Management of Impending Necrosis Associated With Soft Tissue Filler Injections

prior to treatment with hyaluronidase as a hypersensitivity reaction can occur.^4,8,15 It has been previously demonstrated that hyaluronidase has edema-reducing benefits and has been efficacious in mediating rejection-induced edema and necrosis associated with myocardial infarction. ^16-18 It is probable that an increased inflammatory response causes an increase in hyaluronan due to proinflammatory cytokines and growth factors, which is then mitigated by the hyaluronidase.^19-23 Its edema-reducing benefits and theoretical reduction in occluding vessel pressure is why we believe it is efficacious in treating impending necrosis secondary to all products, not just hyaluronic acid.

Additionally, 2% nitroglycerin paste (Nitro-BID, E. Fougera & Co., Melville, NY) is applied to the affected area with the amount dependent on size and area of impending necrosis. The volume of distribution of nitroglycerin is about 3 L/kg, with a half-life of about three minutes and maximal achievable duration of anti-anginal effects being about 12 hours.²⁴ The nitroglycerin paste is applied daily to the affected area so long as the capillary refill rate is less than two seconds. The area is massaged and warm compresses are applied to increase vasodilation. Often, an immediate vasodilatory effect with improvement in the skin color is realized. Care is taken to use a small amount of 2% nitroglycerin paste (approximately a half inch), as too much can lead to unwanted systemic effects.

The patient is started on an aspirin regimen of 325 mg daily to prevent further clot formation due to vascular compromise and an antacid to prevent aspirin-associated gastritis. Topical oxygen cosmeceutical therapy (Dermacyte Oxygen Concentrate, Oxygen Biotherapeutics, Inc., Durham, NC) is applied to the affected area twice-daily. Topical oxygen therapies have demonstrated an enhanced rate of epithelialization of excisional wounds and second-degree burns.²⁵ Hyperbaric oxygen has also been recommended as a treatment option for impending necrosis, depending on the severity of the condition^7,9. However, the risks, benefits and inconveniences associated with the treatment may pose significant barriers to some and the procedure is recommended in instances of severe necrosis or delayed presentations in which the tissue is not healing well.⁴

Patients are followed daily for further signs of occlusion or necrosis. If improvement is noted, nitroglycerin paste massages can be stopped. However, they anecdotally seem to accelerate the reticulated vascular congestion resolution. Topical oxygen therapy and aspirin are continued until the wound is satisfactorily healed. If there is no improvement or if progression of necrosis occurs, the regimen should be repeated daily. If edema is slow to resolve, methylprednisolone (Medrol Dosepak, Pfizer, New York, NY) is added. Hyperbaric oxygen should be considered if the above measures are still not adequate.

As the use of fillers becomes increasingly more common and the skill level of those injecting is so varied, adverse events can be expected to increase as well. Avoiding complications is always the best measure, and with appropriate training and injection techniques, many complications can be avoided. However, adverse events can occur in the best of hands, and early detection is imperative. If a consensus can be agreed on how to treat adverse events effectively, then devastating complications can be prevented. It is our belief that the protocol we are using for treating impending necrosis has been successful for managing immediate and delayed presentation of impending necrosis.

We have successfully treated nine post-filler injection adverse events involving impending necrosis or necrosis following both HA and CaHA injections using our protocol. Proper management of complications associated with soft tissue fillers is imperative as both the number of injections and fillers expands.

The authors have no relevant disclosures.