Treatment Protocol for Acute Arterial Occlusion Secondary to Facial Revolumization Procedures

Artificial dermal fillers and autologous fat grafting have become increasingly popular in recent years, primarily because they augment existing soft tissue volumes, thus producing aesthetic improvements at a lower cost than traditional plastic surgery (ie, facelift), and with nearly no recovery time. According to the American Society for Aesthetic Plastic Surgery, more than 2 million hyaluronic acid (HA) dermal filler procedures were performed in 2016, an increase of 3% from 2015.¹ In addition, 80,000 autologous fat grafting procedures were performed in 2016, an increase of 13% from 2015. In total, there were 2.6 million soft tissue filler procedures in 2016, an increase of 2% from 2015.¹

With the increased demand and access to both artificial dermal fillers and autologous fat grafting, there has been a plethora of reported adverse events, ranging from expected erythema to acute blindness and stroke. Emergency physicians should have a thorough understanding of facial vascular anatomy, as well as the effects of available facial volumization products, including potential complications and treatment options. Through our review of two patient cases, we propose a simplified protocol for the treatment of patients with acute arterial occlusion secondary to facial volumization procedures.

Case 1

A 38-year-old white woman presented to the ED for evaluation of transient blurred vision and blanching of the left cheek and upper lip, which began approximately 40 minutes prior to presentation, immediately after her primary care physician (PCP) injected her left nasolabial fold with calcium hydroxyapatite (CaHA). The patient stated that her vision became blurry and her eyes began to tear within 1 minute of receiving the injection. She further noted that these visual changes were painless and lasted for approximately 30 seconds.

The patient’s PCP believed these symptoms were due to pain at the injection site. While the patient was at her PCP’s office, the reception clerk noticed the blanching of the patient’s left cheek and informed the PCP, who referred the patient to our ED for evaluation.

Workup

The patient’s vital signs at presentation were normal. Her medical history was unremarkable and negative for smoking, alcohol, or drug use. She was not taking any medications and had no known drug allergies. The patient’s history was negative for any prior cosmetic procedures, and she confirmed this was the first and only time had a facial revolumization.

Facial examination revealed a Fitzpatrick scale (FS; a numerical scoring system used to assess a patient’s reaction to ultraviolet radiation) score of type 3. She also had left-sided blanching that extended from the midpoint of the nose diagonally to the lateral midbuccal cheek to the level of the oral commissure, including the cutaneous upper lip, alar, and nasal side wall. There was minimal capillary refill with compression at the affected site, and sensation was diminished to fine touch and pinprick. The facial muscles were intact, and, with the exception of puncture marks along both nasolabial folds, the remainder of the facial examination was normal.

The ophthalmic examination revealed a reactive pupil at 2 mm, white sclera, pink conjunctiva, red reflex, and normal fundoscopic vessels. The patient’s bedside Snellen visual acuity and visual field assessments were normal. The neurological examination was likewise normal, and no other physical findings were noted.

Laboratory evaluation included complete blood count (CBC), Chem 7 panel (creatinine, blood urea nitrogen [BUN], carbon dioxide, chloride, glucose, sodium, and potassium), and international normalized ratio (INR), which were all within normal limits.

Diagnosis and Treatment

The patient was diagnosed with acute angular arterial occlusion and transient retinal artery embolism secondary to facial volumization with CaHA. She was treated with oral acetylsalicylic acid aspirin (ASA) 325 mg, prednisone 40 mg, and sildenafil 50 mg; and subcutaneous (SC) enoxaparin 60 mg (1 mg/kg). Topical nitroglycerin paste 2% was applied to the affected area.

Ophthalmology and plastic surgery services were contacted for consultation. Based on no acute findings on examination, the ophthalmologist provided no additional treatment recommendations. The patient was observed in the ED for 4 hours, during which time the facial blanching resolved and her capillary refill time returned to normal at 2 seconds.

After evaluating the patient, the plastic surgeon recommended discharge home with instructions to continue taking the oral ASA and sildenafil, as well as a methylprednisolone dose pack for 6 days. He also recommended the patient begin hyperbaric oxygen (HBO) therapy the day after discharge, since there was no HBO chamber available during her hospital stay.

The patient complied with all discharge instructions, including HBO therapy. At plastic surgery follow-up, the patient had no long-term adverse effects from the CaHA injection.