Nitrous Oxide Improves Tissue Perfusion in Vascular Occlusion Management

Filler-related vascular occlusion (VO) treatment remains challenging despite established protocols, including high-dose pulsed hyaluronidase injections and ultrasound-guided targeted injections. Managing patients’ pain and anxiety during treatment presents additional difficulties. Nitrous oxide (N(2)O) has been found to be effective for analgesia and anxiolysis in minor procedures, with a 55% reduction in photodynamic therapy pain, and a visual analog scale reduction from 6.6 to 2.9 for aesthetic laser treatment pain. Use of N(2)O for analgesia, anxiolysis, or improvement of perfusion in VO has not been previously reported. We present two cases of filler-related VO management with high-dose hourly hyaluronidase injections and adjunctive use of self-administered 50% N(2)O. Pain and anxiety of the treatment were self-reported by the patients. Capillary refill and livedo reticularis were monitored for establishing VO diagnosis and treatment outcome. In both cases, self-administration of N(2)O led to contemporaneous improvement in skin perfusion. Patients reported decreased anxiety and pain during treatment. Hyaluronidase treatment led to permanent resolution of occlusion symptoms. N(2)O presents a promising adjunctive treatment option for relief of pain and anxiety, and potentially additional perfusion improvement. Further investigation is necessary to better define N(2)O’s role in treating VO.