This case discusses the use of platelet-rich plasma to reverse skin necrosis caused by facial artery occlusion induced by a dermal filler.
Over the last several years, more reports have been published in the literature of vascular compromise caused by inadvertent injection of dermal fillers.
Some of these adverse events may be caused by simple mechanical compression of a facial vessel; however, the most severe events appear to be a result of actual embolization of filler material into a facial artery resulting in vascular occlusion and subsequent necrosis of tissue supplied by the vessel.
Scant information exists in the medical literature regarding how best to manage these difficult and potentially disfiguring injuries. Initial emergency treatment commonly consists of injection of hyaluronidase, topical application of nitroglycerine ointment, oral or topical antibiotics, oral corticosteroids, and sildenafil. Some physicians also advocate hyperbaric oxygen treatments.
This article discusses a patient who experienced an arterial occlusion following dermal filler injection and her subsequent course of recovery aided by aggressive use of platelet-rich plasma (PRP).
The patient
On January 18, 2016, a small amount of calcium hydroxyapatite was injected into the upper nasolabial folds of a healthy 35-year-old woman. She reported no discomfort during or immediately after the injection.
Within a few hours, she noticed that the upper nasolabial fold area on the right and the corner of her lip on the right had turned a little darker. She also noticed some swelling inside of her mouth.
By the next day (post-injection day 1), she noticed an increase in the dark areas and an increase in the swelling inside her mouth. Also, the area was becoming a little painful.
On post-injection day 2, she consulted with a dermatologist who injected hyaluronidase into the area and digitally massaged it. She also was started on topical nitroglycerine, sildenafil, cephalexin, and prednisone (60 mg/day for 3 days, then 40 mg/day for 2 days, then 20 mg/day for 2 days).
On post-injection day 3, she received a hyperbaric oxygen treatment for 45 to 60 minutes. Figure 1 was a photo the patient took with her cell phone on post-injection day 5.
PRP Treatment
On post-injection day 8, she received a second hyperbaric oxygen treatment. On post-injection day 9, she came to our office and I initiated a PRP treatment program. Figure 2 was taken on post-injection day 9 or treatment day 0 (TD 0)
Minimal improvement in the dark necrotic area above the right naris and below the right commissure and some minimal re-epithelization was noted. There was no necrosis or discoloration inside the mouth but there was still a dark necrotic appearing eschar along the nasolabial fold to the lip. Her first treatment with PRP was initiated on TD 0.
Approximately 10 cc of blood was drawn into an 11-cc PRP tube and spun for 12 minutes to separate the red blood cells from the platelets and plasma. Approximately 7 cc of plasma were obtained. Approximately 3 cc of platelet-poor plasma supernatant was discarded and the platelets in the remaining 4 cc of plasma were re-suspended to produce a super-concentrated PRP suspension. Calcium gluconate 0.6 cc was added to activate the platelets.
Several injection sites were chosen and cleaned with betadine. Approximately 3 cc of the PRP was injected under the affected areas with a 30-guage needle and the remainder was dripped onto the raw skin surface and massaged into the tissue. The patient was advised not wash her face for a few hours to allow the PRP to seep into the raw skin.
Two days later, on TD 2, she returned for follow-up. In the interim, she had received one additional hyperbaric oxygen treatment (Figure 3).
Article continues on page 2
{{pagebreak}}
On TD 2, the epithelial borders were still too fragile for the mechanical trauma of microneedling so the PRP injections and topical application were repeated as before with the intention to eventually progress to microneedling to enhance the absorption of the PRP. The patient returned on TD 6 and in the interim, had received an additional hyperbaric oxygen treatment. The PRP injections and PRP topical application were repeated.
She returned on TD 9 and in the interim, had received yet another hyperbaric oxygen treatment. On TD 9, the epithelial borders seemed to be healthy enough to support microneedling. As done previously, approximately 4 cc of super-concentrated PRP were extracted. A small amount of anesthetic cream was applied to the epithelial edges with a Q-tip. Microneedling was performed at a depth of 1 to 1.25 mm. PRP (3 cc) was dripped directly onto the microneedled areas and gently massaged in. PRP (1 cc) was injected along the epithelial borders superficially.
