I would be much grateful to get opinion of other experienced physicians on the following case:

At our clinic a doctor performed botox on the frown area followed by dermal filler with restylane at the same time. the patient flew long distance the next day. A few days later the skin became inflamed and a discharge was produced from the superior end of the frown lines. She went to a local dermatologist where she was visiting who prescribed a topical antibiotic - by the time she came back to see us a week later the skin was inflamed, there seemed like an abrasive ulcer..very superficial like a abrasion rather than the skin split (maybe due to the patient applying gauze and squeezing the discharge..or due to the infection?? but there was no discharge. the skin continued to heal but until a flare up of the infection occurred and she reported some discharge - once again the patient was abroad (work related travels) - by the time she came back the discharge was gone but the skin mildly inflamed. a doctor in our clinic prescribed flucloxacin - not - but this was four weeks ago.....a few days ago she had another flare up.
My quesiton is would injectiong Hyaluronidase when it is not inflamed be a good idea to get rid of the foreign body ...filler material on top of antibiotics (thinking of augmentin this time)?? - i would suspect this infection would keep flaring up as long as the filler was there.
Thank you.

Also guys . what Hyaluronidase..type..dose.. would you use if 0.2ml of hyularonic acid was injection..

drpaul

What happened to your patient is not a rare incident and I don't think it was an infection. From what you described, it sounds like a typical skin erosion on the gabella area. although the Restylane people claimed that you will have a 3% chance of skin erosion by injecting restylane or any other type of HA to the gabella region. But if you inject enough of HA in the area, skin erosion is very likely to occur. 0.2 ml is way too much. This similar unwanted "side effect" happened to my patients 3 times during the past few years. The "infection" as you think it is primarily is not an infection, it most likely comes from too much of HA with a result of pressure occluding the veins nearby. The typical time frame is the patient would feel uncomfortable with some erythema during the 1st 24 hours, then the skin involved becomes purplish with milia formation which you think it is pustules and discharges. The pustules can be easily wiped off but the erythema and purple colour would continue and in the gabella region erosion will occur on the 2nd to 3rd day. The patient will attribute this to her wiping of the area with a guaze but in fact it is due to lack of circulation.

My treatment at this time would be systemic antibiotic, topical is NOT enough. My choice is Zinnat, together with papase or something similar and add something to improve blood circulation. I would also like to inject dexamethasone and gentamycin as soon as possible to decrease the inflammation as well as the 2nd infection. And also a oral decreasing dose of prednisolone for about 5 days from 20 mg downwards. Also best is not to give topical antibiotic especially if it is an ointment. Most cases will completely resolved in 3- 4 weeks.

Of course the best thing to do is to prevent something like this from happening. I now these days seldom seldom inject HA in the gabella region or any area above the eyebrow, dangerous areas. I also had mishap in the forehead. I would only advice my patient to try botox first, if it is not enough and if you must challange yourself to inject HA into the frown line, inject very superficial, into the epidermal dermal junction with no chance of a vein occlusion.

Also I will never inject a patient with HA, restylane Juverderm whatever if the patient is taking a trip the next day. I will always warn them the possibility of a mishap and call my clinic immediately the next day if they feel something is not right.The sooner you can give them a proper treatment the better.

Lastly, Hyaluronidase will be too late if skin erosion occurs, If you have it, by all means give it to the patient but it is not as important as systemic antibiotic and steroid. Luckily most of these patient will resolve completely given the proper treatment and time and no scarring.

I am taking time to do this as I don't want other fellow doctors to make the same mistakes as I did. It would be such an ordeal as you are waiting for the patient to heal completely. Despite what the Restylane or Juverderm people will tell you. I am still a heavy user of Juverderm and Restylane but for the area below the eyebrow. Anything above the eyebrow, for me will be Botox and Dysport.

Has anyone seen any necrosis from Radiesse in the glabella. So far, we've used it with out a problem in that area.

Has anyone seen any necrosis from Radiesse in the glabella. So far, we've used it with out a problem in that area.

Dear Dr. N
I am much obliged for your detailed response. As far as I can make out your are right that's exactly what my patient had - a superficial erosin - plus an infection which made the whole frown area a bit red. You are very right about injection HA in the forehead - I only recommend doing this after botox /dysport however the new partner at my practice had to be convinced - now he is. The combination of antibiotics & dex is quite useful to know for these cases. Once again thanks alot.

Dr. N
Looking at the pictures of my client I must say your were spot on with the diagnosis...skin went purple, with milia formation

drpaul

I hope your patient has a complete recovery. All of mine did. Milia formation means epidermal involvement, should result in no scarring.

One more dangerous area I forgot to point out is injecting the nose bridge at the junction between the bone and the cartilage. This request is very common in asian young ladies, probably not so in caucasian. There are two small veins running out from there to the nasi area. This does not normally occur but happen to me once when I injected only about 0.2 ml of Juvederm ultra plus. This normally never goes wrong with a nose that has never been injected before as you can clearly see where you are injecting your material. But I was requested by the patient to add on some more where there was still some significant HA in the nose bridge and as a result I was kind of injecting blindly, resulting with the same complication.

Despite many expert and world authority will tell you to go deep, deep down to the periosteum, I prefer to go superficial and can see where I am injecting. Good luck.

drpaul

I hope your patient has a complete recovery. All of mine did. Milia formation means epidermal involvement, should result in no scarring.

