Tips on Handling a Dreaded Dermal Filler Complication

Disclaimer: This article is meant to offer some suggestions for treating complications from dermal filler in the naso-labial area and is not intended to be a substitute for individualized, comprehensive patient care in a similar situation.

Working in our busy practices, we may sometimes find ourselves with little time for reading the latest updates or learning the newest techniques. In addition, there is a dearth of information on how to handle the dreaded dermal filler complication of vascular occlusion of the facial artery during naso-labial procedures. Some articles mention the use of a hyperbaric chamber whereas others advocate platelet rich plasma (PRP) treatments in cases of facial artery occlusion from a naso-labial treatment using dermal filler (Toscano, 2017).

Thousands of aesthetic practices provide dermal filler treatments in the US and the potential for complications can grow over time due to increasing numbers of practitioners with varying skill levels and patients with varying medical conditions. Patients can be at risk for developing vascular occlusion during certain procedures and a significant number of practices do not have access to a hyperbaric chamber and/or means to formulate PRP, although these are not the only remedies for facial artery occlusion.Vascular complications have occurred at the hands of expert practitioners so it is important to have an emergency protocol and effective remedies on hand when an emergency arises. Emergency items include topical nitroglycerin paste, hyaluronidase (Vitrace), and heat packs among others.

Complications range from mild to severe and can include hematomas, granulomas and skin necrosis from vascular compromise and should be discussed in your consent forms and consultations with patients. Skin necrosis is a serious complication that can result in permanent scarring if not treated immediately and is the focus of this article.

Experience and skill of injectors has significant influence on treatment outcomes however, complications happen with even the most talented aesthetic practitioners. We can help prevent complications by using small amounts of filler in high risk areas and being acutely aware of any skin changes as we work.

A crucial part of minimizing vascular compromise, besides thorough knowledge of facial anatomy, is recognizing the signs of impending occlusion. Occlusion can occur when filler compresses an artery or when filler actually enters the vessel and blocks blood flow that provides the skin with oxygen and nutrients. Lack of oxygen can end in skin necrosis and death of tissue resulting in scarring.

Impending occlusion signs during treatment include grayish-purplish/blue discoloration of the skin, increased pain disproportionate to procedure, and/or blanching of the skin. On occasion the discoloration can be mistaken for a simple bruise if no other signs are observed. Also, with the addition of lidocaine to many dermal fillers in recent years, pain may be minimal so astute observation is paramount. If you witness any of the above signs, remove the needle immediately and stop the procedure, massage the area vigorously and check for capillary refill. Explain to the patient why you are taking these actions to help avoid unnecessary anxiety.

Observe the area for any unusual discoloration, massage vigorously, and ensure the area regains capillary refill when digital pressure is applied - if this doesn't happen, inject 200u hyaluronidase into the area, this is one of the recommended doses in the literature (Cohen et al., 2015). Immediate observation of the patient as well as daily follow-ups are extremely important to ensure healthy recovery.

CASE STUDY:

This patient experienced no pain during or after injections but had some bluish discoloration resembling a bruise after treatment was completed. The skin blanched upon pressure and did not appear to be anything more than a bruise. When compared to the other side, the skin color looked similar, except for the bruise. Out of an abundance of caution, the patient was asked to send a photograph from work within 4 hours of treatment to monitor discoloration; it continued to resemble a bruise (see above photo). The patient continued to deny any pain or discomfort.

The following day the patient had a "little swelling", a "white spot", and a "growing bruise" (see above photo). On examination, a slight scab was beginning to form as well as some livedo reticularis and still no pain or discomfort. These are urgent signs of occlusion and she was treated with 100 u vitrase and vigorous massage. The patient was monitored for approximately one hour and the area showed signs of re-vascularization (brisk capillary refill with pressure). The patient was instructed to use warm packs to the area 5 times a day, take 325 mg aspirin (she had no history of GI issues), and apply topical antibiotic ointment every day for 2 weeks. During the 2 weeks, she was seen at the clinic most days and the days she could not come in, she sent photographs with the understanding she was to come in immediately if instructed (see below photo). Because of her cooperation and my diligence, she had a full recovery and no residual effects.

Post treatment instructions are important for patients and we provide written documents for patients to refer to at home that describe side effects along with appropriate actions to take if there are any concerns. Protocols for the treatment of occlusion are based on relatively small amounts of clinical experience and data rather than by evidence-based clinical trials; they are presented here merely as suggestions. This case study demonstrates how subtle the signs may be in the initial phases of occlusion and using small amounts of filler, a watchful eye, and having emergency items on hand can avoid poor outcomes.

I look forward to comments and suggestions from other experts who would add input to help others - thank you!

For more information and suggestions: Cohen, J.L...Sykes, J. et al. (2015). Aesthetic Surgery Journal, Volume 35,(7). pp. 844–849 https://academic.oup.com/asj/article/35/7/844/2589169

Toscano, F.E (2017). Reversal of skin necrosis. The dermatologist, Volume 25 (11). pp. 27-28