We report a 52 year-old female who presented to
the dermatology clinic five days post-hospitalization
subsequent to hyaluronic acid (Juvederm
Ultra Plus) filler injection by a mid-level practitioner. One hour
post-injection, the patient reported an intense, diffuse headache
with blurry, double-vision that progressed to severe photophobia.
She immediately went to the emergency room for
evaluation. On examination, no neurologic deficits were identified,
however she experienced difficulty counting fingers.
The patient’s mention of the facial filler as a cause for her visual
symptoms was dismissed by the attending physician. A
CT angiogram was ordered and revealed a 2 mm protrusion at
the level of the anterior communicating artery suspicious for a
tortuous vessel versus saccular aneurysm. A subsequent MRI
confirmed a 2 mm outpouching, but discernment between
aneurysm versus tortuous vessel was not possible with MRI.
She was admitted to the intensive care unit for consultation
The patient’s symptoms slowly improved during a two-day
observation within the ICU. Neurosurgery subsequently recommended
surgical intervention for her suspected aneurysm. The
patient questioned the likelihood of the filler procedure contributing
to her symptoms, but again, the procedure was dismissed
as the etiology. The patient felt uneasy and confused, and left
against medical advice to obtain a second opinion from a different
neurosurgeon. The second neurosurgeon’s opinion did
not substantiate necessity for neurosurgical intervention and interpreted
the findings on the CT angiogram as non-relevant. He
recommended that she see dermatology.
Upon examination in our clinic, the patient had a violaceous, mottled
patch on her left medial cheek. Resolving purpura involved
skin of the inferior orbital rim and the supramalar cheek (Figure 1).
The left eye had red subscleral hemorrhage along the lateral bulb.
The bruise in the midpupillary line was indurated and a healing
puncture wound was identifiable. We injected 75 units of vitrase
mixed with 1 mL saline into the left medial cheek and alar area.
Topical nitroglycerin was prescribed to apply three times daily.
Warm compresses were advised to be used periodically. She
was followed via phone calls daily until follow-up. The mottling
resolved within 24 hours, and no bruising was noted at five days.
The diagnosis was intravascular injection with retrograde cerebral
Hyaluronic acids are very safe in the hands of experienced
dermatologic surgeons. Local serious side effects may still occur,
and are well-reported including ischemia, necrosis, and
infection.1 Prior reports of headaches, blindness, and even
stroke have resulted from arterial embolization in the alar and
glabellar areas from autologous fat.2 Neurologic side effects
from HAs have only been reported in four cases.3-6 Park et al
reported twelve patients with ophthalmic and retinal artery
occlusions, with only four of these being from hyaluronic acids
(others were autologous fat).2
Within the midcheek lies the infraorbital artery as it traverses
medially from the zygoma as a continuation of the transverse
facial artery. This may be inadvertently injected by smallerbore
needles, which was likely the case with our patient.
Although we can’t prove the location of the HA’s travel, it’s
likely that an extremely small amount of HA flowed retrograde
into branches of the ophthalmic artery creating blurriness
and photophobia. The potential for arterial injection is always