Managing intravascular complications following treatment with calcium hydroxylapatite: An expert consensus

Abstract

Background: Inadvertent intra-arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra-arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence-based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA.

Methods: An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra-arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature.

Results: For prevention of intra-arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow-up treatment. A separate section details the treatment options for open and closed wounds.

Conclusions: All physicians should be prepared for the eventuality of intra-arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up-to-date office-based protocol for the prevention and treatment of complications arising from intra-arterial CaHA injection.

Keywords: calcium hydroxylapatite; dermal filler; intra-arterial injection; safety; vascular compromise; vision loss.

Figure 1

Illustration of the main facial arteries and their anastomoses. (fb), frontal branch; (pb), parietal branch; AA, angular artery; ADTA, anterior deep temporal artery; CA, columellar artery; DNA, dorsal nasal artery; ECA, external carotid artery.; FA, facial artery; ILA, inferior labial artery; IOA, infraorbital artery; LNA, lateral nasal artery; MTA, middle temporal artery; PA, philtral artery; PDTA, posterior deep temporal artery; SLA, superior labial artery; SMA, submental artery; SOA, supraorbital artery; STA, superficial temporal artery; STRA, supratrochlear artery; TFA, transverse facial artery; ZFA, zygomaticofacial artery. Copyright Jani van Loghem, UMA‐Institute.com

Figure 2

Possible pathways of central retinal artery embolization. AA, angular artery; CRA, central retinal artery; DNA, dorsal nasal artery; OS, ophthalmic artery; SOA, supraorbital artery; STA, supratrochlear artery. Red arrows: direction of blood flow; white arrows: direction of filler displacement. Copyright Jani van Loghem, UMA‐Institute.com

Figure 3

Treatment algorithm for peripheral ischemia with impending vascular necrosis and retinal ischemia with impending vision loss

Figure 4

Sequence of events in the development of vascular necrosis (courtesy of David Funt). The patient suffered a facial artery embolization with ischemia of the ala following injection in the nasolabial fold, near the pyriform aperture, with CaHA using a sharp needle. Initially, she was treated with massage, warm compresses, oral sildenafil 50 mg daily for 4 d, nitroglycerin paste for 4 d, oral antibiotics, valaciclovir prophylaxis, and open treatment with aquaphor and twice‐daily showering. This demonstrates that early debridement should be avoided because patients usually heal better than initially anticipated

Figure 5

Case report documenting the development of necrosis following injection of CaHA for nasal bridge contouring and its resolution. Courtesy of Professor Yana Yutskovskaya