Successfully Managing Impending Skin Necrosis following Hyaluronic Acid Filler Injection, using High-Dose Pulsed Hyaluronidase

Abstract

Summary:Facial fillers are becoming increasingly popular as aesthetic procedures to temporarily reduce the depth of wrinkles or to contour faces. However, even in the hands of very experienced injectors, there is always a small possibility of vascular complications like intra-arterial injection of filler substance. We present a case report of a patient who developed features of vascular obstruction in right infraorbital artery and tell-tale signs of impending skin necrosis, after hyaluronic acid filler injection by an experienced injector. The diagnosis of a vascular complication was made quickly with the help of clinical features like blanching, livedo reticularis, and poor capillary refill. Patient was treated promptly with “high-dose pulsed hyaluronidase protocol” comprising three 1,000-unit pulses of hyaluronidase, administered hourly. There was no further increase in size of the involved area after the first dose of hyaluronidase. All of the involved area, along with 1 cm overlapping in uninvolved skin area, was injected during each injection pulse, using a combination of cannula and needle. Complete reperfusion and good capillary filling were achieved after completion of 3 pulses, and these were taken as the end-point of high-dose pulsed hyaluronidase treatment. Immediate skin changes after filler injections, as well as after hyaluronidase injections and during the 3-week recovery period, were documented with photographs and clinical notes. Involved skin was found to have been fully recovered from this vascular episode, thus indicating that complete recovery of the ischemic skin changes secondary to possible intra-arterial injection could be achieved using high-dose pulsed hyaluronidase protocol.

Management of delayed skin necrosis following hyaluronic acid filler injection using pulsed hyaluronidase

“…Hyaluronidase is essential for every aesthetic physician practicing in injectables. [4] The high-dose pulsed hyaluronidase protocol[5] suggests using 500 units for one vascular territory and 1,000 units for two areas, and the same has been followed in this case. [1] Also there is no unanimity on dosage and the interval between two doses of hyaluronidase.…”

Managing Complications of Submental Artery Involvement after Hyaluronic Acid Filler Injection in Chin Region

“…3 Although vascular complications can be avoided mostly through detailed knowledge of vascular anatomy, 4 injectors must also learn to recognize the presenting features of such complications quickly to institute hyaluronidase-based treatment protocols. 5 , 6 …”

A 10-point plan for avoiding hyaluronic acid dermal filler-related complications during facial aesthetic procedures and algorithms for management

“…Knowledge of applied facial anatomy is of paramount importance and serves as the foundation for avoiding disastrous complications. 37 , 45 Multiple documented variations and classifications of the vascular arcades in the face render it impossible for the injection specialist to determine the patient’s anatomy. There is no 100% guarantee of avoiding vascular injury once the needle or cannula has penetrated beneath the skin.…”

“…The patient should be given two tablets (650 mg) of aspirin to chew and swallow. 45 High-dose hyaluronidase (500–1000 IU) mixed with lidocaine in repeated hourly doses for 3 hours forms the backbone of the emergent therapy ( Table 3 ). 25 It is advisable to use a large bore cannula for instillation of the hyaluronidase in the subdermal plane to avoid bruising, which would confound the visual feedback of improving skin color.…”