Arterial Embolization and Skin Necrosis of the Nasal Ala following Injection of Dermal Fillers

Abstract

Sir: The most common adverse effects of injection of biodegradable dermal fillers are bruising and erythema in the acute phase and allergic changes, abscess formation, and granulomatous change in the chronic phase.1–3 The most serious side effect is localized tissue necrosis, which is induced by mechanical interruption of local vascularity, though it occurs very rarely (nine in 10,000 patients who underwent collagen implantation).2 The only reported case of arterial embolization induced by hyaluronic acid injection involved the glabellar region.4 A 50-year-old Japanese woman with no previous history of cosmetic surgery underwent injection of hyaluronic acid gel (Restylane; Q-Med, Uppsala, Sweden) to shape the nasal tip contour and of human tissue–derived, reconstituted collagen matrix (Sheba; Hans Biomed, Daejeon, South Korea) for wrinkle correction of the upper white lip and nasolabial fold and augmentation of the upper vermilion. Immediately after the injection, the patient had a striking pain on the left side of her face. A few hours later she noticed reddish discoloration from the left side of the nose and upper lip to the glabellar region, which corresponded to the area nourished by the angular branch of the facial artery. By the third day of onset, blisters had appeared at the left nasal ala. When the patient consulted our hospital on the sixth day, a gangrenous skin necrosis measuring 1 × 1.5 cm was present on the left nasal ala (Fig. 1). Three-dimensional computed tomographic angiography performed on the ninth day demonstrated local occlusion of the angular branch of the facial artery and compensatory dilation of collateral vessels such as the infraorbital artery and its daughter branches. Intravenous administration of alprostadil (Prostandin; 120 μg/day) was then started, and the surrounding erythema decreased with time. The necrosis extended to the surrounding skin and subcutaneous tissue, and was surgically removed on the twelfth day. A full-thickness skin graft taken from the postauricular area was grafted to the residual skin defect on the day 43 and was successfully accepted.Fig. 1.: View of the patient on her first visit (6 days after injection). Gangrenous skin necrosis is seen on the left nasal ala. Erythema was seen on the whole area nourished by the angular branch of the facial artery (i.e., the glabellar region, the left side of the nose, and the left upper lip).In the present case, the alar skin resulted in massive necrosis, despite the absence of filler injection into the ala. Histopathological examination of the biopsy specimen from the nasal ala indicated intra-arterial and subdermal deposition of foreign bodies (Fig. 2), although we could not identify whether they were Restylane or Sheba. Sharp pain and the erythema in the early phase suggest acute and widespread embolization of the artery. Together with the results of the three-dimensional computed tomographic angiography, we diagnosed the patient as having arterial embolizations of the angular branch and its daughter branches.Fig. 2.: Debridement sample. Photomicrograph of subcutaneous tissue shows intra-arterial foreign bodies (*) and thickening of the intima (hematoxylin and eosin stain; scale bar = 300 μm).Like the glabellar region, the nasal ala may be a particular region in which blood supply depends strongly on a single arterial branch. Otherwise, collateral blood supply was blocked by the concurrent filler injection to the nasal tip, which may have been a critical factor in this case. Although accidental intra-arterial injection of dermal fillers is apparently rare, the potential risk of vascular embolization should be noted, especially when injecting into the subcutis of the glabellar region, the nasal ala, and the nasolabial folds. Keita Inoue, M.D. Katsujiro Sato, M.D. Daisuke Matsumoto, M.D. Koichi Gonda, M.D. Kotaro Yoshimura, M.D. Department of Plastic Surgery University of Tokyo School of Medicine Tokyo, Japan