ReveRsal of a deRmal filleR

induced facial aRteRy occlusion Patrick Treacy discusses the factors to consider to avoid adverse

events after the use of a dermal filler as well as the best methods of treating complications, including steroids and hyaluronidase

Keywords Localised adiposities, topical slimming treatment, botanical extracts, ultrasonography, in vivo assessment

ABsTrACT Soft tissue augmentation with dermal fillers has become an integral part of most aesthetic practices. Fortunately, adverse reactions are usually mild and transient. However, significant adverse events such as vascular occlusion also occur. Vascular compromise occurs

because of embolisation and/or compression material into/onto the vasculature. In this article, the author theorises that late onset vascular occlusion may occur not only due to embolisation but because hyaluronic acid (HA) expands due to its hydrophilic action and compresses the

facial artery or its branches. He proposes that intravenous steroids should be added to the accepted reversal protocol. His goal is not to promote this as a definitive measure but rather to establish a discussion on treatment protocols that may be helpful to other physicians in the future.

Within the past 15 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 show the presence and persistence of the filler1. Dermal filler complications are divided into ‘early’ and ‘delayed’ in terms of time of occurrence and ‘minor’ and ‘major’ in terms of severity1, 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 sequelae3, 4. severe vascular adverse events have been reported in the glabellar and nasolabial regions after treatment with both biodegradable and non-biodegradable injectable fillers5.

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, however it is widely accepted that vascular compromise is a function of compression and/or embolisation of material into the vasculature. It has

PATriCK TreACy, Medical Director, Ailesbury Clinics Ltd and Ailesbury Hair Clinics Ltd, Dublin, Cork, London, and Middle East

email: ptreacy@gmail.com

been theorised that, as injected hyaluronic acid (HA) expands because of its hydrophilic action, the facial artery, angular artery, or its branches, become 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 rim6.

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 complications occur, the practitioner should understand how to manage them from observation to surgical intervention7.

Preventing side-effectsThe best way to handle side-effects is to prevent them8. 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 complications9. Hyaluronic acid 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 recovery10. 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

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severe vascular adverse events have been

reported in the glabellar and nasolabial regions after

treatment with both biodegradable and non-biodegradable

injectable fillers.

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reactions, including granuloma formation with poly-l-lactic acid (Sculptra/formerly New Fill, Dermik laboratories, Berwyn, PA, USA) is considerably less likely if a greater dilution and deeper injection technique are employed11. 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 product11, 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 excision12.

Case studyPatient 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 150 units of hyaluronidase and nitropaste to the reticulated area. Because the patient presented 24 hours post-procedure she was given 100 mgs of cortisone IV and commenced on 4 mgs of Dexamethasone Po. It was also considered appropriate to inject 0.2 mls of a dilute solution of 50% dexamethasone 40 mgs/ml into the area where the hyaluronic acid was initially injected.

The patient became hypotensive during treatment and was temporarily referred to the emergency room until stable. This was considered secondary to the nitropaste gel. The hospital was willing to allow the patient to come back to the clinic for further steroid

Figure 1 Images demonstrating management of a patient over 7 days with impending necrosis owing to complications secondary to hyaluronic acid dermal filler injection

Figure 2 Branching patterns of facial artery

ILA

SLA

IAA

LNA

FB

Branching patterns of facial artery according to its termination (ILA, inferior labial artery; SLA, superior labial artery; IAA, inferior alar artery; LNA, lateral nasal artery; FB, forehead branch

Anzeige_Aesthetic_Prime_0814.indd 1 18.08.14 15:07

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Anzeige_Aesthetic_Prime_0814.indd 1 18.08.14 15:07

• Perfect for precise facial markings • Ultraf ine tips ideal for procedures where f ine lines are needed

Oh sooo ne!

treatment and commencement of Chiroxy oxygenating skin cream (Auriga international, Belgium). Chiroxy oxygenating skin cream is designed to increase the oxygen content of your skin by delivering o

2 via

nanosomes. Her symptoms and signs disappeared within a 5 day period and 2 weeks later there was no evidence of any residual vascular deficit.

DiscussionFor 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, become 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. lidocaine significantly decreases pain during injection and post-injection with corresponding increased patient satisfaction13. The efficacy and safety profile of the original filler may be compromised.

Rare complications with HA fillers include vascular 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. The protocol outlined by glaich et al14 calls for a coherent, sequential treatment for vascular compromise resulting from injections of hyaluronic acids. This protocol elaborates a sequence of events that use topical nitroglycerin, hyaluronidase, and other modalities to minimise the damage from impending necrosis. other authors have also published guidelines for the treatment of impending necrosis following soft tissue augmentation following injections of hyaluronic acid15,16. Based upon the experience with hyaluronic acid occlusion, treatment for particular fillers that occlude vascular structures should seek to increase blood flow to the affected areas. This may be accomplished by decreasing pressure in the anatomic compartment (using corticosteroids and hyaluronidase), increasing blood flow (with sildenafil or similar drugs, aspirin, and nitroglycerin paste), and increasing the oxygen content to the affected tissues (hyperbaric oxygen)17.

