WASHINGTON — Intra-arterial embolization during filler injection is rare, but it can happen to even the most experienced physician, said Dr. Claudio DeLorenzi.
Intra-arterial embolization occurs when a filler needle enters an artery. During injection, the filler flows retrograde in the vessel. Once the pressure from injection is stopped, the product is carried through the vasculature and the results can be disastrous, Dr. DeLorenzi said at the annual meeting of the American Society for Aesthetic Plastic Surgery.
Photos courtesy Dr. Claudio DeLorenzi
VIDEO - The lesion on the left from filler injection was originally diagnosed as an infection (Click photo to view video on Facebook).
Local and distal necrosis can occur following intra-arterial embolization. Typically the whole angiosome--the vascular territory of skin and underlying muscles, tendons, nerves, and bones--is affected, resulting in full-thickness necrosis.
The first sign of trouble is severe pain, followed typically by a bluish livedo pattern.
This can progress to hemorrhagic blisters, necrotic eschar, and late scarring. "The severity of some of these complications is extreme by any measure," said Dr. DeLorenzi, who is a plastic surgeon in Kitchener, Ont.
"So if you see this reticular bluish pattern, it means that you need to take action," he said. A crash cart for this complication allows for an immediate response. The cart should contain hyaluronidase--which can reverse the effects of hyaluronic acid fillers--aspirin, nitroglycerine paste, and heat compresses.
Two months after hyaluronidase treatment, the patient had mild scarring.
Dr. DeLorenzi recommended having a low threshold for using hyaluronidase. Recommendations in the literature on the amount to use vary from 25 to 150 units.
Hyaluronidase should be injected diffusely in the affected area, which should then be massaged to distribute the filler. "Even if you've selected a non-hyaluronic acid filler, there may be some role for using hyaluronidase. You may get some improvement in circulation," he said.
Increased risk for intra-arterial embolization appears to be associated with large volumes of filler, small sharp needles, high pressure, deeper injections, and compound type.
"Prevention, of course, is best," said Dr. DeLorenzi. To avoid intra-arterial embolization, he recommends using a small bolus (less than 0.1 cc), a blunt cannula, low pressure, slow injection; knowing the relevant anatomy; being prepared; and using epinephrine prior to the filler procedure (this may reduce the vessel size and the risk of hitting a vessel).
Dr. Delorenzi reported that he is a speaker for Allergan Inc.