Reversal of Skin Necrosis

This case discusses the use of platelet-rich plasma to reverse skin necrosis caused by facial artery occlusion induced by a dermal filler. 

Over the last several years, more reports have been published in the literature of vascular compromise caused by inadvertent injection of dermal fillers. 

Some of these adverse events may be caused by simple mechanical compression of a facial vessel; however, the most severe events appear to be a result of actual embolization of filler material into a facial artery resulting in vascular occlusion and subsequent necrosis of tissue supplied by the vessel. 

Scant information exists in the medical literature regarding how best to manage these difficult and potentially disfiguring injuries. Initial emergency treatment commonly consists of injection of hyaluronidase, topical application of nitroglycerine ointment, oral or topical antibiotics, oral corticosteroids, and sildenafil. Some physicians also advocate hyperbaric oxygen treatments.

This article discusses a patient who experienced an arterial occlusion following dermal filler injection and her subsequent course of recovery aided by aggressive use of platelet-rich plasma (PRP).

The patient

On January 18, 2016, a small amount of calcium hydroxyapatite was injected into the upper nasolabial folds of a healthy 35-year-old woman. She reported no discomfort during or immediately after the injection. 

Within a few hours, she noticed that the upper nasolabial fold area on the right and the corner of her lip on the right had turned a little darker. She also noticed some swelling inside of her mouth.

By the next day (post-injection day 1), she noticed an increase in the dark areas and an increase in the swelling inside her mouth. Also, the area was becoming a little painful. 

On post-injection day 2, she consulted with a dermatologist who injected hyaluronidase into the area and digitally massaged it. She also was started on topical nitroglycerine, sildenafil, cephalexin, and prednisone (60 mg/day for 3 days, then 40 mg/day for 2 days, then 20 mg/day for 2 days). 

On post-injection day 3, she received a hyperbaric oxygen treatment for 45 to 60 minutes. Figure 1 was a photo the patient took with her cell phone on post-injection day 5.

figured 1-5

PRP Treatment

On post-injection day 8, she received a second hyperbaric oxygen treatment. On post-injection day 9, she came to our office and I initiated a PRP treatment program. Figure 2 was taken on post-injection day 9 or treatment day 0 (TD 0)

Minimal improvement in the dark necrotic area above the right naris and below the right commissure and some minimal re-epithelization was noted. There was no necrosis or discoloration inside the mouth but there was still a dark necrotic appearing eschar along the nasolabial fold to the lip. Her first treatment with PRP was initiated on TD 0.

Approximately 10 cc of blood was drawn into an 11-cc PRP tube and spun for 12 minutes to separate the red blood cells from the platelets and plasma. Approximately 7 cc of plasma were obtained. Approximately 3 cc of platelet-poor plasma supernatant was discarded and the platelets in the remaining 4 cc of plasma were re-suspended to produce a super-concentrated PRP suspension. Calcium gluconate 0.6 cc was added to activate the platelets. 

Several injection sites were chosen and cleaned with betadine. Approximately 3 cc of the PRP was injected under the affected areas with a 30-guage needle and the remainder was dripped onto the raw skin surface and massaged into the tissue. The patient was advised not wash her face for a few hours to allow the PRP to seep into the raw skin.

Two days later, on TD 2, she returned for follow-up. In the interim, she had received one additional hyperbaric oxygen treatment (Figure 3).

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