Nitroglycerin, or Not, When Treating Impending Filler Necrosis

Abstract

BACKGROUND Dermal necrosis is a rare yet serious risk associated with cosmetic filler injections, and although current consensus recommends the use of hyaluronidase injections in cases of hyaluronic acid filler, the efficacy of topical nitroglycerin as a treatment has not yet been fully investigated. OBJECTIVE To review the literature on tissue necrosis resulting from soft tissue augmentation and to highlight the use of topical nitroglycerin as a first-line treatment. METHODS A review of the literature was performed with no time limitations resulting in 35 articles and 66 patients who experienced tissue necrosis secondary to injectable fillers. Articles were reviewed for pertinent information and presented. RESULTS Only 7 of the 66 reported cases (10%) used topical nitroglycerin as a treatment. Six of 7 (85%) were successful in halting the impending necrosis. Fifty-nine patients received alternative treatments, with hyaluronidase injection being the most common. Few reports of novel treatments for necrosis included the use of topical growth factors and injection of adipose-derived stem cells. CONCLUSION Topical nitroglycerin is a potentially effective and underused treatment for tissue necrosis from soft tissue augmentation, but because data are very limited, topical nitroglycerin should be used in conjunction with hyaluronidase injections in cases of hyaluronic acid filler dermal necrosis.

The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments

“…70 Nitroglycerin Paste During Vascular Occlusion A recent overview advocates the adjuvant use of nitroglycerin in pending vascular occlusion. 71 However, choke vessel spasm is deemed a major determinant for the location and extent of tissue necrosis and because nitroglycerin paste may induce choke vessel dilation to alleviate flowlimiting spasm, allowing expansion of the number of affected angiosomes and increasing the area of tissue necrosis, the use of nitroglycerin paste is discouraged. 69 The Use of Diagnostic Ultrasound Although technically intricate, accurately performed and interpreted ultrasound may offer a valuable risk reduction tool during blinded injection procedures (Figures 16 and 17).…”

“…A recent overview advocates the adjuvant use of nitroglycerin in pending vascular occlusion. 71 However, choke vessel spasm is deemed a major determinant for the location and extent of tissue necrosis and because nitroglycerin paste may induce choke vessel dilation to alleviate flow-limiting spasm, allowing expansion of the number of affected angiosomes and increasing the area of tissue necrosis, the use of nitroglycerin paste is discouraged. 69 …”

Soft Tissue Dermal Filler–Associated Necrosis and Impending Necrosis: A Systematic Review of the Literature

“…To the knowledge of the authors, this is the first systematic review investigating the relationship between soft tissue fillers and necrosis. Carley and colleagues 41 published a review article about soft tissue fillers and necrosis. The authors have expanded on their work by analyzing a larger cohort of patients, designing the review to be systematic in nature, and evaluating additional patient demographics and clinical features.…”

Management of complications associated with the use of hyaluronic acid fillers. Recommendations of the Aesthetic Dermatology Section of the Polish Dermatological Society

“…Dermatology Review/Przegląd Dermatologiczny 2020/1 jad owadów błonkoskrzydłych; konieczne jest posiadanie zestawu przeciwwstrząsowego w gabinecie; b) podanie kwasu acetylosalicylowego w dawce 600 mg; c) podanie 400 IU hialuronidazy w kilku wkłuciach co 3-4 cm w niedokrwioną okolicę; rekomenduje się podanie hialuronidazy za pomocą igły lub kaniuli o wielkości 25G; d) zastosowanie kompresów rozgrzewających; e) kontrola po 1 godzinie; w przypadku widocznego zbielenia skóry i/lub bólu powtórzyć punkt c; f) kontrola po 6 godzinach; w przypadku widocznego zbielenia skóry i/lub bólu powtórzyć punkt c; g) kontrola w dniu następnym; w przypadku widocznego zbielenia skóry i/lub bólu powtarzać punkt c do całkowitego zniwelowania zbielenia i/lub bólu [22,34,38]. Nie rekomenduje się stosowania nitrogliceryny ze względu na jej zdolność obkurczania naczyń w dłuższym odstępie czasu [53,54]. 7.…”

“…It is recommended to administer hyaluronidase using a needle or 25G cannula; d) use of warming compresses; e) control after 1 hour; in the case of visible concussion and/or pain, point c should be repeated; f) control after 6 hours; in the case of visible concussion and/or pain, point c should be repeated; g) control appointment on the following day; in the case of visible concussion and/or pain, point c should be repeated until concussion and/or pain are completely eliminated [22,34,38]. The use of nitroglycerin is not recommended due to its ability to constrict vessels at longer intervals [53,54]. 7.…”