Inadvertent intra‐arterial injection of deoxycholic acid: A case report and proposed protocol for treatment

Abstract

Deoxycholic acid (ATX‐101) is a secondary bile acid that was approved as an injectable drug for the reduction of submental fat. Necrosis, an uncommon but serious adverse event, can occur due to inadvertent superficial injection or intra‐arterial injection of the acid. The management of the intra‐arterial injection of deoxycholic acid has not been well characterized. Here, we discuss methods to decrease the risk of such injections and draw on existing protocols for the inadvertent intra‐arterial injection of sclerotherapy solutions and dermal fillers to propose a safe, practical approach to treatment. A case report is presented of a 42‐year‐old woman who received a deoxycholic acid injection for the correction of submental fullness, which was complicated by the inadvertent intra‐arterial injection of the acid. The adaptation of published treatment protocols for the inadvertent injection of sclerosing solutions and dermal fillers allowed for a good outcome in this patient. The inadvertent intra‐arterial injection of deoxycholic acid is a rare event. The risk of such injections can be reduced with attention to injection technique and can be managed successfully following the adaptation of protocols in the literature for similar events from vascular compromise due to dermal fillers and sclerosing solutions.

Deoxycholic acid in the submental fat reduction: A review of properties, adverse effects, and complications

“…Still, its approval by control agencies is relatively recent. Even with the confirmation of reduction of submental fat, the DCA presents several limitations due to a variety of adverse events such as edema, pain, local induration, hematomas, numbness, and, less frequently, mandibular nerve paresthesia, ulcerations, skin necrosis, alopecia, and vascular events 2,20,23–27,29–31 . The occurrence of alopecia was inserted in the medicine leaflet after the sales started since it was discovered later, as most of the DCA patients were female 31 .…”

“…Even with the confirmation of reduction of submental fat, the DCA presents several limitations due to a variety of adverse events such as edema, pain, local induration, hematomas, numbness, and, less frequently, mandibular nerve paresthesia, ulcerations, skin necrosis, alopecia, and vascular events. 2,20,[23][24][25][26][27][29][30][31] The occurrence of alopecia was inserted in the medicine leaflet after the sales started since it was discovered later, as most of the DCA patients were female. 31 As deoxycholic acid is a relatively new drug for cosmetic submental fat, case reports are useful in the qualitative detection of new reactions which may be caused by the substance and, therefore, be monitored in subsequent studies.…”

“…Inadvertent intra‐arterial injection of DCA, with consequent skin necrosis, is a severe complications that have also been described in literature 25–27 . The mechanism of damage from intravascular injection of DCA is unknown; however, DCA has vasoconstrictive properties and cause disruption of the cell membrane with cell lysis, cell death, and tissue inflammation 26 . Reflux should always be performed prior to injection to avoid intravascular injection.…”

“…Reflux should always be performed prior to injection to avoid intravascular injection. Lindgren and Welsh 26 have proposed the following protocol to treat vascular injection: if severe pain occurs, injection must be stopped immediately for evaluation. If there is any sign of vascular compromise, or blanching, bruising, the area should be reaspirated and flooded with normal saline and hyaluronidase.…”

“…Wound healing and subsequent skin compromise may be treated by local wound care. Pulsed dye lasers have been used with good result to reduce redness and accelerate wound healing 26,27 . Riswold and Flynn 28 still stress the risk of vascular occlusive events after DCA injection.…”