She returned on TD 14 after having received another hyperbaric oxygen treatment (Figure 4). She had received a total of 5 hyperbaric oxygen treatments and 4 treatments with PRP one of which included microneedling over a 2-week period. The necrosis had nearly completely resolved.
The hyperbaric oxygen treatments were stopped but she continued to receive PRP injections and microneedling treatments at gradually increasing depths on TD 14, 20, and 28. Figure 5 was taken 49 days after the injury and 40 days after PRP treatments were initiated.
Although the necrosis had completely resolved, the patient continued to receive monthly PRP treatments to improve the texture and to soften the edges between the damaged and undamaged areas. Pretreatment with a roller radiofrequency device was added to stimulate additional collagen production before each PRP treatment. The patient felt that the radiofrequency treatments helped accelerate improvement in texture.
Discussion
Inadvertent intra-arterial injection of dermal filler is likely to be significantly more common than reported in the literature. Aspiration prior to injection is recommended by filler manufacturers, however, most of the commercial fillers are not designed to display a flash of blood when the syringe plunger is pulled back. It can be very difficult to determine whether there is intravascular placement of the needle tip prior to injection.
Also, usually these patients do not experience adverse symptoms from intravascular placement of filler until hours later. Phone calls from patients experiencing post-injection symptoms should be taken very seriously.
The use of injected hyaluronidase for emergency treatment of vascular embarrassment from dermal fillers has been recommended by several experts even if the filler causing the vascular compromise is not hyaluronic acid but calcium hydroxyapatite. Injected hyaluronidase may be effective at dissolving hyaluronic acid filler putting direct pressure on a vessel from outside its lumen. Presumably some hyaluronidase may possibly penetrate an occluded vessel to dissolve intravascular hyaluronic acid.
However, it is difficult to understand how hyaluronidase would help relieve pressure or embolization from an injection of calcium hydroxyapatite, a filler which can not be dissolved by hyaluronidase. It is possible that hyaluronidase injected into an area of vascular occlusion or compression as a result of injection of calcium hydroxyapatite may even cause loss of some the patient’s native hyaluronic acid resulting in a volume defect that will require subsequent correction. Additional research would help clarify these points.
Currently, there are no widely accepted treatment protocols to treat the necrotic aftermath of vascular compromise from dermal filler injections. This case demonstrates rapid and dramatic improvement in facial necrosis by the aggressive use of PRP both directly injected and topically applied after microneedling. Physicians with patients who present with this complication might wish to employ aggressive PRP therapy prior to resorting to surgical debridement and repair.
PRP treatments may also be considered in other aspects of wound care. Diabetic ulcers, pressure sores, deep traumatic abrasions, and thermal injuries may benefit from vigorous treatment with PRP.
Dr Toscano is medical director of Red Bamboo Medi Spa in Clearwater, FLDisclosure: The author reports no relevant financial relationships.
This case discusses the use of platelet-rich plasma to reverse skin necrosis caused by facial artery occlusion induced by a dermal filler.
Over the last several years, more reports have been published in the literature of vascular compromise caused by inadvertent injection of dermal fillers.
Some of these adverse events may be caused by simple mechanical compression of a facial vessel; however, the most severe events appear to be a result of actual embolization of filler material into a facial artery resulting in vascular occlusion and subsequent necrosis of tissue supplied by the vessel.
Scant information exists in the medical literature regarding how best to manage these difficult and potentially disfiguring injuries. Initial emergency treatment commonly consists of injection of hyaluronidase, topical application of nitroglycerine ointment, oral or topical antibiotics, oral corticosteroids, and sildenafil. Some physicians also advocate hyperbaric oxygen treatments.
This article discusses a patient who experienced an arterial occlusion following dermal filler injection and her subsequent course of recovery aided by aggressive use of platelet-rich plasma (PRP).
The patient
On January 18, 2016, a small amount of calcium hydroxyapatite was injected into the upper nasolabial folds of a healthy 35-year-old woman. She reported no discomfort during or immediately after the injection.
Within a few hours, she noticed that the upper nasolabial fold area on the right and the corner of her lip on the right had turned a little darker. She also noticed some swelling inside of her mouth.
By the next day (post-injection day 1), she noticed an increase in the dark areas and an increase in the swelling inside her mouth. Also, the area was becoming a little painful.
