Successful Treatment of Infraorbital Occlusion With the High-Dose Pulsed Hyaluronidase Protocol: A Case Report and Literature Review

March 2021 | Volume 20 | Issue 3 | Case Reports | 338 | Copyright © March 2021

Published online February 11, 2021

Nkemjika Ugonabo MD MPHa Melissa Kanchanapoomi Levin MDa,b

aThe Ronald O. Perelman Department of Dermatology, New York Langone Health, New York, NY
bEntiere Dermatology, New York, NY



Facial fillers are an increasingly popular cosmetic procedure used for facial rejuvenation. Regardless of the experience and skill level of the injector, fillers can inadvertently occlude vessels leading to blockage of cutaneous blood supply, ischemic skin necrosis and rarely cerebrovascular strokes and blindness. Injectors should recognize early signs of occlusion and be prepared with knowledge and tools needed to intervene. There are variable treatment protocols currently for occlusion with few case reports documenting efficacy. We present a case of infraorbital arterial occlusion that was swiftly diagnosed and treated with the new high-dose pulse hyaluronidase (HYAL) protocol leading to complete resolution of the occlusion and review of the literature of high-dose pulse HYAL treatment protocol.


A 29-year-old woman presented to a dermatology clinic for soft tissue augmentation of nasolabial folds, cheeks and tear troughs with a hyaluronic acid (HA) based filler, Restylane-L®. An experienced injector performed an injection in the right tear trough using 1.5-inch 27 G TSK cannula. Aspiration was performed for 5 seconds without any flashback. Transient blanching was noticed in the right infraorbital area by the injector immediately following the injection of 0.2 cc. Capillary refill was tested and noted to be delayed. Shortly after, mottling was noted in the infraorbital region extending to the nasolabial fold. Within 5 minutes, the injector initiated the “high-dosed hyaluronidase protocol” to dissolve the HA filler. Based on the area of involvement, 750 U of HYAL were injected into the involved and adjacent areas. Patient was also given 650 mg of aspirin. Reperfusion was repeatedly assessed via capillary refill test, degree of blanching, and symptomatic feedback from the patient. After 30 minutes, blanching had improved significantly, and patient reported decreased pain. However, residual mottling, though decreased from prior, was still noted to be present. Thus, four additional injections of 250 U of HYAL were made 30 to 60 minutes apart over the next 120 minutes. 60 minutes later, the patient was observed to have continued persistence of good capillary refill (Figure 1). The patient was observed for a total of 4 hours and a total of 1750 U HYAL was given while warm compresses were applied for 10–15 minutes each time. The patient was discharged on 325 mg aspirin daily for 7 days. She was seen daily and was noted to have ecchymosis in the area (Figure 2). This gradually resolved leaving no post-procedure scarring, post-inflammatory hyperpigmentation, or skin changes after 2 weeks (Figure 3).'