One more dangerous area I forgot to point out is injecting the nose bridge at the junction between the bone and the cartilage. This request is very common in asian young ladies, probably not so in caucasian. There are two small veins running out from there to the nasi area. This does not normally occur but happen to me once when I injected only about 0.2 ml of Juvederm ultra plus. This normally never goes wrong with a nose that has never been injected before as you can clearly see where you are injecting your material. But I was requested by the patient to add on some more where there was still some significant HA in the nose bridge and as a result I was kind of injecting blindly, resulting with the same complication.

Despite many expert and world authority will tell you to go deep, deep down to the periosteum, I prefer to go superficial and can see where I am injecting. Good luck.

I totally agree with Dr. N. I would totally avoid the heavily linked hyaluronic acid products in frown lines and even in crow's feet area. The better choice would be Restylane fine lines, which is not yet available in the USA. As for periorbital area, I am really cautious about the tear trough area and injecting Hyaluronic acid products there. With fat injections, you may have a rare complication of blindness or stroke in the area...Does anyone know what the chances are with Hyaluronic acid injections in tear troughs?

thank you very much guys for your feedback

Dr. N -
I have done alot of cases of the nasal bridge raising in young asians...probably a couple of hundred so far. And you are right about those veins...in fact sometimes you can see them become engorged even if you didn't puncture it because of pressure from injecting the filler elsewhere....for some reason more common on the right side of the nose.
I started off with putting only between .2-.3 ml...however, couldn't get much better results because the amount of HA was low......I started doing under the dermis....bending the needle before so you can still see the tip after insertion poking the skin up..and gently putting .2-.3 ml before the junction of the cartilage and the bone....massaging it alittle and then puttin a the same amount more....and then if required putting some after the junction of the cartilage and bone....usually never put it in the junction, this way its quite easy to put around .7-.8 ml in some patients...usually with a longer nose than the ones that would require .5ml..........i think putting alittle, massaging it , then putting more and then massaging...put more..etc..etc has a good benefit...you can stop early if you think you've come across the vein , or if you end up causing too much swelling that compresses it too much....i have probably done a few hundred this way as our community is very high in asian patients..however, my filler of choice is Teosyal Global...as its swiss made with a lower count bacterial fermanation used it has much less swelling than restylane.
I would like to hear your view

drpaul

I totally agree with your way of injecting the nose with HA. Massaging is the key word, and putting in slowly bit by bit is essential to avoid vein compression. I am based in asia so I deal with asian nose everyday. Yes, I would also bend the needle to an angle about 30 degree, with the eye of the needle facing upward. I would also squeeze up the skin with 2 fingers before inserting the needle and would also lift up the skin a bit with the needle, injecting while retracting. For my own rule, I almost never inject more than 0.5 ml at one sitting. I prefer to ask the patient to come back 3-4 weeks later for a touchup if needed.

My choice of material would be Juverderm ultra plus, for no particular reason except I am so used to it for the past 3 years. many of my collegue like to use Perlane, the softer Restylane family is too soft and do not hold up well for the nose bridge.

RyanT

I seldom touch the tear trough although injecting the tear trough has been heavily promoted by the HA suppliers lately so they call sell more products. Unless you are really skillful and experienced, injecting the tear trough usually results in trouble. Not blindness, but rather uneven outcome, brusing to say the least. Many victims would describe the result as worms lying in their eyebag.

If I am forced to do the tear trough, usually try to salvage a patient been injected by other practitioners, I would use Restylane Vital, inject really tiny amount bit by bit and very superficial, you can almost see your material just underneath the skin. This is very important to me as I can see where I am injecting and to avoid injecting into the infra-orbital blood vessel at all cost. Yes at times this will creat the tyndall effect which I can live with.

Hope this will help

drpaul

I totally agree with your way of injecting the nose with HA. Massaging is the key word, and putting in slowly bit by bit is essential to avoid vein compression. I am based in asia so I deal with asian nose everyday. Yes, I would also bend the needle to an angle about 30 degree, with the eye of the needle facing upward. I would also squeeze up the skin with 2 fingers before inserting the needle and would also lift up the skin a bit with the needle, injecting while retracting. For my own rule, I almost never inject more than 0.5 ml at one sitting. I prefer to ask the patient to come back 3-4 weeks later for a touchup if needed.

My choice of material would be Juverderm ultra plus, for no particular reason except I am so used to it for the past 3 years. many of my collegue like to use Perlane, the softer Restylane family is too soft and do not hold up well for the nose bridge.

RyanT

I seldom touch the tear trough although injecting the tear trough has been heavily promoted by the HA suppliers lately so they call sell more products. Unless you are really skillful and experienced, injecting the tear trough usually results in trouble. Not blindness, but rather uneven outcome, brusing to say the least. Many victims would describe the result as worms lying in their eyebag.

If I am forced to do the tear trough, usually try to salvage a patient been injected by other practitioners, I would use Restylane Vital, inject really tiny amount bit by bit and very superficial, you can almost see your material just underneath the skin. This is very important to me as I can see where I am injecting and to avoid injecting into the infra-orbital blood vessel at all cost. Yes at times this will creat the tyndall effect which I can live with.

Hope this will help