Just Accepted by Journal of Cosmetic and Laser Therapy
Treatment of glabella skin necrosis following injection of Hyaluronic acid-filler using plateletrich plasma Boo Kyoung Kang, In Jung Kang, Ki Heon Jeong, Min Kyung Shin DOI: 10.3109/14764172.2015.1052512
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
ABSTRACT Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, there can be various complications following HA-filler injection. Skin necrosis is rare but one of the most disastrous side effects that, if not treated promptly and effectively, can result in permanent and potentially disfiguring scarring. Thus early, proper management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma(PRP) and provide full follow-up clinical photos.
© 2015 Informa UK, Ltd. This provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles do not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosages, the method and duration of administration, and contraindications. It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner. There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article. Any use of the Just Accepted articles is subject to the express understanding that the papers have not yet gone through the full quality control process prior to publication.
Treatment of glabella skin necrosis following injection of Hyaluronic acid-filler using platelet-rich plasma
Boo Kyoung Kang, In Jung Kang, Ki Heon Jeong, Min Kyung Shin Department of Dermatology, College of Medicine, Kyung Hee University, Seoul, Korea
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
Correspondence: Min Kyung Shin, MD., PhD, Department of Dermatology, College of Medicine, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea, Tel: (82-2) 958-8300, Fax: (82-2) 969-6538, E-mail: [email protected]
Short title: Treatment of skin necrosis with PRP ABSTRACT Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, there can be various complications following HA-filler injection. Skin necrosis is rare but one of the most disastrous side effects that, if not treated promptly and effectively, can result in permanent and potentially disfiguring scarring. Thus early, proper management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma(PRP) and provide full follow-up clinical photos.
Keywords: Soft-tissue filler, HA filler, Hyaluronic acid
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J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, early and delayed complications, ranging from minor to severe, possible following HA-filler injection [1]. The most severe early complication is tissue necrosis, possibly due to interruption of the vascular supply to the area by direct injury, compression of vasculature, or obstruction of the vessel by the HA filler [2]. Skin necrosis results in scarring, asymmetry, and permanent disfigurement. Thus early management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma(PRP) and provide full follow-up clinical photos. The patient was a 46-year-old female who presented with inflammatory symptoms with redness, swelling, numerous pustules and dark regional necrosis on the glabella, forehead and dorsum of the nose after injection of HA filler 2 days prior. We treated her conservatively, with hyaluronidase, oral antibiotics, 15 mg of prednisolone and dressings. The wound continued to progress with erosion and expanded skin necrosis on the fourth day after injection of filler. We performed gentle debridement and injected PRP intradermally and applied it topically with an occluded dressing. PRP was prepared by first drawing a 12-mL blood sample in a sterile tube containing 1 mL of citrate phosphate dextrose adenine solution. The tubes were centrifuged at 3,000 revolutions per minute(rpm) for 5 minutes. A total of 3 mL of PRP was subsequently aspirated and prepared for activation by adding calcium chloride (0.1 mL per 0.9 mL of PRP). On the 10th day after filler injection, the wound was completely re-epithelialized with residual linear reticulated erythema and a depressed scar. Additional PRP therapy was administered to the wound after 2 weeks with topical fusidic acid. A well demarcated scar was observed after 8-weeks of follow-up. Over the next 3 months, she underwent a series of three treatments with a carbon dioxide laser. After 10 months, the scar had improved with satisfactory results and only a slightly noticeable scar remained (Fig. 1). The glabella is one of the most susceptible zones to tissue necrosis due to its vascular anatomy. Small vessels branching from the supratrochlear and supraorbital arteries with limited collateral circulation provide blood supply to the glabellar region, and the hydrophilic action of HA fillers can sometimes compress this vasculature [3]. In the early stages of necrosis, conservative management(e.g. topical nitroglycerin and warm compresses) can be applied to stimulate vasodilatation. Hyaluronidase is also known to resolve HA filler-induced vascular compression with successful outcomes [3]. Early and proper management is important and if wounds become aggravated, they may require more invasive treatment modalities, such as surgical debridement and different types of local flaps or grafts. One of the strengths of this report is there were multiple follow-up time points to appropriately track patient status. We used PRP early for scar revision, and the skin defect present following debridement of the necrotic tissue healed considerably with PRP therapy. Platelet-derived growth factors(GFs) including PDGF (platelet-derived growth factor), TGF- (transforming growth factor- ), VEGF (vascular endothelial growth factor), EGF (endothelial growth factor), and FGF (fibroblast growth factor) are biologically active substances that enhance tissue repair mechanisms such as chemotaxis, cell proliferation, angiogenesis, extracellular matrix deposition, and remodeling. They exhibit extensive tissueforming abilities, such as the initiation and modulation of wound healing. Platelet-derived GFs in the form of activated PRP were efficacious in accelerating healing of non-healing ulcers, diabetic wounds, and surgical flaps [4]. Sung et al [5] reported that adipose-derived stem cell therapy was effective in one patient with nasal skin necrosis after filler injection. PRP therapy is also effective in stimulating the healing of necrotic tissue and has additional advantages that it is easy to obtain from patients’ blood and procedurally simple. In this report, we shared our experience with a case of HA-filler complication treated with PRP. We would like to emphasize in our report that when used as an adjuvant to standard hyaluronidase therapy, PRP may reduce scar formation and post-procedural complications arising from filler -induced vascular injury. Funding sources: None. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. Acknowledgments: The English in this document(KHMED1409-05) has been checked by professional editor(eWorld Editing Inc). For a certificate, please send e-mail to [email protected].
