Introduction

Use of dermal fillers for rhinoplasty has become an integral part of aesthetic practices. There are many options for use with fillers including Calcium hydroxylapatite (CaHA), hyaluronic acid (HA), collagen, poly-L-lactic acid (PLLA) and botulism. Those are popular used in Taiwan but only HA has antidote if an undesirable outcome occurs. The growing complications in filler injection occur ranging from mild bruising, blanching, hyperemia, violaseous to severe injection ischemia and even necrosis1,2. HBOT used as an adjunctive therapy to treat injection ischemia and prevent this complication.

Case Report

Case 1:

43-year-old male healthy patient experienced immediate pain and blanching after HA injection. Left nasolabial fold and gingiva were hyperemic, his nasal tip was violaceous. There was concern for impending necrosis (figure 1a). He was under oral antibiotics, NSAID control. He accepted HBOT at 2-2.5 ATA, 80-120 minutes daily for total 15 sessions (Figure 1b). Non-surgical debridgement is needed and completely recovery.

Case 2:

A healthy 23-year-old female presented to our office four days after having 0.6cc of Calcium hydroxylapatite filler injection by an outside clinic. She previously had filler rhinoplasty a year ago with no complications. She felt intense pain and blanching initially on the right side of her face. Her face including nose, cheek, upper cutaneous lip, and chin was tender and hyperemic. Her nasal tip was violaceous (Figure 2a).She was under oral antibiotic control and has 2 sessions of HBOT at 2.5ATA, 80-90 minutes daily (Figure 2b). Unfortunately her nasal tip developed to full thickness of necrosis and then she was hospitalized for surgical debridgement. (Figure 2c)

Case 3:

42-year-old healthy women referred from outside clinic because of developing hyperemic, reticular pattern and  of her nose after CaHA injection 3 days ago (Figure 3a).She received total 7 sessions of HBOT at 2.5ATA,80-120 minutes and completely recovery without surgical debridgement (Figure 3b,3c).

Case 4:

20-year-old female developed unilateral nasal blanching and intense pain following a HA injection. She was referred at next days because of developing hyperemic lesion. She received oral antibiotics control and 2 sessions of HBOT at 2.5ATA, 80-90 minutes. Complete recovery without scarring. 

Figure 1a

shows hyperemic and violaceous of unilateral nasolabial fold and nasal tip before HBOT

Figure 1b

shows hyperemic and violaceous of unilateral nasolabial fold and nasal tip before HBOT

Figure 1c

Shows recovery after HBOT

Figure 2a

shows Right facial hyperemic and alar violaceous at 3rd day post filler injection

Figure 2b

shows Right alar full thickness of necrosis at 8th day post filler injection

Figure 2c

Shows Right full thickness alar necrosis after 2 sessions of HBOT at 10th day

Figure 2d

shows Right alar wound after surgical debridgement at 11th day

Figure 3a

shows hyperemic of Left nasolabial fold and cheek at 3rd day post filler injection

Figure 3b

Shows improvement after 7 sessions of HBOT

Figure 3c

Shows full recovery at 10th day post last session of HBOT

Discussion

Vascular compromise can occur either by direct injury to the vessel, compression of the vessel from nearby product, or arterial embolization from product injected into a vessel. There are only a few case reports of vascular compromise following fillers injection3,4. Patients with prior surgery or injection to the area may be at increased risk for vascular compromise due to altered blood supply and scarring in the area. More common reactions to injections include redness, swelling, pain, and pruritus, which must be distinguished from true vascular compromise5.Early recognition of vascular compromise and even vascular necrosis with specific protocol for treatment after filler injection improves the outcome of wound healing6.”The Gold Standard of Therapy” for Necrosis has always been a wide surgical debridement and aggressive antibiotic therapy7.When used in conjunction with Hyperbaric Oxygen Therapy, it offers several mechanisms of action to improve ischemia and reduce tissue loss8. 

Hyperbaric Oxygen Therapy increases the oxygenation of tissue, increases angiogensis and also promotes osteoblast and fibroblast function9. Hyperbaric Oxygen Therapy is an important part of a comprehensive treatment program of ischemic injury following vascular occlusion. When a patient is given 100% oxygen under pressure, hemoglobin is saturated, but the blood can be hyper-oxygenated by dissolving oxygen within the plasma (blood)10.

Conclusions

Treatment outcome was satisfactory in three cases. One was failure because of late referral. Report of HBOT in complications of dermal filler has positive effect but there is a lack of high quality, valid research evidence regarding the effects of HBOT on injection necrosis. The times of session were according to the outcome after every session. Those cases highlights the need for immediate recognition and treatment of vascular occlusion should it occur. Early recognition of vascular necrosis with specific protocol for treatment after fillers injection improves the outcome of injection necrosis.

Acknowledgement

I would like to express my gratitude to all those who have supported me during this study. I thank Doctor Te-Chun Hsia, Director of Hyperbaric oxygen center, Chest and Critical medicine who giving me permission to commence this study to do the necessary research work and to use departmental data. He encouraged me to go ahead with this study. 

I thank my colleagues from the Hyperbaric oxygen center, China Medical University Hospital and Department of Emergency Medicine, Chu Shang Show Chwan Hospital supported me in my research work.

I would like to give my special thanks to my wife whose patient love enabled me to complete this study.