factors 11 , the popularity and demand for patients by these professionals increases with the main objective of aesthetic facial procedures 12 . Although non-surgical, and with a safety margin, they can result in a strange or artificial appearance 13 , in addition to leading to complications and adverse effects after treatment 14 , causing damage to the patient 15 . It is of outmost importance that the professional is safe in making decisions when performing such procedures and attention to the limit of his attributions as a dentist 16 .
As a result of the increase in non-surgical aesthetic procedures, and aiming to alert professionals about possible damages and risks inherent to the technique, the objective of this systematic literature review was to list the complications resulting from orofacial harmonization procedures, identifying the most affected areas, contributing to conscious decision making and safer facial aesthetic procedures for the quality of life of the patient.

Search strategy
This systematic review was conducted in accordance with the guidelines of the PRISMA protocol 17 , with the focus question: "What are the complications resulting from orofacial harmonization procedures?". The articles were selected based on the inclusion criteria: population, intervention, comparison and outcomes (PICO) which are shown in Chart 1.

Eligibility criteria
The articles were initially separated by titles, where those that did not have the topic were initially excluded. The articles selected by titles were evaluated by the reviewers through their abstracts and papers that did not meet the inclusion criteria and the repetitions found were discarded. Subsequently, a full article evaluation was carried out, where the methodological quality of each study was independently assessed by the two reviewers and the systematic selection of the studies was carried out, only those that presented the parameters of the inclusion criteria were selected for the discussion of the work.
Inclusion criteria were studies that presented complications in facial harmonization after orofacial harmonization procedures, in vivo work in humans. Exclusion criteria were literature reviews; research carried out on animals or that did not present complications resulting from orofacial harmonization procedures in the medical and dental areas.

Assessment the study quality
The bias classification of each selected study was performed using the scale: Joanna Briggs Institute 2017-Critical Appraisal Checklist for Case Reports 18 , with a maximum score of 8 points, counting only the positive ones, showing the limitations of the studies.

