Novel hyaluronidase technique helps manage vascular complications of dermal fillers
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WAILEA, Hawaii — Vascular occlusion is the most ominous complication of hyaluronic acid dermal fillers, according to a speaker here.
Vascular occlusion occurs when the filler is unintentionally injected into a blood vessel, causing embolic phenomena and tissue necrosis.
“You don't see occlusions very often, but when they do happen, they can be devastating to the patient, especially, but also to the practitioner,” Steven G. Yoelin, MD, said at Hawaiian Eye/Retina 2024.
Understanding the underlying anatomy is the first important step in order to avoid injecting the filler into the vasculature. Using small-bore needles, a slow injection technique and smaller boluses and putting less pressure on the plunger can also help prevent this complication. Overall, higher-risk areas such as the glabella, forehead and the nasal bridge are best avoided, Yoelin said.
Blanching is the first sign that occlusion has occurred, followed over time by bruising and discoloration, while pain is not always present.
Hyaluronidase is the best weapon currently available to manage this complication, Yoelin said. The high-dose pulsed hyaluronidase protocol by DeLorenzi entails “flooding” the area with a sufficient quantity of the enzyme to hydrolyze the filler throughout the entire block of tissue and dissolve the occlusion. More recently, ultrasonography-guided hyaluronidase has been introduced. By visualizing the exact location of the filler, a more targeted treatment can be performed. However, ultrasound devices are not available in every esthetic practice and interpreting U.S. images requires a learning curve.
An alternative and more efficacious way to deliver the hyaluronidase directly into the vascular supply is by cannulating the facial artery at the antegonial notch.
Yoelin explained that first, he locates the ipsilateral notch and injects lidocaine. Then he draws up 1 ml hyaluronidase in a 3cc luer lock syringe and mounts on the same syringe a 25-gauge, 1-inch butterfly. After priming the tubing and the needle, with the patient in the sitting position, he moves the needle perpendicular to the skin surface. As soon as the skin is penetrated by the needle, Yoelin asks his assistant to create negative tension on the plunger and just lets it keep advancing.
Blood flow will then deliver the enzyme everywhere along the facial artery, reaching the area of vascular occlusion.
“It works like magic,” Yoelin said. “The hard part here is finding that blood vessel. If you don't find it, you can always go back to the flooding technique. But I urge you to think about this technique.”
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Yoelin SG. Dreaded complications of aesthetic procedures. Presented at: Hawaiian Eye 2024; Jan. 13-19, 2024; Wailea, Hawaii.
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