correcting-dermal-filler-complications
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작성자 Vanessa 작성일26-06-25 18:41 조회9회 댓글0건관련링크
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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 on my screen. As I was between patients I saw the first few words:
I didn’t want to bother you, but I thought I would check, is this normal?
Normally, I would leave my experienced team to deal with all patient emails, however, this was a I had treated 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), there was any (yes), and various other questions. A photo immediately arrived 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 as soon as she could.
In the meantime, the clinic ran as normal, were seen, and, in the back of my mind, my file was being pulled out and the algorithm for vascular (VO) ran through. By the time the at the clinic, I had her notes (after images were normal, no and no altered capillary refill time (CRT), reviewed the ACE for VO, and had all the drugs at hand, just in case.
My patient is a 42-year-old with asymmetry. I had treated her 12 months previously with dermal filler with great success. Her 12-month review had recently passed and there was distinct volume loss to the temple, medial and lateral suborbicularis oculi fat (SOOF), as well as the tear trough. Her left side was always more depleted than the right and we had a plan to stabilise the deep fat pads, deep alignment and then review, to address 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 noticed some (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
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 hypoxia to the skin.
Rapid action is necessary to the before necrosis establishes, leading to tissue breakdown and wounds.
In this patient, the pallor stage was not visible in clinic, occurred at 24 hours in the livedo reticularis phase.
Phases of a VO
1. Pallor – Occurs with immediate of an arteriole as the blood flow is and blocks tissue . Lasts seconds – or persists longer.
2. Livedo – A mottled pattern appears on the skin from the of blood from the venous network. Can occur rapidly, lasting hours.
3. Pustules – Typically at 72 hours due to the in pH and sweat, along with metabolic changes due to allowing staph. aureus bacterial .
4. Coagulation – change and can occur before formation. Caused by hypoxia, the skin darkens as cell lysis occurs and there is a leaking of blood into the . Skin tissue remains firm due to the necrotic process.
5. Tissue destruction – Skin breaks down due to a of denatured structural proteins (collagen, fibrin, elastin) neutrophils, bacteria, and haemoglobin. 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 (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
• the area firmly, applying heat to encourage vasodilation
• Assess
• Get help
• Hyaluronidase (do not skin test, ensure anaphylaxis are at hand just in case)
• 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 ischemia. More than one vial may be needed
• Apply heat and area vigorously (helps mechanical breakdown of HA)
• Assess CRT and if >3 seconds repeat hyaluronidase hourly
• Review patient daily
• Clinical resolution may be required over the following days to avoid deterioration
• Make detailed notes and take images and videos
• Advise so they are aware of the situation.
Medications that may help Aspirin or 300mg stat and 75mg per day.
The following may also help reverse compromise:
• Nitroglycerin paste
• oxygen
• only if indication
• Wound management
• Antivirals if tissue has started to break down
• .
PROGRESS OF THIS PATIENT’S VASCULAR EVENT
On arrival in clinic the day after dermal filler treatment, we talked through the openly. She was not in pain; her CRT was sluggish in the area treated and the surrounding vascular . Livedo was present with non-blanching erythema and even greying of the tissue in the distal vascular .
My gut feeling was the vessel had experienced a spasm, affecting the distal branches delivering to the skin.
With open discussion we planned her treatment. Immediate aspirin, hyaluronidase and were started due to the delayed presentation, to try to decrease and .
Day two
As I was attending a 10 minutes away from her the following day, we to review at the conference, where I arranged a private room and place where we could treat her again. 1500IU of was administered, were started and after consulting with colleagues a short course of prednisolone commenced.
Day three
We arranged chamber starting the following day along with review and a further 1500IU as the area was still firm. Tiny white started to appear in the apical to the side of the nose. The erythema was and the was improving.
Day four
The area was one last time with 1500IU and a further session attended. Bruising from flooding can be seen in the filler treatment area.
Day five
A small area in the apical triangle has for necrotic .
Day seven
The patient has a further hyperbaric . The bruising, inflammation and and the apical crusting was mildly better.
Day 10
Further hyperbaric 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 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 erythema in completion with laser or excel V+ .
The patient is hugely 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 featured in . June 2024.
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