On post-injection day 2, she consulted with a dermatologist who injected hyaluronidase into the area and digitally massaged it. She also was started on topical nitroglycerine, sildenafil, cephalexin, and prednisone (60 mg/day for 3 days, then 40 mg/day for 2 days, then 20 mg/day for 2 days).
On post-injection day 3, she received a hyperbaric oxygen treatment for 45 to 60 minutes. Figure 1 was a photo the patient took with her cell phone on post-injection day 5.
PRP Treatment
On post-injection day 8, she received a second hyperbaric oxygen treatment. On post-injection day 9, she came to our office and I initiated a PRP treatment program. Figure 2 was taken on post-injection day 9 or treatment day 0 (TD 0)
Minimal improvement in the dark necrotic area above the right naris and below the right commissure and some minimal re-epithelization was noted. There was no necrosis or discoloration inside the mouth but there was still a dark necrotic appearing eschar along the nasolabial fold to the lip. Her first treatment with PRP was initiated on TD 0.
Approximately 10 cc of blood was drawn into an 11-cc PRP tube and spun for 12 minutes to separate the red blood cells from the platelets and plasma. Approximately 7 cc of plasma were obtained. Approximately 3 cc of platelet-poor plasma supernatant was discarded and the platelets in the remaining 4 cc of plasma were re-suspended to produce a super-concentrated PRP suspension. Calcium gluconate 0.6 cc was added to activate the platelets.
Several injection sites were chosen and cleaned with betadine. Approximately 3 cc of the PRP was injected under the affected areas with a 30-guage needle and the remainder was dripped onto the raw skin surface and massaged into the tissue. The patient was advised not wash her face for a few hours to allow the PRP to seep into the raw skin.
Two days later, on TD 2, she returned for follow-up. In the interim, she had received one additional hyperbaric oxygen treatment (Figure 3).
Article continues on page 2
{{pagebreak}}
On TD 2, the epithelial borders were still too fragile for the mechanical trauma of microneedling so the PRP injections and topical application were repeated as before with the intention to eventually progress to microneedling to enhance the absorption of the PRP. The patient returned on TD 6 and in the interim, had received an additional hyperbaric oxygen treatment. The PRP injections and PRP topical application were repeated.
She returned on TD 9 and in the interim, had received yet another hyperbaric oxygen treatment. On TD 9, the epithelial borders seemed to be healthy enough to support microneedling. As done previously, approximately 4 cc of super-concentrated PRP were extracted. A small amount of anesthetic cream was applied to the epithelial edges with a Q-tip. Microneedling was performed at a depth of 1 to 1.25 mm. PRP (3 cc) was dripped directly onto the microneedled areas and gently massaged in. PRP (1 cc) was injected along the epithelial borders superficially.
She returned on TD 14 after having received another hyperbaric oxygen treatment (Figure 4). She had received a total of 5 hyperbaric oxygen treatments and 4 treatments with PRP one of which included microneedling over a 2-week period. The necrosis had nearly completely resolved.
The hyperbaric oxygen treatments were stopped but she continued to receive PRP injections and microneedling treatments at gradually increasing depths on TD 14, 20, and 28. Figure 5 was taken 49 days after the injury and 40 days after PRP treatments were initiated.
Although the necrosis had completely resolved, the patient continued to receive monthly PRP treatments to improve the texture and to soften the edges between the damaged and undamaged areas. Pretreatment with a roller radiofrequency device was added to stimulate additional collagen production before each PRP treatment. The patient felt that the radiofrequency treatments helped accelerate improvement in texture.
Discussion
Inadvertent intra-arterial injection of dermal filler is likely to be significantly more common than reported in the literature. Aspiration prior to injection is recommended by filler manufacturers, however, most of the commercial fillers are not designed to display a flash of blood when the syringe plunger is pulled back. It can be very difficult to determine whether there is intravascular placement of the needle tip prior to injection.
Also, usually these patients do not experience adverse symptoms from intravascular placement of filler until hours later. Phone calls from patients experiencing post-injection symptoms should be taken very seriously.
