Management of Delayed Skin Necrosis Following Hyaluronic Acid Filler Injection Using Pulsed Hyaluronidase

Facial fillers are minimally invasive aesthetic procedures performed for facial rejuvenation and contouring all over the world. Fillers even in the most experienced hands can lead to fatal complications such as vascular complications that need to be managed immediately with the help of hyaluronidase protocols mentioned in literature. In this case report, a patient was asymptomatic with no signs of vascular occlusion such as blanching or poor capillary refill for 48 h. He came after more than 48 h of the filler injection with complaints of pulsating pain in the right infraorbital and nasolabial area. We noticed necrosed microvesicles in the infraorbital artery territory with signs of impending skin necrosis extending from right infraorbital region up to the nasolabial fold (slightly medial to it). He was treated immediately with three pulsed doses of 500 units higher dilation of 10 ml each every hour (reconstitution carried out using 3mL normal saline). The skin color improved with decreased pain, and the next day (after 14 hours) we injected 500 units of hyaluronidase in higher dilution of 10mL as slight redness was still present. Skin redness, swelling, and pain disappeared the following day. Skin was completely healed and by 15 days we noticed slight post-inflammatory hyperpigmentation, which was easily managed with Q-switched laser and creams. We hereby report a case of delayed skin necrosis (>48 h) following filler injections in the cheek area, in the infraorbital artery vascular territory, which was successfully managed with pulsed dose of hyaluronidase.