Temporary reduction of wrinkle depth, improvement of facial contours, elimination of asymmetries, restoration of volumes – this is a partial list of the results that can be achieved with dermal fillers. However, even in the hands of an experienced injector, a hyaluronic acid syringe can, albeit in extremely rare cases, cause vascular complications, for example, with intra-arterial injection of the gel. This article estet-portal.com presents a clinical case from the practice of Dr. Beatriz Molina (Beatriz Molina): obstruction of the right angular artery, followed by the appearance of symptoms of skin necrosis after hyaluronic acid filler injections.
- Clinical case description: early signs and management of skin necrosis after HA filler
- Discussion of the problem of diagnosis and timely treatment of skin necrosis after HA filler
Clinical case description: early signs and management of skin necrosis after HA filler
A 30-year-old patient in the author's clinic underwent injectable rhinoplasty with a hyaluronic acid filler (HA concentration 20 mg/ml) using a 25G cannula. Previously, in order to make the procedure more comfortable, the patient was injected with 0.1 ml of lidocaine into the tip of the nose. During the administration of the anesthetic and immediately after this injection, the patient did not feel any pain or discomfort.
Photo 1: the patient before the procedure
Then 0.2 ml of hyaluronic acid was injected into the back of the nose without any visible disturbance. After another 0.1 ml of filler was injected into the right side of the nose, the skin of the patient instantly turned pale.
The doctor immediately interrupted the injection of the filler and removed the cannula. The patient still felt no pain or discomfort. Meanwhile, the doctor began to check the filling of skin vessels. Capillary refill time – the time interval during which the color of the external capillary bed is restored after pressure. The test results indicated damage to the vessel. There were no other symptoms at this stage.
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After informing the patient about the risk of skin necrosis, the doctor recommended that hyaluronidase be administered immediately to dissolve the hyaluronic acid filler. However, the patient decided to wait 30-60 minutes before re-examination.
After 30 minutes, the following symptoms appeared, indicating a risk of further skin necrosis:
- mesh livedo on the right side and at the tip of the nose, corresponding to the location of the right angular artery;
- discoloration has begun to spread to other parts of the nose;
- painful sensations appeared in the area of the tip of the nose.
Photo 2–4: patient 30 minutes after HA injections: livedo reticularis and discoloration
At this stage, the patient agreed to receive hyaluronidase injections. First, she was injected with 1500 units. enzyme, diluted 1 ml of saline using a cannula and a needle, which ensured the study of the entire problem area.
The introduction of hyaluronidase led to instantaneous reperfusion of the remaining areas, as well as a decrease in the degree of pain in the area of the nasal tip. After the enzyme injections, the patient spent 30 minutes under the LED-device. The procedure is known for its regenerating and anti-inflammatory effects.
Read also: Dublin protocol for the treatment of complications after fillers (video)
After that, the pain in the area of the affected area completely disappeared. Good capillary refill was restored. The patient went home, and the next morning, 16 hours later, she returned to the clinic for a follow-up examination.
There was no pain, but a slight discoloration of the affected area remained. Therefore, the author introduced another 750 units. enzyme with a 30 gauge needle superficially into the problem area. The patient spent another 30 minutes under the LED-device, after which she was discharged.
Photo 5: patient 16 hours after hyaluronidase injection
After 24 hours on the phone, the patient reported that there were no alarming symptoms and asked when the injection rhinoplasty procedure could be repeated.
Doctor recommended to wait at least 6 weeks for complete
The author cited this case of injection of hyaluronic acid into the angular artery to demonstrate to injectors the early symptoms of ischemic
skin necrosis after filler. Timely diagnosis and management of this complication is essential for a favorable treatment outcome.
The insertion of a filler into an artery can be identified by:skin blanching;
- appearance of livedo mesh;
- pain.
- Pain – an important diagnostic criterion for intra-arterial filler injection. However, if a local anesthetic is used, this symptom may go unnoticed.
Most studies report thatskin blanching
is temporary and may last only a few seconds. Very often, this symptom is missed by the practitioner if they do not carefully evaluate the skin at the time of filler injection. Prior to
livedo reticularis, vascular injury may be indicated by impaired perfusion or capillary refill (either painful or painless).
Hyaluronidase is often used in the management of complications caused by intravascular injection of hyaluronic acid filler. This enzyme must be at hand for any injection doctor. The dose of hyaluronidase varies depending on the affected area, as well as the type of filler injected. For each vascular pool, it is recommended to inject
minimum 750 units. enzyme.However, the generally accepted dosage and interval between injections of hyaluronidase has not been established in the literature. Optimal time to start therapy in case of intra-arterial injection of filler – as soon as possible after the diagnosis of the complication, but
no later than 72 hours from the moment of its development. Otherwise, the risk of skin necrosis and scarring increases.
You may also be interested in:Safely injecting fillers: how to prevent possible complications Agreed expert opinions recommend injecting hyaluronidase every hour until the skin is reperfused, its color returns to normal (blanching/livedo disappears), and pain in the affected area subsides.
The introduction of adequate amounts of highly concentrated hyaluronidase allows the hyaluronic acid to dissolve in the vascular pool.
Remember that even the most experienced doctors are not immune from complications. If a filler enters an artery with subsequent circulatory disturbance, it can lead to serious consequences, including ischemic necrosis of the skin. Therefore, it is very important to learn to recognize the signs and symptoms of this complication in a timely manner in order to provide the patient with timely assistance.
Adapted from Aesthetics.
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