Case Report 6: Reversal of a dermal filler compressive alar necrosis with the use of intravenous steroids as well as hyaluronidase

Patient was a 37-year-old woman who received HA injection to the left nasolabial fold. She had an uneventful procedure but reported back to the clinic with an erythematous reaction and some pain in the nasolabial and malar area the next day. In view of the vascular compromise she was immediately treated with 350 units of hyaluronidase (diluted with 2% lidocaine) into the reticulated area every twelve hours and commenced on oral nitrates (Viagra 50mgs PO. Because the patient presented 24hrs post procedure and the possibility of a venous obstruction existed, she was given 100mgs of cortisone IV and commenced on 4mgs of Dexamethasone PO. She was also injected with 0.2mls of a dilute solution of 50% dexamethasone 40mgs/ml into the area where the hyaluronic acid was initially injected.

Day 0 Prior to vascular occlusion

The next day the patient received another 350 units of hyalase and continued her steroids and nitrates. She was not referred for hyperbaric oxgen but instead was commenced on chiroxy oxygenating skin cream (Auriga international Belgium). Chiroxy oxygenating skin cream is designed to increase the oxygen content of your skin by delivering O2 via nanosomes. This product may no longer be available to use. Her symptoms and signs disappeared within a five day period and two weeks later there was no evidence of any residual vascular deficit. 

Day 1 Vascular occlusion

Day 2 Vascular occlusion

Day 5 Vascular occlusion

Discussion

Within the past fifteen years, facial soft-tissue augmentation has become very popular in aesthetic clinics around the world. Although most biodegradable type products are considered safe, adverse events do occur that are time limited. The products have been observed to have severe, persistent, and recurrent complications. Histological examinations in these cases, often shows the presence and persistence of the filler (1). Dermal fillers complications are divided into early and delayed in terms of time of occurrence and minor and major in terms of severity (1) (2). Minor complications occurring immediately or hours to days after injection include injection site reactions such as bruising, erythema, pain and tenderness, swelling, and itching. These events usually resolve within a week without sequelae (3) (4). Severe vascular adverse events have been reported in the glabellar and nasolabial regions after treatment with both biodegradable and non-biodegradable injectable fillers (5). Although rarely reported in the literature, complications related to interrupted blood supply to the nose can occur with nasolabial fold dermal injection. The exact mechanism of this event is unknown. It has been theorized that, as injected HA expands because of its hydrophilic action, the facial artery, angular artery, or its branches becomes compressed. The facial artery runs in an oblique direction over the mandible toward the nasal sidewall. It passes under the zygomaticus muscles, crossing the nasolabial fold. It turns to run in the alar crease and along the lateral nasal wall, where it terminates in the angular artery, which continues toward the medial orbital rim (6).

Day 7 Vascular occlusion

There are several important factors that may lessen the occurrence of adverse events. Before injecting any dermal filler, a thorough medical history including medication (especially blood thinners), allergies, and scarring history (e.g., tendency for keloids) should be taken. The injector should be well trained in injection technique and know which filler to implant at which depth. Understanding the anatomy, limitations of the filler and proper technique can reduce the risk of adverse effects. When a complication occurs, the practitioner should understand how to manage them from observation to surgical intervention (7).

The best way to handle side effects is to prevent them (8). For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications (9). Hyaluronic acid (HA) dermal fillers are the most widely used injectables to augment facial volume without surgery. They are popular because of their ease of administration, predictable effectiveness, good safety profile, and quick patient recovery (10). Since its reformulation in mid-1999, the biologically engineered hyaluronic acid filler Restylane (Medicis Pharmaceuticals, Scottsdale, AZ, USA) elicits less than one allergic reaction in 1600 treatments. Skin reactions, including granuloma formation with poly-L-lactic acid (New-Fill/Sculptra, Dermik Laboratories, Berwyn, PA, USA) is considerably less likely if a greater dilution and deeper injection technique are employed (11).

Day 10 Vascular occlusion

Inflammatory nodules are likely to be caused by a low-grade infection maintained within a biofilm surrounding the hydrophobic silicone gel and the combination gels. Aquamid gel may prevent formation of a biofilm through its high water-binding capacity, explaining why late inflammatory nodules are not seen after injection of this polyacrylamide hydrogel product (11) (12). All gels act as foreign bodies. Host response ranges from a few macrophages to an intense foreign-body reaction with fibrosis, depending on gel type. For polymer gels the filling effect stems from their volume. For combination gels it stems from the intended host foreign-body reaction to the microparticles. Infectious nodules must be treated with antibiotics. Granulomas must be treated with a combination of both steroids and antibiotics or excision (12).  

Conclusion

 For the moment, there is no ideal dermal filler as they have widely varying properties, associated risks, and injection requirements that contribute to adverse events for the patient. The majority of adverse reactions are mild and transient, such as bruising and  oedema secondary to trauma or the physical characteristics of the material itself.

However, although serious adverse events are rare, vascular complications either arterial or venous can occur that are related to volume of filler used and the technique of placement in the region of terminal vessels. It is possible that injected HA expands because of its hydrophilic action and the underlying facial artery, angular artery, or its branches becomes compressed. This results in vascular compromise that can lead to skin necrosis unless it is immediately treated. The author proposes that intravenous steroids and anti-histamines should be given to all these patients.

