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Correcting Dermal Filler Complications

Published 3rd June 2024
min read

Expert Reviewed 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 innocently arrived on my screen. As I was patients 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 treated with the previous day and, the patient, something within the email didn’t seem right. later, I was on the phone with her, asking if she was in pain (no), there was any (yes), and various other . A photo immediately arrived of the kind we have all seen at training. This was not normal, and we needed to bring her in. Being 90 away from the clinic, she arrived as soon as she possibly could.

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

My patient is a 42-year-old with . I had treated her 12 months previously with dermal filler with great success. Her 12-month review had recently passed and there was volume loss to the temple, medial and lateral 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, deep alignment and then review, to address the tear trough .

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 unusual after-effects, until seven hours after the filler, when the noticed some numbness (she thought initially it was the local anesthetic 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

are often in pain, have reduced CRT in the area and surrounding skin, and display pallor and then .

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

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

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

Phases of a VO

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

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

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

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

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

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, applying heat to vasodilation

• Assess

• Get help

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

• Disinfect the skin

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

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

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

• Assess CRT and if >3 seconds repeat hourly

• Review daily

• Clinical may be over the following days to avoid deterioration

• Make notes and take images and videos

• Advise insurers so they are aware of the .

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

The following may also help reverse compromise:

• Nitroglycerin paste

• oxygen

• only if clinical indication

• Wound management

• Antivirals if tissue has started to break down

• Antibiotics.

PROGRESS OF THIS PATIENT’S VASCULAR EVENT

On arrival 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 pathway. Livedo reticularis was present with non-blanching erythema and even greying of the tissue in the distal vascular .

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

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

Day two

As I was 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 hyaluronidase was administered, exosomes were started topically and after consulting with a short course of prednisolone .

Day three

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

Day four

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

Day five

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

Day seven

The has a further chamber session. The bruising, and vascular compromise and the apical triangle was mildly better.

Day 10 

Further chamber session

Day 12

Day 16

Day 45

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

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 resolve the in with laser or excel V+ .

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

This was in . June 2024.

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