Delayed Management of Hyaluronic Acid Facial Artery Occlusion Using Ultrasound-Guided Intraarterial Hyaluronidase Injection: A Case Report

Goals/Purpose: The occurrence of hyaluronic acid (HA) filler complications has risen with the increasing popularity of nonsurgical facial rejuvenation procedures. The most dreaded complication is arterial occlusion, known for causing irreversible soft tissue necrosis, blindness, and even cerebral embolism. High-dose subcutaneous pulsed hyaluronidase (HYAL) combined with additional symptomatic topical and systemic treatment has given favorable clinical outcomes, especially when HYAL was injected rapidly after the onset of arterial occlusion. Underreported in the literature, irreversible and disfiguring soft injuries are still current and cause important patient psychological burden.

Methods/Technique: In this article, we present a case of percutaneous ultrasound-guided intraarterial HYAL injection for the management of facial artery vascular occlusion of a 36-year-old woman. Sixteen hours post-injection of HA in the nasolabial fold for esthetic purposes, the patient consulted at a private plastic surgery practice. In this case, clinical signs of vascular compromise such as pain, numbness, facial asymmetry, and skin blanching rapidly followed by livedo and a dusky purple discoloration progressed despite 7 hours of combination treatment with high dose subcutaneous pulsed HYAL, warm compresses, skin massaging, topical nitroglycerin 2% paste, oral aspirin regimen, and nerve blocs. Using a team-based approach the patient was referred to the regional hospital where an interventional radiologist proceeded with an ultrasound-guided injection of 750 U of HYAL in the facial artery using a 25G needle under local anesthesia.

Results/Complications: Within 2 hours post intraarterial injection tissue necrosis progression slowed and by day 3, purple skin discoloration and edema were replaced by pustules. On day 20 post intraarterial HYAL injection patient's skin healed completely without any residual scarring or pigmentation.

Conclusion: This case has shown the efficiency of intraarterial HYAL injection as a rescue treatment in the context of delayed presentation and failed response to treatment of facial artery occlusion with high-pulsed subcutaneous HYAL injection.