Dr Patrick Treacy shares some of his most challenging aesthetic dermatological cases. This month, he talks about the reversal of a dermal filler facial arterial occlusion with hyaluronidase and intravenous steroids

1. 52 Aesthetic Medicine • October 2014
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Dr Patrick Treacy shares some of his most challenging
cases. This month, he talks about the reversal of a dermal
filler compressive alar necrosis due to the use of intravenous
steroids as well as hyaluronidase
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish
Association of Cosmetic
Doctors and Irish regional
representative of the British
College of Aesthetic Medicine
(BCAM). He is European medical
advisor to Network Lipolysis
and Consulting Rooms and
holds higher qualifications in
dermatology, laser technology
and skin resurfacing. In 2012
and 2013 he won awards for
‘Best Innovative Techniques’
for his contributions to
facial aesthetics and hair
transplants. Dr Treacy also
sits on the editorial boards
of three international
journals and features regularly
on international television and
radio programmes. He was a
faculty member at IMCAS
Paris 2013, AMWC Monaco
2013, EAMWC Moscow 2013
and a keynote speaker for
the American Academy of
Anti-Ageing Medicine in
Mexico City this year.
>>
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 shows 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 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 theorised 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,
CASE FILES www.aestheticmed.co.uk
I N J ECTA B L ES

2. 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 a complication occurs, the practitioner should understand how to manage them from observation to surgical intervention7.
The 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 (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 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 1,600 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 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
The patient was a 37-year-old Irish woman who received HA injection to the left nasolabial fold in another clinic. She apparently had an uneventful procedure but reported to the Ailesbury clinic with an erythematous reaction and pain in the nasolabial and malar area the next day. On examination the patient had developed a reticular reaction in the area of her left face in keeping with vascular occlusion and early necrosis . 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 24hrs post procedure she was given 100mgs of cortisone IV and commenced on 4mgs of Dexamethasone PO. It was also considered appropriate to inject 0.2mls of a dilute solution of 50% dexamethasone 40mgs/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 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 O2 via nanosomes. Her symptoms and signs disappeared within a five-day period and two weeks later there was no evidence of any residual vascular deficit. >
53
Aesthetic Medicine • October 2014
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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
CASE FILES
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INJECTABLES

3. 54 Aesthetic Medicine • October 2014
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DISCUSSION
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
satisfaction13. 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. AM
Lignocaine
significantly decreases
pain during injection
and post injection with
corresponding increased
patient satisfaction
REFERENCES
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review. Dermatol Surg 2005;31(11 Pt 2):1616–25. Review.
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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
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