Regarding reversal of a hyaluronic acid induced embolus, the author recommends starting at higher

Table 1

author’s hLa

reversal protocol

Discontinue injection ofHLA immediately

Massage the affected areaimmediately

Apply warm packs of gauzeto area (microwave)

Apply nitro-paste or 10 mgstransderm-nitro patches(Novartis) for a period of

up to 12 hours

Mix 300 units of hyalase(0.2mls) with 0.2mls

(Wockhardt UK) of 2%lidocaine and adrenaline

(Astra Zeneca)

Inject hyalase in 5–8 lots of75u to occluded area

Hydrocortisone 100mg IV stat

Dexamethsone 4mgs dailyPO X 3/7

Figure 3 effects of a large filler bolus

Figure 4 effects of a small filler bolus

Table 2 Typical complication progression after accidental intra-arterial injection of hyaluronic acid

CLINICAL FINDINgS TIMINg

Blanching: invariably immediate, usually seen during Lasting seconds to tens of the actual injection seconds

Livedo pattern or immediate reactive hyperaemia Minutes: sometimes up to if insufficient material injected to occlude the artery tens of minutes

Blue-black discolouration Tens of minutes to hours

Blister/bullae formation Hours to days

Skin breakdown, ulceration, demarcation, slough Days to weeks

When a large bolus of filler material enters a small- or medium-sized vessel, the material may flow retrograde to the blood flow’s normal direction after it has filled in the distal segment, because there is nowhere else for the filler to go. If the filler bypasses a tributary during its retrograde flow, it may enter this particular pathway and be carried to distant areas. This is probably the pathophysiology responsible for injury sites distant to the original injection site

Usually carried downstream by blood flow. May cause limited obstruction that can be bypassed via abundant collateral vessels. The problem is in a region with restricted collaterals (eg, the glabellar region). Effect depends on the presence or absence of enough collateral circulation in the target tissues

Micro volume of filler does not completely obstruct blood supply

Angular artery

Distal branches

Supratochlear arteryDorsal nasal artery

Ophthalmicartery

Facial artery

External carotid artery

Internal carotid artery

Distal branches

Collateral flow

Proximal branches

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.

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levels of hyalase, possibly in the region of 150 to 300 iu, and then treating repeatedly until the circulation returns. Repeated treatment, massage, and the other recommendations to promote vasodilation are continued. It is probable as the material starts to break down, it flows further downstream, where it probably opens collateral vessels, or it can flow further past these and obstruct a slightly different area. When it gets to the precapillary arterioles, it gets permanently stuck, unless it is bathed in more hyaluronidase (HyAl) and is hydrolysed.

There are so many variables in a typical case that it is impossible to be specific, since the manner of manipulation of the area, the quantity and nature of the filler within the vessel, and the actual location of the emboli all factor into the equation. The absolute quantity of hyaluronidase is probably irrelevant during an acute event, it’s the results that count.

Declaration of interest None

Figures 1 © Dr Treacy, 3-4 original artwork © Claudio De Lorenzi redrawn for Prime Journal © Kevin February

One of the most significant adverse events associated with injections of soft tissue augmentation products is vascular occlusion

Vascular complications with HA fillers include embolism or compression during or after the event which results in reticulation some hours later

The author postulates the use of higher doses of Hyalase than the normal protocols and the uses of intravenous steroids in these patients

Key points References1. Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to dermal fillers: review. Dermatol Surg 2005; 31 (11 Pt 2): 1616–252. gladstone HB, Cohen JL. Adverse effects when injecting facial fillers. Semin Cutan Med Surg 2007; 26(1): 34–93. Baumann LS, Shamban AT, Juvederm 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: S128–354. 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, 20075. Bachmann F, Erdmann R, Hartmann V, Wiest L, Rzany B. The spectrum of adverse reactions after treatment with injectable fillers in the glabellar region: results from the Injectable Filler Safety Study Dermatol Surg 2009; 35 Suppl 2: 1629–346. grunebaum LD, Bogdan Allemann I, Dayan S, Mandy S, Baumann L. The Risk of Alar Necrosis Associated with Dermal Filler Injection. Dermatol Surg 2009; 35 Suppl 2: 1635–407. gladstone HB, Cohen JL. Adverse effects when injecting facial fillers. Semin Cutan Med Surg 2007; 26 (1): 34–98. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol 2013; 6: 295–316

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; 7 (3–4): 171–610. Christensen L, Breiting V, Janssen M, Vuust J, Hogdall E. Adverse reactions to injectable soft tissue permanent fillers. Aesthetic Plast Surg 2005; 29(1): 34–4811. Christensen L. Normal and pathologic tissue reactions to soft tissue gel fillers. Dermatol Surg 2007; 33 Suppl 2: S168–7512. Lowe NJ, Maxwell A, Patnaik R. Adverse Reactions to Dermal Fillers: Review. Dermatologic Surgery 2005; 31(s4):1626–163313. Smith L, Cockerham K Hyaluronic acid dermal fillers: can adjunctive lidocaine improve patient satisfaction without decreasing efficacy or duration? Patient Prefer Adherence 2011; 5: 133–914. glaich AS, Cohen JL, goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32(2): 276–28115. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase. Dermatol Surg 2007; 33(3): 357–36016. Dayan SH, Arkins JP, Mathison CC. Management of impending necrosis associated with soft tissue filler injections. J Drugs Dermatol 2011; 10(9): 1007–1012 17. Beer K, Downie J, Beer J . A treatment protocol for vascular occlusion from particulate soft tissue augmentation. J Clin Aesthet Dermatol 2012; 5(5): 44–7

• Perfect for precise facial markings • Ultraf ine tips ideal for procedures where f ine lines are needed

Oh sooo ne!

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