The use of injected hyaluronidase for emergency treatment of vascular embarrassment from dermal fillers has been recommended by several experts even if the filler causing the vascular compromise is not hyaluronic acid but calcium hydroxyapatite. Injected hyaluronidase may be effective at dissolving hyaluronic acid filler putting direct pressure on a vessel from outside its lumen. Presumably some hyaluronidase may possibly penetrate an occluded vessel to dissolve intravascular hyaluronic acid.
However, it is difficult to understand how hyaluronidase would help relieve pressure or embolization from an injection of calcium hydroxyapatite, a filler which can not be dissolved by hyaluronidase. It is possible that hyaluronidase injected into an area of vascular occlusion or compression as a result of injection of calcium hydroxyapatite may even cause loss of some the patient’s native hyaluronic acid resulting in a volume defect that will require subsequent correction. Additional research would help clarify these points.
Currently, there are no widely accepted treatment protocols to treat the necrotic aftermath of vascular compromise from dermal filler injections. This case demonstrates rapid and dramatic improvement in facial necrosis by the aggressive use of PRP both directly injected and topically applied after microneedling. Physicians with patients who present with this complication might wish to employ aggressive PRP therapy prior to resorting to surgical debridement and repair.
PRP treatments may also be considered in other aspects of wound care. Diabetic ulcers, pressure sores, deep traumatic abrasions, and thermal injuries may benefit from vigorous treatment with PRP.
Dr Toscano is medical director of Red Bamboo Medi Spa in Clearwater, FL
Disclosure: The author reports no relevant financial relationships.
This case discusses the use of platelet-rich plasma to reverse skin necrosis caused by facial artery occlusion induced by a dermal filler.
Over the last several years, more reports have been published in the literature of vascular compromise caused by inadvertent injection of dermal fillers.
Some of these adverse events may be caused by simple mechanical compression of a facial vessel; however, the most severe events appear to be a result of actual embolization of filler material into a facial artery resulting in vascular occlusion and subsequent necrosis of tissue supplied by the vessel.
Scant information exists in the medical literature regarding how best to manage these difficult and potentially disfiguring injuries. Initial emergency treatment commonly consists of injection of hyaluronidase, topical application of nitroglycerine ointment, oral or topical antibiotics, oral corticosteroids, and sildenafil. Some physicians also advocate hyperbaric oxygen treatments.
This article discusses a patient who experienced an arterial occlusion following dermal filler injection and her subsequent course of recovery aided by aggressive use of platelet-rich plasma (PRP).
The patient
On January 18, 2016, a small amount of calcium hydroxyapatite was injected into the upper nasolabial folds of a healthy 35-year-old woman. She reported no discomfort during or immediately after the injection.
Within a few hours, she noticed that the upper nasolabial fold area on the right and the corner of her lip on the right had turned a little darker. She also noticed some swelling inside of her mouth.
By the next day (post-injection day 1), she noticed an increase in the dark areas and an increase in the swelling inside her mouth. Also, the area was becoming a little painful.
On post-injection day 2, she consulted with a dermatologist who injected hyaluronidase into the area and digitally massaged it. She also was started on topical nitroglycerine, sildenafil, cephalexin, and prednisone (60 mg/day for 3 days, then 40 mg/day for 2 days, then 20 mg/day for 2 days).
On post-injection day 3, she received a hyperbaric oxygen treatment for 45 to 60 minutes. Figure 1 was a photo the patient took with her cell phone on post-injection day 5.
PRP Treatment
On post-injection day 8, she received a second hyperbaric oxygen treatment. On post-injection day 9, she came to our office and I initiated a PRP treatment program. Figure 2 was taken on post-injection day 9 or treatment day 0 (TD 0)
Minimal improvement in the dark necrotic area above the right naris and below the right commissure and some minimal re-epithelization was noted. There was no necrosis or discoloration inside the mouth but there was still a dark necrotic appearing eschar along the nasolabial fold to the lip. Her first treatment with PRP was initiated on TD 0.
Approximately 10 cc of blood was drawn into an 11-cc PRP tube and spun for 12 minutes to separate the red blood cells from the platelets and plasma. Approximately 7 cc of plasma were obtained. Approximately 3 cc of platelet-poor plasma supernatant was discarded and the platelets in the remaining 4 cc of plasma were re-suspended to produce a super-concentrated PRP suspension. Calcium gluconate 0.6 cc was added to activate the platelets.
