CHICAGO – Hyaluronidase can speed the resolution of postoperative periorbital lymphedema in patients undergoing Mohs micrographic surgery and flap repair, a prospective case series suggests.
Lymphedema resolved in all seven cases treated with hyaluronidase (Hyalase) injections in 4-6 weeks, compared with 3 months as would be expected, Dr. Sweta Rai, of St John’s Institute of Dermatology, King’s College London, said at the annual meeting of the American Society for Dermatologic Surgery.
Dr. Sweta Rai
“In the periorbital area where the skin is very thin and therefore even small amounts of lymphovascular fluid is visible, postoperative lymphedema is a cosmetic concern, especially as patients want to resume their daily activities as soon as possible postoperatively,” she said in an interview.
Hyaluronidase is widely used in cosmetic surgery in the breakdown of hyaluronic acid fillers, where the mucolytic enzyme splits and lowers the viscosity of hyaluronic acid in the extracellular matrix.
Dr. Rai and her coauthor Dr. Hooman Khorasani, chief of Mohs, reconstructive, and cosmetic surgery at Mount Sinai School of Medicine in New York, turned to hyaluronidase because it’s well documented that hyaluronic acid is produced by the body as an automatic response to promote wound healing
Patients undergoing Mohs surgery for large eye tumors often require complex flap repairs that cross the lower eyelid and cheek junction, which results in greater lymphedema. Hyaluronic acid produces a scaffolding effect at the wound site that, in combination with periorbital lymphedema when the vascular channels are cut, is thought to lead to fluid stasis. Hyaluronidase breaks down this scaffolding, allowing the lymphovascular fluid to drain into the subcutaneous tissue, Dr. Rai explained.
Courtesy of Dermatologic Surgery Department, King's College Hospital-NHS Foundation Trust
This patient is 1 week postop after an advancement flap.
The investigators use a 1,500-unit vial of generic hyaluronidase diluted with 1.5 mL of normal saline and inject 100-150 units subcutaneously starting 2 weeks postoperatively at the time of suture removal and repeat the injections every 2 weeks until the swelling resolves.
Patients should undergo an intradermal prick test prior to injections to exclude the risk of type I hypersensitivity anaphylaxis previously reported with human hyaluronidase injections, Dr. Rai cautioned.
In all seven patients, aged 42-80 years, periorbital lymphedema resolved with 150-450 units of hyaluronidase. The patients included a women referred for treatment 2 months after Mohs surgery. The index case, involving a man with a periorbital defect and a medially based advancement flap, resolved with only a single 150-unit injection given 2 weeks after surgery, Dr. Rai said.
“Most of my patients are working and lead busy work and social lives, and they’ve all commented on how pleased they are with the results and on how quickly they are able to resume their normal lives,” she said.
The maximum number of injections needed in the cohort was three. No adverse events have been reported.
Courtesy of Dermatologic Surgery Department, King's College Hospital-NHS Foundation Trust
The same patient is 4 weeks postop, after receiving one hyaluronidase injection 2 weeks postop.
Session comoderator Dr. Seemal Desai, a dermatologist in private practice near Dallas, said the technique is very practical, hits an unmet need, and could potentially prevent tropia when used around the eye.
“My only comment is that if you’re using human hyaluronidase, the skin testing to make sure there is no anaphylaxis is important,” he said. “But if you’re using synthetic or recombinant hyaluronidase, which is really what we use here more, I don’t think that would be an issue. I think this was a great idea to do this, especially for advancement flaps.”
Fellow comoderator and Mohs surgeon Dr. Ramona Behshad, in private practice in St. Louis, Mo., said the case series provides a novel and practical use for hyaluronidase, which is “very underused” in dermatology practices and often goes to waste because it expires.
Dr. Rai and her maxillofacial surgery colleagues at King’s College are performing a randomized controlled trial using hyaluronidase on all head and neck postoperative wounds to assess its effect on postoperative lymphedema and recovery times with and without the agent. “Hopefully, this will provide further information on its efficacy including other sites on the head and neck,” she said.