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1. 2. 3. 4.
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
5.
REFERENCES Rodriguez J, Andre P. Hyaluronic acid and its use as a “rejuvenation” agent in cosmetic dermatology. Semin Cutan Med Surg 2004; 23:218-22. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol 2002; 146:928–9. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32:276-81. Alsousou J, Thompson M, Hulley P, Noble A, Willett K. The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery. J Bone Joint Surg 2009; 91:987-96. Sung HM, Suh IS, Lee HB, Tak KS, Moon KM, Jung MS. Case Reports of Adiposederived Stem Cell Therapy for Nasal Skin Necrosis after Filler Injection. Arch Plast Surg. 2012; 39:51-4.
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Figure legend
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
Figure 1 Ill-demarcated central necrotic discoloration and marginal pustules surrounded by an erythematous patch on the forehead, glabella and nasal dorsum area. (B) Abscess and erosion formation over the course of the first 4 days after hyaluronic acid injection. (C) Six days after PRP treatment, the wound was healing, although a persistent defect remained. (D) Improvement of the scar was noted after 8 weeks of follow-up and two PRP treatments. (E) Photo taken at the last follow-up visit, which was 10 months and three CO2 laser scar revision sessions after presentation.
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Treatment of glabella skin necrosis following injection of Hyaluronic acid-filler using plateletrich plasma Boo Kyoung Kang, In Jung Kang, Ki Heon Jeong, Min Kyung Shin DOI: 10.3109/14764172.2015.1052512
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
ABSTRACT Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, there can be various complications following HA-filler injection. Skin necrosis is rare but one of the most disastrous side effects that, if not treated promptly and effectively, can result in permanent and potentially disfiguring scarring. Thus early, proper management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma(PRP) and provide full follow-up clinical photos.
© 2015 Informa UK, Ltd. This provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles do not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosages, the method and duration of administration, and contraindications. It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner. There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article. Any use of the Just Accepted articles is subject to the express understanding that the papers have not yet gone through the full quality control process prior to publication.
Treatment of glabella skin necrosis following injection of Hyaluronic acid-filler using platelet-rich plasma
Boo Kyoung Kang, In Jung Kang, Ki Heon Jeong, Min Kyung Shin Department of Dermatology, College of Medicine, Kyung Hee University, Seoul, Korea
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
Correspondence: Min Kyung Shin, MD., PhD, Department of Dermatology, College of Medicine, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea, Tel: (82-2) 958-8300, Fax: (82-2) 969-6538, E-mail: [email protected]
Short title: Treatment of skin necrosis with PRP ABSTRACT Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, there can be various complications following HA-filler injection. Skin necrosis is rare but one of the most disastrous side effects that, if not treated promptly and effectively, can result in permanent and potentially disfiguring scarring. Thus early, proper management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma(PRP) and provide full follow-up clinical photos.
