38.1 Patient History Leading to the Specific Filler Problem

38.1.1 Case 1

A 39-year-old man presented for a second opinion following Sculptra injection to the face for HIV lipoatrophy approximately 2 weeks prior. The patient was treated with oral antibiotics, ice, massage, and topical Mederma prior to his presentation. Despite these measures, the patient reported the “blood spot” under his eye was not improving. He had a history of HIV for 10 years with a CD4 count of 220 and viral load of 0. He had no previous injections (Fig. 38-1).

38.1.2 Case 2

A 48-year-old woman presented with redness of her glabella, nasal dorsum, and right nasal sidewall and right nasolabial region after Juvederm injections 2 days previously. She was reported having transgingival block prior to injections and began to notice immediate facial swelling. Juvederm was injected over the area of swelling. She returned to the doctor the following day due to pain and facial swelling and was given hyaluronidase and nitropaste. She was otherwise healthy without history of scarring or previous injections (Fig. 38-2).

38.2 Anatomic Description of the Patient’s Current Status

Both patients presented with one of the most feared complication of injectable fillers: vascular occlusion. Case 1 presented in the late remodeling phase after vascular occlusion affecting the dermis of the left cheek, and case 2 presented 2 days following vascular compromise of the branches of the facial artery and angular artery (i.e., superior labial artery, inferior alar artery, lateral nasal artery, and dorsal nasal artery), involving the right nasolabial region, right superior labial region, right nasal ala, right nasal sidewall and dorsum, and the glabella region. There was a classic dusky, blue-red discoloration with blister formation, hyperemia, and necrosis.

Injectable fillers are increasing in popularity for use in facial volume augmentation and treatment of rhytides. The mechanism of tissue ischemia is likely a result of direct occlusion of small arteries and arterioles with the injectable particle rather than external pressure on the arterial supply. Intravenous injection is unlikely to cause significant side effects. Depending on the particle size of the particular filler, intra-arterial injection may occlude small arteries or arterioles. In cases 1 and 2, arterial occlusion likely occurred at the level of small arteries and arterioles supplied by the facial artery. The particle size of poly-L-lactic acid (PLLA; Sculptra, Valeant Aesthetics, Bridgewater, NJ) Sculptra (PLLA) is 40 to 63 µm. Small superficial arteries of the face may be around 1 mm, while arterioles are 17 to 22 µm.

The quantity and extrusion are more likely to account for vascular occlusion. Injection of 0.1 mL or less to any single area may minimize the risk of vascular occlusion. Dilution or reconstitution of the filler material in saline or lidocaine may help decrease the total filler delivered to any given location.

It is our practice to only inject filler slowly as the needle is being withdrawn to minimize the risk of intra-arterial injection. Additionally, the use of larger gauge needles or cannulas can lessen the risk of cannulating a facial artery during deep injections.

Blindness is also a known risk of intra-arterial filler injection. This is believed to be related to the pressure of the injection causing the injected filler to pass via bridging collateral arteries from the external carotid circulation to the internal carotid circulation (e.g., to the ophthalmic artery) before returning to normal anterograde flow. Therefore, gentle force should always be used when injecting fillers to minimize this risk.