Vascular Compromise and Alopecia After Hyaluronic Acid Filler Injection in Temple Region

Abstract

Hyaluronic acid filler injection is widely applied in facial shaping and facial filling. Although hyaluronic acid injection is thought to be relatively safe and effective, there are still incidents being reported occasionally. The authors report here a case of alopecia at vascular compromise area after receiving hyaluronic acid filler injection in the left temple region, skin necrosis, and alopecia were well recovered with the treatment of hyaluronidase and external application of minoxidil.

Hyaluronic acid injections are popular nonsurgical cosmetic procedure. Although the safety profile is favorable, adverse reactions can occur.1,2

The common complications of hyaluronic acid filler injection include vascular infarction and compromise; inflammatory reactions; nodules, granulomas.3

Alopecia is an extremely rare adverse reaction, and hereby we describe a case of alopecia at vascular compromise area after receiving hyaluronic acid filler injection in the left temple region.

CASE PRESENTATION

A 50-year-old woman presented with rash and pain after injection of hyaluronic acid on the left side of the temple.The patient underwent Hyaluronic Acid (HA) filler injection at a plastic surgery clinic for bilateral temple augmentation. However, the brand name of hyaluronic acid filler and injection dose is unknown. The patient stated that no significant pain or other immediate discomfort after injection. Ice compress was applied to the bruise area immediately after injection for 10 minutes. No other special treatments were given. However, several hours after the injection, mild swelling and red bruise appeared on her left forehead, temple region and periocular area, accompanied by painful and numb feeling. Afterwards, aggravated rash and pain, with the development of large area of map-like red and purple bruise and excessive swelling, occurred on the same area of her face in left forehead, temple region, and periocular area. The bruise failed to fade by pressing and caused severe pain. In such a situation, the patient visited our hospital on the third day after injection. On examination there is swelling, map-like red and purple bruise, and tenderness in left forehead, temple region, and periocular area (Fig. 1A). Physical examination did not reveal other abnormalities.

When considered the possible consequence of vascular embolization at the injection site, we injected hyaluronidase into her embolism area immediately, gave oral antibiotics, and applied Qingpeng ointment to the rash area. In addition, we required the patient to use hot compress on the affected area and kept a regular follow-up.

The pain was relieved after the treatment, and rash stopped evolving and gradually darkened, ruptured and crusted. One week after the treatment, the patient stated that pain was basically disappeared. Large areas of dark fuchsia stain and crust formation could be observed at her left forehead, temple region, and periocular area. Two weeks after treatment, scattered crust, and erythema after crust sheded were observed at her left forehead and temple region. Rash at periocular area were basically subsided. However, alopecia occurred along the path of embolism in upper forehead area where the crust shed. Hair follicle was observed in alopecic area. There existed large area of hair loss occurred in hair growth area where rash occurred (Fig. 1B). After 2 months of external application of minoxidil to alopecic area, the rash subsided and new hair grow (Fig. 1C).

DISCUSSION

The patient’s embolism area distributed along superficial temporal artery. Alopecia occurred after ischemic skin injury, possibly due to local compression, tissue hypoxia, and hair follicle dystrophy. The patient received active treatment after complications and recovered well.

Superficial temporal artery ascends in anterior-superior region of auriculotemporal nerve, and mostly divides into the frontal and parietal branches from 4 cm above the zygomatic arch. The frontal branch of superficial temporal artery passes through superficial temporal fascia, reaches the forehead through temple region. There it extends down to posterior orbital branch and finally converges to supratrochlear artery. Besides, the frontal branch in subcutaneous tissue converges to supraorbital artery at frontalis muscle.4

Temporal fossa depression not only affects the beauty of upper facial profile, but also some people in China thought it related to “physiognomy.” Therefore, people with love for beauty preferred to choose injection to fill temporal fossa. Considering relatively high density of blood vessels in the temporal fossa region, injection staff should be familiar with anatomical structure, bypass import blood vessels, operate normatively, and be suggested to inject horizontally into periosteum.

Though unavoidably filler injection may induce complications, the most severe complications related to vascular injuries and embolization in general. Prognosis of embolism is highly related to location of embolism, the exent of vascular injury, filler material and whether timely and effective treatment is applied. Hyaluronidase can be used to reverse hyaluronic acid fillers. Even though the probability is relatively low that location of hyaluronidase injection is identical to that of vascular obstruction, hyaluronidase injected in the ischemic area still yields certain curative effect.5 Early-stage and middle-stage embolism may be mostly well recovered with timely and proper treatment.3

Alopecia occurred after receiving hyaluronic acid filler injection may be well recovered with timely and proper treatment. After recognition of vascular complications we suggest immediate injection of hyaluronidase, and regular follow-up is required. In addition to improving techniques to maximize safety during filler injections, the ability to deal with complications should be more valued.