Necrosis and Hair Loss after Dermal Filler Injected into Temples
Necrosis is the most feared complication for injectors of dermal filler. In this case it occurred during injection of dermal filler in temples. Fortunately the product we were using was a hyaluronic acid dermal filler. The benefit of these products in this circumstance is their reversability.
The procedure was carried out as normal, I injected local anesthetic then used a needle to make an opening for the cannula, I inserted the cannula and started to inject.
Immediately there appeared a large white area over the right side of the forehead up to the hairline at the scalp. I have had several vascular incidents where dermal filler has caused blockage of vessels previously, so I knew what was happening and I knew how to treat it. The blockages that I have seen before had much smaller areas of skin that they supplied. This artery/arteriole supplied a large proportion of the temple and forehead.
Treatment of the interuption to vascular supply was instituted immediately:
* Stopped injecting
* Massage and warm compresses to the area
* Nitrate patch
* Hyaluronidase/ hyalase injection to remove the dermal filler
* Aspirin
The treatments above caused the white area on the forehead to resolve within minutes, as the skin reperfused.
After this it was time to monitor the area over the next week.
Over the next couple of days, the temple appeared bruised, there was a large bruise which extended to the eyelid (The bruise was caused by the injection of the hyalase). by day 10 the temple area was almost normal, but there was an area of scabbing in the scalp (we had missed diagnosing this area when the event occurred). This wound resolved over the next few weeks but at 6 weeks, the hair in the area that had the scabbing had fallen out.
We were concerned that this hair loss may be permanent, but we just played the waiting game. After discussion with the patient, we decided to inject Platelet Rich Plasma in the protocol for hair loss (an experimental treatment) into the affected area. We planned to do 3 treatments, 1 month apart. We did the first 2 treatments, but by the time came for the 3rd treatment (at 3.5 months after the initial vascular event), the patient had full regrowth of the hair in the area.
The patient also had 2 treatments of PRP in her eye area at the time of the hair loss treatment
Many prayers were said during these months:)
Thankyou to the patient for being so calm and positive during this time, and also, thanks for allowing me to post this story on my blog
The patient before treatment
Immediately after treatment. NB nitrate patch and bruise from Hyaluronidase
24 hours after interuption to vascular supply.
Day 3 post injection
Day 4 post injection event
Day 10 after injections; This is where the real problem started. Temple area is healing well, but there was an area in the scalp that was also effected more seriously, which we had not noticed until today. It was a healing scab at this stage, about the size of a 30mm in diameter. At this stage we were concerned that it may scar and effect the hair growth in the area.
4 weeks after injection: The area is healing, but time will just have to tell how well it is going to heal
At 6 weeks after injection. there is hair loss in the area of necrosis.
At 8 weeks after injection: Hair loss still present
3 months after injections. Hair is just starting to regrow
3.5 months after treatment, hair has regrown.
This is the after photo after treatment. (We injected multiple areas on the day of treatment, including the temples)
Interestingly, in this photo, it is easy to see where the dermal filler was removed from the right temple (when we had to dissolve it)
We really need to refill this temple, the patient has been keen all along to refill it, but I am concerned about her vascular anatomy in the area
Dr. Ron Feiner says:
So well managed Dr. Naomi! Congratulations! Facial injecting is artistry and science combined but treatment of an adverse episode is very much science alone. The patient is very fortunate that you had the skills and commitment to deal with it so diligently. Thank you for sharing this with us. We should all learn from your experience as it can occur at any time with any injector.
February 27th, 2013 at 12:01 pm
drnaomi says:
Thanks Ron,
My colleagues will feel this blog post!
Complications are the worst part of our job! It was a very difficult time.
The patient was amazing throughout and so generous to let me post her photos. We both wanted to share it to help others who may come across something similar.
If any injectors read my blog and can add anything or critique what I did for management, please comment, because this is medicine, and we will never stop learning:)
ps Great news, i treated this patient’s right temple yesterday with no problems. I infiltrated the whole area with dilute local anaesthetic with adrenaline and used a skin booster (paranoia!). I expect that the patient will require a second treatment, which isn’t ideal, but it was more about doing no harm, and slowly and safely getting improvement.
February 27th, 2013 at 11:14 pm
jill says:
Thank you for this post. It is very helpful to me as a nurse injector. I want to remain on top of possible complications and continuously learn from experts such as yourself! I am curious to know if the cannula was the culprit and able to puncture the vessel? I feel more confidence with cannula use and had not heard of a vascular incident using a cannula. You handled the situation perfectly and this is a great resource for other injectors. Thank you!
March 30th, 2013 at 11:27 pm
drnaomi says:
Hi Jill,
Thanks for your comment. I am not sure exactly why this happened. The pathology in necrosis with dermal fillers is that there is interruption to the blood supply to the skin supplied by a blood vessel. This may be caused by compression of an artery or occlusion with dermal filler material.
It may be that compression of the artery was the more likely cause in this case (NB this is not an evidence based comment).
In this case I was not using a large amount of dermal filler (< 0.5mls) in the area.
I understand your feeling of confidence with cannulas. I feel it too. However, in my cannula use I have noticed that they can also puncture vessels and cause bleeding and bruising. This occurs less so than with needles, but it does occur.
Great to know that injectors read my blog as well as cosmetic patients! Please feel free to share your injecting experiences on my blog. The more information we share, the better for our industry:)
March 31st, 2013 at 12:14 am