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Correcting Dermal Filler Complications

Published 3rd June 2024
min read

Expert By

Dr Anna Hemming recounts how she handled a rare & particularly challenging complication

At 1.42 pm, on a Thursday lunchtime, the notification of an email arrived on my screen. As I was between I saw the first few words:

I didn’t want to bother you, but I I would check, is this normal?

Normally, I would leave my experienced team to deal with all emails, however, this was a patient I had with the previous day and, the patient, within the email didn’t seem right. Moments later, I was on the phone with her, asking if she was in pain (no), whether there was any blanching (yes), and various other questions. A photo of the kind we have all seen at complications training. This was not normal, and we needed to bring her in. Being 90 away from the clinic, she arrived as soon as she could.

In the meantime, the clinic ran as normal, were seen, and, in the back of my mind, my complications file was being pulled out and the algorithm for vascular occlusion (VO) ran . By the time the patient arrived at the clinic, I had reviewed her notes (after images were normal, no mottling and no altered refill time (CRT), the ACE guidelines for VO, and had all the emergency drugs at hand, just in case.

My is a 42 with asymmetry. I had treated her 12 months with dermal filler with great success. Her 12-month review had recently passed and there was volume loss to the temple, medial and suborbicularis oculi fat (SOOF), as well as the tear trough. Her left side was always more than the right and we had a plan to stabilise the deep fat pads, bringing deep alignment and then review, to the tear trough depressions.

At the review, the tear trough filler was used to lift the under-eye, especially on the left. The immediate results were lovely, there was no pain or after-effects, until seven hours after the filler, when the some numbness (she thought initially it was the local from the treatment).

In the evening, the area was slightly pinker, but it wasn’t until the next day and 24 hours after treatment that she emailed, as the area was still a bit pink.

HOW TO ASSESS POTENTIAL VO

Patients are often in pain, have CRT in the area and surrounding skin, and pallor initially and then .

Immediate action is required if there is any suspicion of VO or spasm of the nerves causing hypoxia to the skin.

Rapid action is necessary to reverse the hypoxia before necrosis establishes, leading to tissue breakdown and wounds.

In this patient, the pallor stage was not visible in clinic, presentation at 24 hours in the livedo reticularis phase.

Phases of a VO

1. Pallor – Occurs with immediate blockage of an as the blood flow is interrupted and blocks tissue perfusion. Lasts seconds – or persists longer.

2. Livedo – A mottled on the skin from the build-up of deoxygenated blood from the venous . Can occur rapidly, lasting hours.

3. Pustules – at 72 hours due to the in pH and sweat, along with metabolic changes due to allowing staph. aureus bacterial overproduction.

4. Coagulation – necrotic change and can occur before formation. Caused by worsening hypoxia, the skin as cell lysis occurs and there is a leaking of blood into the . Skin tissue remains firm due to the coagulative necrotic process.

5. Tissue destruction – Skin breaks down due to a build-up of denatured (collagen, fibrin, elastin) neutrophils, bacteria, and . Devitalised tissue is moist creamy/yellow or green (slough) and then becomes black (dark) and dry. This occurs days after the occlusion.

HOW TO TREAT A VO?

• Stop treatment (if they are with you) and inform them about what is happening

• Check and video CRT on both affected and unaffected skin for comparison

• If CRT is delayed, it indicates vascular compromise

• Massage the area firmly, heat to encourage vasodilation

• Assess

• Get help

• Hyaluronidase (do not skin test, ensure anaphylaxis medications are at hand just in case)

• Disinfect the skin

• Reconstitute 1500 hyaluronidase in 1ml NaCl 0.9% or 1-2% lidocaine

• 1500IU by needle or throughout the affected artery and wider area of . More than one vial may be needed

• Apply heat and massage area vigorously (helps mechanical breakdown of HA)

• Assess CRT and if >3 seconds repeat hyaluronidase hourly

• Review patient daily

• may be over the following days to avoid deterioration

• Make notes and take images and videos

• Advise insurers so they are aware of the .

Medications that may help Aspirin or Clopidogrel 300mg stat and 75mg per day.

The following may also help reverse compromise:

• Nitroglycerin paste

• Hyperbaric oxygen

• Steroids only if indication

• Wound management

• Antivirals if tissue has started to break down

• .

PROGRESS OF THIS PATIENT’S VASCULAR EVENT

On in clinic the day after dermal filler treatment, we talked through the situation openly. She was not in pain; her CRT was sluggish in the area treated and the surrounding vascular . Livedo reticularis was present with and even greying of the tissue in the distal vascular .

My gut feeling was the vessel had a spasm, affecting the distal delivering oxyhaemoglobin to the skin.

With open discussion we her treatment. Immediate aspirin, hyaluronidase and antibiotics were started due to the delayed presentation, to try to formation and necrosis.

Day two

As I was attending a conference 10 minutes away from her the following day, we planned to review at the conference, where I arranged a private room and place where we could treat her again. 1500IU of was administered, exosomes were started and after consulting with a short course of commenced.

Day three

We arranged the following day along with review and a further 1500IU as the area was still firm. Tiny white pustules started to appear in the apical triangle to the side of the nose. The erythema was shrinking and the was .

Day four

The area was injected one last time with 1500IU hyaluronidase and a further hyperbaric . from hyaluronidase can be seen in the filler area.

Day five

A small area in the apical triangle has potential for necrotic .

Day seven

The patient has a further hyperbaric chamber session. The bruising, inflammation and vascular and the apical triangle crusting was mildly better.

Day 10 

Further hyperbaric chamber session

Day 12

Day 16

Day 45

Day 12, 16 and 45 saw huge improvements in the look and feel of skin, with reduced numbness. The patient was left with a small amount of . The apical triangle intact and didn’t breakdown.

IN TOTAL

• 9 appointments

• 4 x 1500 IU hyaluronidase

• Aspirin 300mg stat, 75mg OD

• Flucloxacillin 500mg QDS 7/7

• 40mg OD 5D

• 5 hyperbaric chamber sessions

We have our next review planned and aim to help the in with laser genesis or excel V+ treatment.

The is hugely relieved that we were able to get on top of the vascular event as soon as we were aware of it. She is happy with our treatment.

This article was originally featured in . June 2024.

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