Description of Event or Problem · 1
ON (B)(6) 2011, A LITERATURE REPORT FROM (B)(4) WAS RETRIEVED DESCRIBING A (B)(6) FEMALE WHO RECEIVED AN INJECTION OF RESTYLANE (CROSS-LINKED HYALURONIC ACID DERMAL FILLER). MEDICAL HISTORY INCLUDED NO PREVIOUS AESTHETIC SURGERY. THE PT'S SKIN TYPE AND CONCOMITANT MEDICATIONS WERE NOT REPORTED. THE PT RECEIVED AN INJECTION OF RESTYLANE (AMOUNT INJECTED NOT REPORTED) ON AN UNK DATE FOR WRINKLE CORRECTION OF THE NASOLABIAL FOLD. PRE-PROCEDURE MEDICATIONS USED AND ADDITIONAL PROCEDURES PERFORMED AT THE TIME OF IMPLANTATION WERE NOT REPORTED. ON AN UNK DATE, IMMEDIATELY AFTER THE INJECTION, THE PT REPORTED A SHARP PAIN ON THE RIGHT SIDE OF HER FACE. A FEW HRS LATER, A REDDISH DISCOLORATION APPEARED ON THE RIGHT SIDE OF THE NOSE AND ALONG THE NASOLABIAL FOLD. FOUR DAYS AFTER THE PROCEDURE, WITH A REFERRAL FROM A LOCAL GENERAL CLINIC, THE PT VISITED THE HOSP. THE PT PRESENTED WITH A GANGRENOUS SKIN NECROSIS MEASURING 1.5 CM X 1.3 CM AND ESCHAR INVOLVING THE RIGHT NASAL ALAR REGION. INTENSE ERYTHEMA WAS SEEN ON THE AREA NOURISHED BY THE LATERAL NASAL BRANCH AND ANGULAR ARTERY OF THE FACIAL ARTERY. INTRAVENOUS ADMINISTRATION OF 5,000 IU OF LOW MOLECULAR-WEIGHT HEPARIN (LMWH) AND ALPROSTADIL (10 MG/ 2ML AMPULES [AMP], 5 NG/KG PER MINUTE) WAS THEN STARTED AND CONTINUED FOR 5 DAYS. A THREE DIMENSIONAL COMPUTED TOMOGRAPHIC (3D-CT) ANGIOGRAPHY WAS PERFORMED 10 DAYS AFTER THE PROCEDURE AND DEMONSTRATED SUSPICIOUS VASCULAR OCCLUSION OF THE TERMINAL-BRANCH ARTERIOLE OF THE ANGULAR ARTERY AND COMPENSATORY DILATION OF COLLATERAL VESSELS. THE WOUND WAS TREATED WITH DILIGENT MOISTURIZED WOUND CARE AND DAILY DRESSINGS FOR 16 DAYS, UNTIL DEMARCATION OF THE WOUND WAS EVIDENT. THE NECROSIS EXTENDED TO THE SURROUNDING SKIN AND SUBCUTANEOUS TISSUE BUT NOT TO THE LOWER LATERAL CARTILAGE AND WAS SURGICALLY REMOVED ON DAY 20. HISTOPATHOLOGICAL EXAMINATION OF THE BIOPSY SPECIMEN, OBTAINED FROM THE RIGHT NASAL ALAR REGION, SHOWED SEVERE EPIDERMAL NECROSIS WITH ACUTE AND CHRONIC NONSPECIFIC INFLAMMATION AND MULTIFOCAL AMORPHOUS MATERIAL DEPOSITION IN THE DERMIS AND VASCULAR LUMEN. A FULL-THICKNESS SKIN GRAFT, HARVESTED FROM THE IPSILATERAL POSTAURICULAR AREA, WAS SUCCESSFULLY PERFORMED. THE PT HAD BEEN FOLLOWED FOR 3 MONTHS AND POSTOPERATIVELY, THE RIGHT NASAL ALAR HAD CONTRACTED SLIGHTLY. THE AUTHORS CONCLUDED THAT THE SKIN OF THE PT'S RIGHT NASAL ALAR SUBUNIT BECAME COMPLETELY NECROTIC, DESPITE THE ABSENCE OF DIRECT FILLER INJECTION INTO THE NASAL ALAR AREA. THE 3D-CT ANGIOGRAPHY, ALTHOUGH NOT DEFINITIVELY SHOWING VASCULAR OCCLUSION, INDICATED COMPENSATORY DILATION OF COLLATERAL VESSELS AND THUS ARTERIAL EMBOLIZATION OF THE ANGULAR BRANCH AND ITS SEVERAL TERMINAL BRANCHES (LATERAL NASAL ARTERY, SUPERIOR AND INFERIOR ALAR BRANCH) OR A PERMANENT MASS EFFECT DUE TO INAPPROPRIATE FILLER MATERIAL. HISTOPATHOLOGIC EXAMINATION OF THE BIOPSY SPECIMEN, OBTAINED FROM THE RIGHT NASAL ALAR REGION, SHOWED THAT THE MARGIN OF THE WOUND WAS CONFINED TO THE NASAL ALAR SUBUNIT BECAUSE THE NASOLABIAL AREA (THE COURSE OF THE ANGULAR BRANCH) WAS INTACT. ACCORDINGLY, ALTHOUGH INTRA-ARTERIAL EMBOLIZATION OF THE ANGULAR BRANCH COULD NOT BE CONFIRMED DIRECTLY, EPIDERMAL NECROSIS AND INTRAVASCULAR AND SUBDERMAL FOREIGN-BODY DEPOSITION COULD BE IDENTIFIED. THE SUBDERMAL DEPOSITIONS OF DERMAL FILLER SUGGESTED LEAKAGE INTO A TERMINAL BRANCH ARTERIOLE. TOGETHER, THESE FINDINGS LED TO THE CONCLUSION THAT THE DEVELOPMENT OF LOCALIZED SKIN NECROSIS OF THE NASAL ALAR REGION WAS DUE TO INTRAVASCULAR EMBOLIZATION OF THE TERMINAL-BRANCH ARTERIOLE AFTER THE ACCIDENTAL INTRA-ARTERIAL INJECTION OF DERMAL FILLER. SHARP PAIN AND THE WHITISH CHANGE IN THE EARLY PHASE AFTER INJECTION SUGGESTED ACUTE EMBOLIZATION OF THE ARTERY OR MASSIVE COMPRESSION OF THE ARTERIAL BRANCH BY FILLER MATERIAL. OVER THE NEXT 2 TO 3 DAYS, THE SKIN APPEARED DUSKY AND THEN BLACK, WITH AN ESCHAR OF NECROTIC SKIN DEVELOPING OVER AN ULCER. A GENERAL PHYSICIAN PERFORMED THE INJECTION PROCEDURE, AND THE PT VISITED THE HOSP 4 DAYS LATER, SO INITIAL MGMT WITH HYALURONIDASE WAS NOT POSSIBLE. AS SOON AS THE PT WAS ADMITTED TO THE HOSP, SHE WAS TREATED WITH INTRAVENOUS LMWH AND ALPROSTADIL TO VASODILATE THE AFFECTED AREA AND TO PREVENT PROGRESSION OF THE NECROSIS. THE SURROUNDING ERYTHEMA DECREASED WITH TIME, AND SPREAD OF THE NECROSIS WAS PREVENTED.