DISCUSSION
The demand for an improvement in aesthetics has increased the number of facial cosmetic procedures performed 52 . In view of this, this study carried out an extensive analysis of possible complications after orofacial harmonization procedures so that patients and professionals are aware of these events, enabling the detection and immediate treatment.
Most of the adverse effects are non-significant and temporary, but in some exceptions they can cause a worsening of the patient's aesthetic aspect and dissatisfaction 53 , causing damage and/or psychological shock in the face of frustration with their appearance, which can lead to the repair of the damage by civil liability professional 54 . However, even with a greater frequency of performing these services, there is still little scientific literary approach on the possible complications resulting from these procedures.
Consequences have been reported such as severe headache 45 lasting days, bilateral parietal headache lasting fifteen days associated with dry eye, progressive forehead ptosis, diplopia and loss of muscle control 24 . In the eyes, one of the most affected regions, it was possible to observe signs and symptoms such as dry eye 19,22 after one month of the procedure, the symptoms remaining for four months 22 , eye pain with pupillary constriction and visual disturbances that resulted in permanent pupil defects even after two months after the event 25 , vascular problems such as occlusion of the ophthalmic artery (OAO) and anterior ophthalmic optic neuropathy (AION) have also been reported 30 . Visual loss occurred partially, with increased visual acuity after twenty-four hours 20 and prolonged visual loss even after one year of the complication report 33 , the absence of light perception, esotropia 45 , strabismus and ischemic oculomotor nerve paralysis secondary to an occlusion vascular obstruction of an arterial branch filled with hyaluronic acid also occurred 38 .
Blepharoptosis 48 , cutaneous necrosis, edema, yellow discoloration 31 , reactions similar to xanthelasmas have been reported on the lower eyelids 41 and a slight blue discoloration of the skin was observed even after six years of the most recent procedure 42 . In the regions of the glabella and forehead, where aging wrinkles are very evident, glabellar protrusion and the appearance of new very deep wrinkles occurred, in the glabellar protrusion there was a relapse with disappearance after four weeks 26 , pale areas, redness, swelling, severe pain, purple and skin necrosis 44 . There was a report of filling material applied to cheeks that migrated to the patient's forehead, forming a nodule that was resolved only with plastic surgery 45 . Changes in the skin at the procedure site ranged from blisters, erosion and subcutaneous necrosis after treatment with microned ultrasound (MFUS) 47 , facial edema and bruising after facial applicators 51 .
In the nose region, especially after filling procedure using hyaluronic acid, there were cases of nasal necrosis 24,34,37,38 , with initial symptoms of swelling, edema, pain and erythema 34 , dark color 37 and numbness. Cosmetic rhinomodulation procedures end up being a non-invasive cosmetic alternative to alter the nasal appearance. There were reports of two patients who recovered after appropriate treatments for necrosis of the nasal tissue, but in one case the patient had a permanent scar resulting from the complication 24 . In the lower third of the face, the nasopalatine duct cyst was observed, caused by the foreign body reaction, that is, the material injected with botulinum toxin 32 , pain, and a 3cm nodule occurred in the region of zygomatic arch after application in the region with hyaluronic acid 29 .
Necrosis in the chin region associated with lingual paresthesia was detected after filling with       hyaluronic acid in the submental region, the ischemia of the tongue occurs by injecting material into the submental artery or its branches 46 . Still in the lower region of the face, the appearance of a deep horizontal line that was highlighted when the patient smiled, due to the application of botulinum toxin to correct gingival smile, the complication disappeared only after the effect of botulinum toxin ceased in three months 49 . A more serious complication caused breathing difficulties and dyspnea in a patient who required hospitalization and intubation for mechanical ventilation in an intensive care unit (ICU) diagnosed with myasthenia gravis, after a cosmetic procedure with botulinum toxin 39 . In the procedures performed on the lips, it was common to observe asymmetry, infections, fibrosis, hardening of the lips 21 , migration of the material used 32 and painful injuries 35 . Systemic complications after the cosmetic procedure were also detected in a patient with no history of diseases, manifesting with fever, astralgia and arthritis 23 . The present study had several relevant limitations: the nationality of the studied patients, which was not clarified; the techniques of the procedures performed; quantity and brand of material used with its concentration; the professional's specialty was also not specified. Such information would bring greater wealth to the discussion since several professionals are able to perform such procedures, and their qualification would help to demonstrate to these classes how their care is being performed and the most common complications, in addition to detecting possible failures of execution in the procedure. The amount of material and the concentration would provide a greater explanation of why there are some complications and, consequently, try to reduce such occurrences.
Given the above, the importance of a detailed history of procedures performed by the patient is emphasized 31,35 , before performing the facial cosmetic procedure, as well as the complete understanding of the facial and vascular anatomy by the professional 27,43,48,50,51 . Which can be a contributing factor to the induction of complications related to the training and execution of procedures by the professional, with complications resulting from injection in the blood vessels, vascular lesions and occlusion, infections caused by contamination of the product and technical errors of the injection of the material 57 .
It is evident the importance of ensuring the keeping of good photographic documentation and always maintaining a good relationship with the patient until the complication is resolved 24 . It must be communicated to the patient that even though it is a simple and non-invasive procedure, complications can occur 20,22,26 . The professional must exercise preventive measures so that complications do not occur 38 , respecting professional ethics and responsibility, ensuring the patient's health and dignity 16,55 , such measures avoid suffering and irreparable losses that can cause damage. Damage caused to the patient resulting from treatments can characterize civil liability 55,56,58 , as well as, criminal liability events can occur through bodily injury that offend the patient's bodily integrity or health [58][59][60] . Thus, the importance of carrying out extensive studies for the detailed understanding of the possible causes and mechanisms of these events is evident in order to guarantee safer and more satisfactory aesthetic procedures for the professional and the patient.

CONCLUSIONS
It is possible to conclude that even the execution of less invasive facial cosmetic procedures can cause possible immediate or late complications after the procedure in areas of forehead, nose, lips and mainly, in the eyes and periocular region, which were the most affected with dry eyes, diplopia, visual loss and ptosis. It is important to make patients aware of this possibility beforehand. Professionals must remain alert for the immediate detection of any complications.