Should I be concerned with necrosis and/or major facial disfiguration? (photo)

Question

Had Juvederm Voluma w/ little to no bruising previously; this most recent time, however, there were severe complications. My right side either had some sort of reaction, blistering, major swelling, & brusing. I'm being treated by my MD w/ over 20 yrs experience & this has never happened w/ his patients. He's injected the hydrolanaise. I'm taking antibiotics, aspirin, & some 'herpes' meds w/ constant warm rag. He's in touch w/ other docs & Allergen. Was curious of other MD's opinions.

Jason Emer, MD · Answer

I recommend staying with your Doctor's protocols for vascular occlusion. It can sometimes take a series of hyaluronidase treatments to reverse, but it will help resolve this in addition to the other treatments. Hyperbaric oxygen may also give improvement.Its important this is done:1) hyaluronidase daily injections 2) hyperbaric oxygen daily3) oral antibioitics 2x daily4) oral steroids daily5) oral viagra 2x dily6) oral aspirin 2x daily7) topical nitroglycerine paste 2-3 x dailyBest, Dr. Emer.

Kyle Coleman, MD · Answer

This does appear to be a vascular occlusion.  It sounds like you are on the right protocol.  Larger volumes of hyaluronidase  may be necessary.   I would continue to aspirin, warm compresses.  Ask your physician about nitropaste to increase blood flow in the area.  A word on the good side is that this doesn't look to be necrosis as much as occlusion which will likely result in better outcomes.  You may need multiple laser treatments for the color or texture afterward but it does look like you won't need a surgical intervention.  Best of luck.

Nelson Castillo, MD · Answer

Thank you for sharing your experience and I am sorry to hear of your filler related issues.  It appears that the Voluma placement led to inadvertent blockage of an artery in your right cheek causing the skin and tissues supplied by that vessel to be deprived of oxygen and nutrients.  Your physician has done the correct treatment with immediate placement of hyaluronidase (it may take several treatments) as well as placement on antibiotics.  I would keep the area moistened with Aquaphor and allow your body time to heal, while maintaining in close contact with your doctor to report any changes.  Best wishes.

Glenn Messina, MD · Answer

In looking at your photo the areas involve extend beyond the immediate injection site and into areas supplied by the artery in that region. I believe some of the filler either pressed the artery closed or went into the artery clogging it thus reducing blood flow to the tissues and they began to die. The medication used to break down the filler will also break down hyaluronic acid in the skin so you will develop more bruising but its essential to restore the blood flow and that is the treatment of choice. I don't know the timing form injection the reversing the filler hopefully is was in the first 24 hours if not immediately after the skin changes color.

Its important now to promote healing definitely follow up with your doctor as much as needed, keep it clean. The area may deteriorate and begin to breakdown. If there is a hyperbaric chamber in town consider treatments, the chamber will force more oxygen into the tissue and promote healing.  Time will tell but statistically these things as horrible as they look early on heal nicely. Please keep us informed on your progress.

Alex Eshaghian, MD, PhD · Answer

Thank you for
your question lhorner. I am sorry to hear about your situation. Voluma is a
filler used to enhance the appearance of the face. With any filler injection there is the possibility that the product enters a blood vessel and stops the blow from flowing to where it should go. In these cases one may see color changes, swelling, blisters, and skin death (necrosis). Occlusion should be treated immediately and monitored closely. Treatments include hyaluronidase, antibiotics, antivirals, aspirin, topical nitroglycerin, warm compresses, and hyperbaric oxygen. Please consult
with a doctor for specific recommendations.  Good luck!

Keith Denkler, MD · Answer

Hang in there with your doctor. It seems that the Voluma infiltrated and artery.  Currently it needs to be watched and followed to see where it demarcates. It may heal just fine as the face is well vascularized with collateral circulation, but it is too early to tell.

Michele S. Green, MD · Answer

I am so sorry since it sounds like you are having a vascular occlusion from the injection.  Your physician seems to be taking the right steps to help you. I would also look into hyperbaric oxygen and nitropaste as well.  Please keep us posted.  Best, Dr. Green

Sheryl D. Clark, MD, FAAD · Answer

Dear lhorner:   I am so sorry you are going through this.  Most cases such as yours resolve beautifully without scarring.  It is good that you are being treated early with appropriate medications.  The chances are very good that this will not lead to permanent scarring.Voluma requires much more hyaluronidase than other HA fillers, 100s of units rather than 100 or less. Nitropaste can be helpful in dilating the vessels as well. Once the surface is healed, topical retinoids can help to prevent scarring.   All the best to you,   Dr. Clark

Steven F. Weiner, MD · Answer

I do believe this was a vascular occlusion. The key to best outcomes is immediate recognition of this and reversal with hyaluronidase. It requires much more than the usual dosing for correcting a filler lump - hundreds of units versus 100 or less. All the other meds are appropriate at this point. I would consider HBO (hyperbaric oxygen). From what I have seen at meetings, most heal very well without much scarring if treated appropriately. I always use cannulas for this injection because I believe it is safer. It is harder for a cannula to enter a vessel than a needle. Down the road after healing has occurred, laser treatments might be needed to get the optimal outcome. In the meantime, occlusive dressings, ointments, or Biafine would help healing process. Best wishes.

Anthony J. Taglienti, MD · Answer

Thank you for your question. With your last injection, it seems as though you had an arterial occlusion. The skin in the overlying area has been compromised, and it will take time to see exactly what the outcome is (likely weeks to months). Your physician did everything right by dissolving the product, starting you on aspirin and covering you with an antiviral. The only other potential is starting you on a low dose steroid to help with swelling, and even an antibiotic if you begin to have signs of an infection. You should have close follow-up with him, and keep him abreast of changes. After a couple of days, he may start you on an antibiotic cream. The best case scenario is that all of this resolves without any noticeable change to your overlying skin - which very well may happen. The absolute worst case scenario is that the skin sloughs and you may have scarring - which can likely be fixed at a later time. The good news is that the blood supply to the face is relatively robust, and most of the time - especially when quick action is taken, which it seems like it was - you will heal up fine. But, for the time being, it is a waiting game. If you smoke, I suggest you stop immediately. Hang in there and keep your surgeon informed.

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