Introduction
Since vascular occlusion caused by filler injections occurs 6 times more frequently when administered using a needle than when using a blunt-tipped cannula,1 injection of dermal fillers with a cannula is widely considered a safer option. However, vascular occlusion resulting from cannula-administered filler injections persists in 1 in 40,882 cases,1 causing unwanted outcomes including blindness, necrosis, and stroke.2 These localized hypoperfusions often result from injecting filler either directly into or immediately surrounding the vessels of the glabella, nasal dorsum, forehead, nasolabial folds, and periorbital region, forming a filler embolus, or compressing the vessel, respectively.2 Duplex ultrasound devices can visualize these subcutaneous side effects, imaging the impacted direction and continuation of blood flow following cannula-administered filler injections.3
Here, we detail a case of vascular occlusion and skin necrosis following cannula-administered filler into the temple region, highlighting an important variation from the expected pattern of injection-caused vascular occlusion as well as simplifying best practices to counteract an occlusion.
Case report
A 49-year-old woman received 1.0 cc of hyaluronic acid dermal filler (Versa, Revanesse) to her temples at an outside clinic. The injector initially attempted to administer the filler with a needle, but due to bleeding, switched to a 25G blunt-tipped cannula. The filler was injected bilaterally along the sphenoid and temporal aspects of her temple area, totaling approximately 0.5 cc volumetric units per side. At the time of filler placement, she had no complications or complaints; however, 2 days later, she noticed a slight bruise on her left frontal temporal area. The following day, the bruising darkened, covering more of her left temple and forehead, and she experienced headaches and vomiting.
Approximately 4 days after the initial filler injection, she entered our office for assessment and treatment. Examination revealed diffuse ecchymosis in a reticular pattern that covered her left forehead, temple, and upper and lower eyelid, modeling an arterial vascular occlusion (Fig 1, A). There was also an area of scattered skin necrosis and wet sloughing along the hairline in the reticular bruising. We could visualize and feel the filler superficially, and upon palpation, the patient noted severe pain. Thus, due to the location of the bruising, we determined that the occlusion likely occurred at the frontal branch of the superficial temporal artery.
Fig 1.
Vascular occlusion presentation (A) 48 hours after the initial filler injection and the time of presentation to our office, (B) 24 and (C) 48 hours after treatment with hyaluronidase, and (D) 1 month postfiller injection.
A total of 450 units of hyaluronidase (Hylenex, Halozyme) was injected near the original cannula entry point, as a small scab was located near the left lateral brow. During the injection, we thoroughly massaged the area to ensure that the hyaluronidase penetrated well and recommended applying a topical platelet-derived exosome product (Plated Intense, Rion Aesthetics Inc) as often as needed to keep the area moist and promote wound healing.
The next day (5 days after filler injection), the patient returned for a follow-up visit. The bruising had significantly improved (Fig 1, B), and the open areas were crusting over. Pulsed-dye laser was performed to improve the resolution of bruising4 (VBeam Perfecta, Candela Medical) with settings of 6 J/10 ms/10 mm. The patient no longer experienced any pain, headaches, or nausea. She returned the following day for another follow-up and pulsed-dye laser treatment (Fig 1, C). She had slight scabbing, but the rest of her skin was smooth and intact, and the bruising greatly improved.
A follow-up was performed via email at 10 days and 1 month postfiller (Fig 1, D). All sequelae were completely resolved, no hair loss was noted, and the patient was back to baseline.
Discussion
Although vascular occlusion with a blunt-tipped cannula is extremely rare,1 as an occlusion could cause blindness, necrosis, and stroke,2 it is imperative that injectors always have hyaluronidase readily available. Providers should also look for specific signs and symptoms to effectively identify the timing and severity of the occlusion. Immediate signs of an occlusion include proximal and/or distal severe pain from the injection site and a decrease in blood supply to the occluded area, causing sudden pallor of the skin. Delayed signs of an occlusion include blue or gray pigmentation, beginning up to hours following the injection, and skin surface breakdown, as shown in the figures below, in the days following the treatment.
When vascular occlusion is first suspected, we recommend approximately 70 to 100 units per estimated 0.1 cc of hyaluronic acid filler injected into the occluded area. In the case of our patient, we injected 450 units.5 We advise erring on the side of higher hyaluronidase volumes when needed. Some papers suggest injecting 1500 units in the event of an immediately diagnosed occlusion, with pulsed dosing every hour if needed.6 Since our patient did not note symptoms of an occlusion until 48 hours after their filler injection, less hyaluronidase was utilized.
Currently, evidence-based medicine does not support topical nitroglycerin,7 aspirin,8 hyperbaric oxygen,7 or phosphodiesterase inhibitors such as sildenafil.9 Therefore, we recommend taking the simplest approach: hyaluronidase injection, close follow-up, and wound care if needed. Vascular occlusions can occur whether a needle or cannula is used. There are some reports that cannulas may actually have a higher rate of vascular occlusion.10 We recommend that large gauge cannulas be used (eg, 22G or 25G) rather than small gauge cannulas. Aspiration does not seem to prevent vascular occlusion due to filler rheology and variations in finger pressure while utilizing the syringe plunger.
To mitigate the risks of vascular occlusion, avoidance is imperative. Every injector should master a thorough knowledge of facial anatomy before touching a syringe of filler. All areas of the face are at risk for vascular occlusion. Additionally, the injector should be able to recognize the physical signs of impending and delayed vascular occlusion and be knowledgeable of how to manage an occlusion at every stage. By using an ultrasound device, injectors can more effectively visualize how their filler placement can impact perfusion, helping reduce the risk of an occlusion. We also suggest simplifying the approach to vascular occlusion by utilizing hyaluronidase as soon as possible, with frequent follow-up to ensure full resolution.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
Patient consent: The authors obtained written consent from patients for their photographs and medical information to be published in print and online, with the understanding that this information may be publicly available. Patient consent forms were not provided to the journal but are retained by the authors.
IRB approval status: Not applicable.
References
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