Abstract
We present an uncommon case of nasal alar and facial necrosis following calcium hydroxylapatite filler injection performed elsewhere without direct physician supervision. The patient developed severe full-thickness necrosis of cheek and nasal alar skin 24 h after injections into the melolabial folds. Management prior to referral included oral antibiotics, prednisone taper, and referral to a dermatologist (day 3) who prescribed valacyclovir for a presumptive herpes zoster reactivation induced by the injection. Referral to our institution was made on day 11, and after herpetic outbreak was ruled out by a negative Tzanck smear, debridement with aggressive local wound care was initiated. After re-epithelialization and the fashioning of a custom intranasal stent to prevent vestibular stenosis, pulsed dye laser therapy was performed for wound modification. The patient healed with an acceptable cosmetic outcome. This report underscores the importance of facial vasculature anatomy, injection techniques, and identification of adverse events when using fillers. A current treatment paradigm for such events is also presented.
Highlights
Injectable fillers are a common, minimally invasive approach in the early treatment of facial aging due to volume depletion
In a recent 5-year review assessing soft tissue fillers, calcium hydroxylapatite (CHA) was associated with the greatest risk of complications (2.6%), which include cellulitis, tissue necrosis, and nodule formation.[1]
Adequate data is not available to quantify the risk of necrosis with CHA fillers, smaller studies estimate this incidence to correlate with the known 0.001% incidence of collagen or hyaluronic acid fillers.4e6 The glabellar region is most notoriously at risk for tissue necrosis following filler injection due to its reliance on the supratrochlear blood supply
Summary
Injectable fillers are a common, minimally invasive approach in the early treatment of facial aging due to volume depletion. In a recent 5-year review assessing soft tissue fillers, CHA was associated with the greatest risk of complications (2.6%), which include cellulitis, tissue necrosis, and nodule formation.[1] More severe, but less common complications include herpes zoster reactivation, arterial embolization leading to infarction, temporary blindness and oculomotor palsy.[2,3] The most feared complication is vascular compromise and tissue necrosis. There have been recently reported cases of nasal alar necrosis following both CHA and hyaluronic acid injection.[7] We present a recent case of soft tissue necrosis of the melolabial and nasal ala region that was not accurately identified, leading to delay in therapeutic intervention and increase in patient morbidity. 24 h following the injection, the patient noted swelling and skin changes to her left alar crease She initially sought treatment at the spa and was treated for presumptive infection with ciprofloxacin and prednisone taper. The patient healed with an acceptable result and declined additional scar revision surgery (Figure 2)
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