Keywords: Soft-tissue filler, HA filler, Hyaluronic acid
1
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, early and delayed complications, ranging from minor to severe, possible following HA-filler injection [1]. The most severe early complication is tissue necrosis, possibly due to interruption of the vascular supply to the area by direct injury, compression of vasculature, or obstruction of the vessel by the HA filler [2]. Skin necrosis results in scarring, asymmetry, and permanent disfigurement. Thus early management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma(PRP) and provide full follow-up clinical photos. The patient was a 46-year-old female who presented with inflammatory symptoms with redness, swelling, numerous pustules and dark regional necrosis on the glabella, forehead and dorsum of the nose after injection of HA filler 2 days prior. We treated her conservatively, with hyaluronidase, oral antibiotics, 15 mg of prednisolone and dressings. The wound continued to progress with erosion and expanded skin necrosis on the fourth day after injection of filler. We performed gentle debridement and injected PRP intradermally and applied it topically with an occluded dressing. PRP was prepared by first drawing a 12-mL blood sample in a sterile tube containing 1 mL of citrate phosphate dextrose adenine solution. The tubes were centrifuged at 3,000 revolutions per minute(rpm) for 5 minutes. A total of 3 mL of PRP was subsequently aspirated and prepared for activation by adding calcium chloride (0.1 mL per 0.9 mL of PRP). On the 10th day after filler injection, the wound was completely re-epithelialized with residual linear reticulated erythema and a depressed scar. Additional PRP therapy was administered to the wound after 2 weeks with topical fusidic acid. A well demarcated scar was observed after 8-weeks of follow-up. Over the next 3 months, she underwent a series of three treatments with a carbon dioxide laser. After 10 months, the scar had improved with satisfactory results and only a slightly noticeable scar remained (Fig. 1). The glabella is one of the most susceptible zones to tissue necrosis due to its vascular anatomy. Small vessels branching from the supratrochlear and supraorbital arteries with limited collateral circulation provide blood supply to the glabellar region, and the hydrophilic action of HA fillers can sometimes compress this vasculature [3]. In the early stages of necrosis, conservative management(e.g. topical nitroglycerin and warm compresses) can be applied to stimulate vasodilatation. Hyaluronidase is also known to resolve HA filler-induced vascular compression with successful outcomes [3]. Early and proper management is important and if wounds become aggravated, they may require more invasive treatment modalities, such as surgical debridement and different types of local flaps or grafts. One of the strengths of this report is there were multiple follow-up time points to appropriately track patient status. We used PRP early for scar revision, and the skin defect present following debridement of the necrotic tissue healed considerably with PRP therapy. Platelet-derived growth factors(GFs) including PDGF (platelet-derived growth factor), TGF- (transforming growth factor- ), VEGF (vascular endothelial growth factor), EGF (endothelial growth factor), and FGF (fibroblast growth factor) are biologically active substances that enhance tissue repair mechanisms such as chemotaxis, cell proliferation, angiogenesis, extracellular matrix deposition, and remodeling. They exhibit extensive tissueforming abilities, such as the initiation and modulation of wound healing. Platelet-derived GFs in the form of activated PRP were efficacious in accelerating healing of non-healing ulcers, diabetic wounds, and surgical flaps [4]. Sung et al [5] reported that adipose-derived stem cell therapy was effective in one patient with nasal skin necrosis after filler injection. PRP therapy is also effective in stimulating the healing of necrotic tissue and has additional advantages that it is easy to obtain from patients’ blood and procedurally simple. In this report, we shared our experience with a case of HA-filler complication treated with PRP. We would like to emphasize in our report that when used as an adjuvant to standard hyaluronidase therapy, PRP may reduce scar formation and post-procedural complications arising from filler -induced vascular injury. Funding sources: None. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. Acknowledgments: The English in this document(KHMED1409-05) has been checked by professional editor(eWorld Editing Inc). For a certificate, please send e-mail to [email protected].
2
1. 2. 3. 4.
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
5.
REFERENCES Rodriguez J, Andre P. Hyaluronic acid and its use as a “rejuvenation” agent in cosmetic dermatology. Semin Cutan Med Surg 2004; 23:218-22. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol 2002; 146:928–9. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32:276-81. Alsousou J, Thompson M, Hulley P, Noble A, Willett K. The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery. J Bone Joint Surg 2009; 91:987-96. Sung HM, Suh IS, Lee HB, Tak KS, Moon KM, Jung MS. Case Reports of Adiposederived Stem Cell Therapy for Nasal Skin Necrosis after Filler Injection. Arch Plast Surg. 2012; 39:51-4.
3
Figure legend
J Cosmet Laser Ther Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
Figure 1 Ill-demarcated central necrotic discoloration and marginal pustules surrounded by an erythematous patch on the forehead, glabella and nasal dorsum area. (B) Abscess and erosion formation over the course of the first 4 days after hyaluronic acid injection. (C) Six days after PRP treatment, the wound was healing, although a persistent defect remained. (D) Improvement of the scar was noted after 8 weeks of follow-up and two PRP treatments. (E) Photo taken at the last follow-up visit, which was 10 months and three CO2 laser scar revision sessions after presentation.
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