Several injection sites were chosen and cleaned with betadine. Approximately 3 cc of the PRP was injected under the affected areas with a 30-guage needle and the remainder was dripped onto the raw skin surface and massaged into the tissue. The patient was advised not wash her face for a few hours to allow the PRP to seep into the raw skin.
Two days later, on TD 2, she returned for follow-up. In the interim, she had received one additional hyperbaric oxygen treatment (Figure 3).
Article continues on page 2
{{pagebreak}}
On TD 2, the epithelial borders were still too fragile for the mechanical trauma of microneedling so the PRP injections and topical application were repeated as before with the intention to eventually progress to microneedling to enhance the absorption of the PRP. The patient returned on TD 6 and in the interim, had received an additional hyperbaric oxygen treatment. The PRP injections and PRP topical application were repeated.
She returned on TD 9 and in the interim, had received yet another hyperbaric oxygen treatment. On TD 9, the epithelial borders seemed to be healthy enough to support microneedling. As done previously, approximately 4 cc of super-concentrated PRP were extracted. A small amount of anesthetic cream was applied to the epithelial edges with a Q-tip. Microneedling was performed at a depth of 1 to 1.25 mm. PRP (3 cc) was dripped directly onto the microneedled areas and gently massaged in. PRP (1 cc) was injected along the epithelial borders superficially.
She returned on TD 14 after having received another hyperbaric oxygen treatment (Figure 4). She had received a total of 5 hyperbaric oxygen treatments and 4 treatments with PRP one of which included microneedling over a 2-week period. The necrosis had nearly completely resolved.
The hyperbaric oxygen treatments were stopped but she continued to receive PRP injections and microneedling treatments at gradually increasing depths on TD 14, 20, and 28. Figure 5 was taken 49 days after the injury and 40 days after PRP treatments were initiated.
Although the necrosis had completely resolved, the patient continued to receive monthly PRP treatments to improve the texture and to soften the edges between the damaged and undamaged areas. Pretreatment with a roller radiofrequency device was added to stimulate additional collagen production before each PRP treatment. The patient felt that the radiofrequency treatments helped accelerate improvement in texture.
Discussion
Inadvertent intra-arterial injection of dermal filler is likely to be significantly more common than reported in the literature. Aspiration prior to injection is recommended by filler manufacturers, however, most of the commercial fillers are not designed to display a flash of blood when the syringe plunger is pulled back. It can be very difficult to determine whether there is intravascular placement of the needle tip prior to injection.
Also, usually these patients do not experience adverse symptoms from intravascular placement of filler until hours later. Phone calls from patients experiencing post-injection symptoms should be taken very seriously.
The use of injected hyaluronidase for emergency treatment of vascular embarrassment from dermal fillers has been recommended by several experts even if the filler causing the vascular compromise is not hyaluronic acid but calcium hydroxyapatite. Injected hyaluronidase may be effective at dissolving hyaluronic acid filler putting direct pressure on a vessel from outside its lumen. Presumably some hyaluronidase may possibly penetrate an occluded vessel to dissolve intravascular hyaluronic acid.
However, it is difficult to understand how hyaluronidase would help relieve pressure or embolization from an injection of calcium hydroxyapatite, a filler which can not be dissolved by hyaluronidase. It is possible that hyaluronidase injected into an area of vascular occlusion or compression as a result of injection of calcium hydroxyapatite may even cause loss of some the patient’s native hyaluronic acid resulting in a volume defect that will require subsequent correction. Additional research would help clarify these points.
Currently, there are no widely accepted treatment protocols to treat the necrotic aftermath of vascular compromise from dermal filler injections. This case demonstrates rapid and dramatic improvement in facial necrosis by the aggressive use of PRP both directly injected and topically applied after microneedling. Physicians with patients who present with this complication might wish to employ aggressive PRP therapy prior to resorting to surgical debridement and repair.
PRP treatments may also be considered in other aspects of wound care. Diabetic ulcers, pressure sores, deep traumatic abrasions, and thermal injuries may benefit from vigorous treatment with PRP.
Dr Toscano is medical director of Red Bamboo Medi Spa in Clearwater, FL
Disclosure: The author reports no relevant financial relationships.
