Management of Delayed Skin Necrosis Following Hyaluronic Acid Filler Injection Using Pulsed Hyaluronidase.

Chauhan A, Singh S.J Cutan Aesthet Surg. 2019 Jul-Sep;12(3):183-186. doi: 10.4103/JCAS.JCAS_129_18.PMID: 31619891

Abstract: Facial fillers are minimally invasive aesthetic procedures performed for facial rejuvenation and contouring worldwide. Fillers even in the most experienced hands can lead to fatal complications such as vascular complications that must be managed immediately with the help of hyaluronidase protocols mentioned in the literature. In this case report, one patient was asymptomatic with no signs of vascular occlusion such as blanching or poor capillary refill for 48 hours. He came more than 48 hours after the filler injection with complaints of throbbing pain in the right infraorbital and nasolabial area. We observed necrosed microvesicles in the territory of the infraorbital artery with signs of contiguous skin necrosis extending from the right infraorbital region to the nasolabial fold (slightly medial to it). He was immediately treated with three pulse doses of 500 units of the highest expansion of 10 ml each hourly (reconstitution is performed using 3 ml of normal saline). Skin color improved with pain reduction and the next day (after 14 hours) we injected 500 units of hyaluronidase in larger dilution of 10 ml as mild redness was still present. The skin redness, swelling and pain disappeared the next day. The skin healed completely and after 15 days we noticed mild post-inflammatory hyperpigmentation, which was easily managed with lasers and creams. We hereby report a case of delayed skin necrosis (>48 hours) after filler injections in the cheek area, in the vascular territory of the infraorbital artery, which was successfully managed with pulsatile hyaluronidase.