Treatment Protocol for Acute Arterial Occlusion Secondary to Facial Revolumization Procedures

Case 2

A 54-year-old Asian woman presented to the ED for evaluation of a 24-hour history of progressive and persistent pain, swelling, and discoloration of the nasolabial and upper lip region. She stated her symptoms began within 1 hour of receiving a fat graft injection into the affected area by her cosmetic surgeon. After examining the patient, the cosmetic surgeon referred her to the ED for further evaluation. The patient stated that she had undergone six prior facial revolumization procedures, but noted the recent procedure was her first autologous fat graft.

Workup

The patient’s medical history was unremarkable. Her social history was positive for one glass of wine per day and negative for smoking. The patient was not taking any medications and had no known drug allergies.

The patient’s vital signs at presentation were normal. She was evaluated approximately 30 hours after the fat graft procedure. Facial examination revealed an FS of type 4 with right-sided ischemia along the cutaneous upper lip, alar, and cheek (Figure 1).

Capillary refill time with compression was 0 in the affected area. Sensation to fine touch and pinprick was 0. 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 neurological examination was likewise normal, and no other physical findings were noted. Laboratory evaluation included CBC, Chem 7 panel, and INR, which were all within normal limits.

Diagnosis and Treatment

The patient was diagnosed with acute angular arterial occlusion with soft tissue ischemia secondary to facial revolumization with autologous fat grafting. She was given oral acyclovir 800 mg, ASA 325 mg, cephalexin 500 mg, prednisone 40 mg, and sildenafil 50 mg; and SC enoxaparin 60 mg (1 mg/kg). Topical nitroglycerin paste 2% was applied to the affected area.

Plastic surgery services were contacted for consultation. After evaluating the patient, the plastic surgeon recommended discharge home with instructions to continue taking the oral acyclovir, ASA, cephalexin, prednisone, and sildenafil for 6 days. He also recommended the patient start HBO therapy the day after discharge home.

The patient refused HBO therapy, but did visit a plastic surgeon for a follow-up examination 3 days after discharge from the ED. A photograph of the patient’s nasolabial and upper lip region taken during this visit is presented in Figure 2.

Five days after discharge from the ED, the patient presented to a plastic surgery clinic for evaluation; a photograph was also obtained at this visit (Figure 3). The plastic surgeon at this clinic referred the patient to a tertiary center for a second opinion regarding the need for HBO therapy. The plastic surgeon at the tertiary center affirmed the initial plastic surgeon’s diagnosis and recommendation for HBO therapy. Although the patient did not return for further evaluation, she underwent 10 HBO treatments at the tertiary center with an acceptable aesthetic result.

Noninvasive Injectable Cosmetic Facial Augmentation

Facial augmentation procedures include the use of autologous adipose bovine collagen, HA gels, CaHA, and plastic compounds to fill wrinkles, folds, or soft tissue defects due to normal aging or trauma. Plastic surgeons traditionally use adipose and manufactured products for scar revision, midfacial restoration of volume loss from aging or trauma, cheek and chin augmentation, tear-trough correction (the diagonal crease running from the inner eye canthus to the maxilla resulting in a groove that creates a tired appearance), nose reshaping, lip enhancement, and correction of facial asymmetry.

Today the use of manufactured soft tissue revolumization products (ie, fillers) is no longer solely in the purview of plastic surgeons, but rather has become ubiquitous with nonsurgeons and allied health care professionals. As the overall number of revolumization procedures increases, so too does the risk for local and distant vascular complications.

Dermal Fillers

Dermal fillers vary widely in their respective properties, solubility, injection-technique flow requirements, and inherent complication risks. Regardless of type, all dermal fillers have the potential to cause serious complications. Most adverse events are related to substance type, volume, and injection technique. Bruising and trauma-related edema following dermal filler procedures are considered normal.

Though complications from dermal filler injections are rarely lethal, serious adverse events can result in permanent functional and aesthetic deficits. With proper physician training, planning, and injection technique, most adverse events can be avoided.

Hyaluronic Acid. Hyaluronic acid (HA)-containing injectable gel fillers (eg, Belotero, Juvederm, Perlane, and Restylane) are one of the most commonly used volumization products—especially by nonplastic surgeons. These gel fillers, which vary in viscosity and elasticity, may be injected from the superficial dermis to the periosteum. Dilution, dispersion, and degradation may be achieved in vivo either by high arterial flow or hyaluronidase.

Calcium Hydroxylapatite. Calcium hydroxylapatite (Radiesse) microsphere fillers consist of a very viscous paste that is mixed with lidocaine prior to injection to increase its flowability. The CaHA solution is injected at the deep dermis to periosteum level. Since CaHA is not easily diluted, dispersed, or degraded by high arterial flow, it tends to retain its consistency. When this procedure is performed by a novice, it can result in complete occlusion at the injection site or through embolization via antegrade or retrograde flow.

Poly-L-lactic Acid. Poly-L-lactic acid (PLLA; Sculptra) is a low-viscosity fluid comprised of synthetic polymer beads. The PLLA microparticles are not dissolvable or degradable by high arterial flow, and are designed to induce an inflammatory response with neocollagenesis.

Polymethyl Methacrylate. Polymethyl methacrylate (PMMA; Bellafil) consists of a combination of microscopic synthetic polymer beads suspended in a variety of substances. For facial enhancement, PMMA is usually suspended in HA or bovine collagen. Off-label use of silicon oils and gels such as PMMA are gaining in popularity—often with disastrous consequences such as acute arterial occlusion, bone erosion, and skin ulcerations.^2,3

Autologous Adipose Tissue. Plastic surgeons primarily use autologous adipose tissue to volumize the face, breasts, buttocks, and scars. Autologous fat grafts are typically placed in fat, superficial and deep muscles, and deep fat pads through a 2- to 2.5-mm facial fat grafting cannula using a multichannel technique that leaves minute amounts of fat in each channel. Fat embolization may occur when a nonfacial fat graft cannula or needle used to transplant the fat graft enters an artery either through direct sharp puncture or traumatic tear cannulation.^4-9