Abstract

Facial fillers are minimally invasive aesthetic procedures done for facial rejuvenation and contouring all over the world. But as all good things have some negative effects, fillers even in the most experienced hands can lead to fatal complications such as vascular complications which need to be managed immediately with the help of hyaluronidase protocols mentioned in literature.¹

In our present case discussed below, patient was asymptomatic with no signs of vascular occlusion like blanching or poor capillary refill for 48 hours. He came after more than 48 hours of the filler injection with complaints of pulsating pain in the right infraorbital and nasolabial area. We noticed necrosis of microvesicles in the infraorbital artery territory with signs of impending skin necrosis extending from right infraorbital region up to the nasolabial fold (slightly medial to it). He was treated immediately with 3 pulsed doses of 500 units each hour. The skin color improved with decreased pain and the next day (after 14 hours) we injected 500 units of hyaluronidase in higher dilution of 10 ml since slight redness was still present. Skin redness, swelling and pain disappeared the following day. Skin completely healed and by 15 days we noticed slight Post Inflammatory Hyperpigmentation (PIH) which was easily managed with Q-switched laser and creams.

We hereby report a case of delayed skin necrosis (>48 hours) following filler injections in the cheek area, in the infraorbital artery vascular territory which was successfully managed with pulsed dose of hyaluronidase.¹

Case Report

50-year-old male patient was injected in a private clinic in Delhi: NCR for multiple areas of face on both sides. The experienced injector performed the filler injection with 27 G ½ sharp needle. The hyaluronic acid concentration was 20mg/ml and the filler also contained lignocaine. A written informed consent was taken from the patient before starting the procedure. HA Filler was injected at 4 different sites on each half of the face. 0.1 ml was injected each at the zygomatic arch and zygomatic eminence. 0.05 ml was injected below the infraorbital foramen level and 0.1 ml was injected at the nasolabial region (canine fossa). The injections were completed both sides uneventfully and patient did not complain of any excessive pain or discomfort after the injections. Patient left the clinic uneventfully. The next day as a routine, a follow-up call was made and patient expressed his happiness about the procedure without any complaints of pain or redness. But the next day that is more than 48 hours of the procedure patient called up and over phone he complained about redness and pulsating pain in right cheek area only. We told him to come to the clinic immediately. He came within 2 hours of the call and on examining him, we were shocked to see necrosis of microvesicles in the infraorbital artery territory with signs of impending skin necrosis and redness (livedo reticularis) extending from infraorbital region up to the nasolabial fold and slightly medial to it, along with tenderness of tissues. We suspected vascular compromise of the infraorbital artery territory area with minimal involvement of the communication with the facial artery as it did not extend beyond the nasolabial fold and also spared the angular artery and lateral nasal artery territory area (lateral nasal wall, sides, ala and other nasal areas with its anastomosis). We immediately started hyaluronidase injections. One vial of hyaluronidase contains 1500 units, so we decided to split the 1500 units into 3 equal divided doses and injected every hour rather than 1500 units direct dose. We first gave 500 units using 25 G cannula all along the cheek and nasolabial areas extending slightly beyond the involved areas territory. After one hour we did not notice any improvement and pain was still persisting so we gave another 500 units of hyaluronidase. After 2 hours, pain had decreased significantly but some swelling and redness was still present. We repeated another 500 units of hyaluronidase and after three hours following 3 pulsed doses of hyaluronidase, we saw a remarkable change in the skin color, redness and swelling. We observed the patient for one hour more and thereafter he was sent back home and advised to inform immediately if he felt any more pain or redness and if swelling increased. The next day that is exactly 14 hours following our last (3rd) pulsed dose of hyaluronidase patient came to the clinic. Patient had no complaints of pain but we saw minimal redness in the nasolabial area. We repeated 500 units more of hyaluronidase with higher dilution of 10 ml. We observed for one hour after which he was sent home and reviewed after 48 hours. On this review, redness and swelling had completely disappeared and healing had started well. Patient was on regular follow up and we reviewed him after 15 days and we saw complete healing of the tissues with no residual scarring. For his PIH we gave him Q switched laser therapy and creams to apply. We followed the patient for 3 months and at the end of 3 months, skin had completely healed without any residual scarring or pigmentation.

Discussion

We are presenting this case report because of its uniqueness in the fact that most of the intra-arterial occlusions and signs of ischemic skin necrosis occur immediately or within few hours of the filler injection going intravascular. There have been very rare reports of delayed necrosis all over the world following filler injections. In the present case patient reported pain only after 48 hours following filler injections which is an important sign of intra-arterial injection², but may not be appreciated well because of lignocaine present in filler injections². This case report is a caution for all injectors that signs and symptoms can occur even after 48 hours following injections and one has to be careful and vigilant if any patient complains of any excessive pain or redness later on also. Thorough knowledge of the anatomy is utmost important for demarcating accurately the vascular territory involved, in our present case the infraorbital artery was involved with minimal involvement of the communication with facial artery and its branches especially the angular and lateral nasal artery which supply the entire nasal area and lateral nasal walls with their corresponding anastomosis. We would like to quote an article in by Bravo et al,⁵ where the authors had reported case of delayed necrosis more than 36 hours of HA injection in the zygomaticofacial artery territory. The hypothesis given was of an embolus after the injection and poor collateral circulation to supply nutrition to the area, resulting in late necrosis. This may be probable cause in our case also along with a component of external compression of the vessel due to edema around the foramen level rather than intravascular injection of the filler causing complete occlusion. Hyaluronidase is essential for every aesthetic physician practicing in injectables.³ The high dose pulsed hyaluronidase protocol 6 suggests using 500 units for 1 vascular territory and 1,000 units for 2 areas and the same has been followed in this case.¹ Also there is no unanimity on dosage and the interval between 2 doses of hyaluronidase.⁴ In our case we used 500 units of hyaluronidase as pulsed doses every hour followed by one more 500 units in more dilution of 10 ml the next day. This helped us to completely heal the skin without any residual scarring. The high-dose pulsed hyaluronidase works on the principle of achieving high concentration levels of hyaluronidase at local tissue level for sufficiently long duration for it to dissolve the HA material present in the affected areas of filler injections.¹

We like to conclude by saying fillers though quite lucrative can lead to devastating complications if not managed properly and adequately. Thorough anatomical knowledge of the vascular territories is of utmost importance before venturing into injectables.

References
1. DeLorenzi C. New high dose pulsed hyaluronidase protocol for hyaluronic acid filler vascular adverse events. Aesthetic Surg J. 2017;37:1–12.
2. Andre P, Haneke E. Nicolau syndrome due to hyaluronic acid injections. J Cosmet Laser Ther. 2016;18:239–244.
3. De Almeida ART, Saliba AFN. Hyaluronidase in cosmiatry: what should we know? Surg Cosmet Dermatology. 2015;7:197–203.
4. De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: prevention, assessment, and treatment. Clin Cosmet Investig Dermatol. 2015;8:205–214.
5. Bravo, et al. Delayed- type Necrosis after Soft Tissue Augmentation with Hyaluronic Acid. J Clin Aesthet Dermatol. 2015;8(12):42–47
6. Loh K, Kapoor K, et al. Successfully Managed Impending Skin Necrosis following Hyaluronic Acid Filler Injection, using High-Dose Pulsed Hyaluronidase immediately after the filler injections. PRS Glob Open. 2018 Feb; 6(2): e1639