There are also issues related to the recent use of adjunctive lidocaine in fillers that may make vessels more exposed to accidental infiltration. Lignocaine significantly decreases pain during injection and post injection with corresponding increased patient satisfaction (13). The efficacy and safety profile of the original filler may be compromised. Rare complications with HA fillers include venous compression during or after the event which results in reticulation some hours later and the author postulates the use of intravenous steroids in these patients. These patients normally show no evidence of vascular compromise during injection

References

(1) Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to dermal fillers: review. Dermatol Surg 2005;31(11 Pt 2):1616–25. Review.

 (2) Gladstone HB, Cohen JL. Adverse effects when injecting facial fillers. Semin Cutan Med Surg 2007;26:34–9.

(3) Baumann LS, Shamban AT, Juve′derm vs. Zyplast, Nasolabial Fold Study Group, et al. Comparison of smooth-gel hyaluronic acid dermal fillers with cross-linked bovine collagen: a multicenter, double-masked, randomized, within-subject study. Dermatol Surg 2007;33 (Suppl 2):S128–35.

 (4) Pinsky MA, Thomas JA, Murphy DK, et al. Juvederm injectable gel: A multicenter, double-blind, randomized study of safety and effectiveness. Poster presented at the American Society for Aesthetic Plastic Surgery Annual Meeting, New York, NY, April 19–24, 2007.

 (5) Bachmann F, Erdmann R, Hartmann V, Wiest L, Rzany B Dermatol Surg. 2009 Oct;35 Suppl 2:1629-34. doi: 10.1111/j.1524-4725.2009.01341. The spectrum of adverse reactions after treatment with injectable fillers in the glabellar region: results from the Injectable Filler Safety Study.

 (6) Lisa Danielle, Grunebaum MD, Inja Bogdan Alleman MD, Steven Dayan MD, Stephen Mandy, Leslie Baumann The Risk of Alar Necrosis Associated with Dermal Filler Injection Dermatologic Surgery Volume 35, Issue Supplement s2, pages 1635–1640,October 2009

 (7) Gladstone HB, Cohen JLSemin Cutan Med Surg. 2007 Mar;26 (1):34-9.Adverse effects when injecting facial fillers.

(8) Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013 Dec 12;6:295-316. doi: 10.2147/CCID.S50546.

 (9)  Andre P, Lowe NJ, Parc A, Clerici TH, Zimmermann U. Adverse reactions to dermal fillers: a review of European experiences. J Cosmet Laser Ther. 2005 Dec;7 (3-4):171-6.

 (10)  Christensen L, Breiting V, Janssen M, Vuust J, Hogdall E Adverse reactions to injectable soft tissue permanent fillers. Aesthetic Plast Surg. 2005 Jan-Feb;29(1):34-48. Epub 2005 Mar 11.

 (11)  Christensen L. Normal and pathologic tissue reactions to soft tissue gel fillers. Dermatol Surg. 2007 Dec;33 Suppl 2:S168-75.

 (12) Nicholas J. Lowe MD, FRCP, FACS, ChB C. Anne Maxwell MB, Rickie Patnaik MD, Nicholas J. Lowe, C. Anne Maxwell, Rickie Patnaik Adverse Reactions to Dermal Fillers: Review Dermatologic Surgery (Impact Factor: 1.87). 10/2005; 31(s4):1626 - 1633. DOI:10.2310/6350.2005.31250

(13)  Smith L, Cockerham K Hyaluronic acid dermal fillers: can adjunctive lidocaine improve patient satisfaction without decreasing efficacy or duration? Patient Prefer Adherence. 2011 Mar 14;5:133-9. doi: 10.2147/PPA.S11251.

Dr. Patrick Treacy is Chairman of the Irish Association of Cosmetic Doctors and Irish Regional Representative of the British Association of Cosmetic Doctors. Honorary Board Member of the World Medical Trichologist Association. Fellow of the Royal Society of Medicine and the Royal Society of Arts. (London). Honorary Ambassador to the Michael Jackson Legacy Foundation and the Haiti Leadership Foundation, which opened orphanages in both Haiti and Liberia the past year. He holds Honours Degrees in Molecular Biology and Medicine. He is the recipient of the Norman Rae Gold medal from the Royal College of Surgeons in Dublin. He has also received many national and international academic awards including the prestigious AMEC Award in Paris and runner up Aesthetic Doctor of the Year UK & Ireland 2016.  

He has authored or co-authored more than 200 articles in medical and scientific journals and published many peer-reviewed papers within these disciplines, including a sentinel study on the rising incidence of cutaneous malignant melanoma for the Mayo Clinic, Rochester in 1990. He pioneered facial implant techniques for HIV related facial lipodystrophy and early radiosurgery venous thermocoagulation. He is an advanced aesthetic trainer and has trained over 800 doctors and nurses from around the world. 

He is a renowned international guest speaker and features regularly on national television and radio programmes. He has featured on the Today Show, Ireland AM, CNN, Dr. Drew, RTE, TV3, Sky News, BBC and Newsweek.