title: Calcium hydroxylapatite associated soft tissue necrosis: a case report and treatment guideline.
abstract: We present an uncommon case of nasal alar and facial necrosis following calcium hydroxylapatite filler injection performed elsewhere without direct physician supervision. The patient developed severe full-thickness necrosis of cheek and nasal alar skin 24 h after injections into the melolabial folds. Management prior to referral included oral antibiotics, prednisone taper, and referral to a dermatologist (day 3) who prescribed valacyclovir for a presumptive herpes zoster reactivation induced by the injection. Referral to our institution was made on day 11, and after herpetic outbreak was ruled out by a negative Tzanck smear, debridement with aggressive local wound care was initiated. After re-epithelialization and the fashioning of a custom intranasal stent to prevent vestibular stenosis, pulsed dye laser therapy was performed for wound modification. The patient healed with an acceptable cosmetic outcome. This report underscores the importance of facial vasculature anatomy, injection techniques, and identification of adverse events when using fillers. A current treatment paradigm for such events is also presented.
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, University of California Irvine, 101 The City Drive, Bldg. 56, Suite 500, Orange, CA 92868, USA. Electronic address: ltracy@uci.edu.
authors.forename: Lauren
authors.initials: L
authors.lastname: Tracy
authors.affiliation: Larrabee Center for Plastic Surgery, 600 Broadway, Suite 280, Seattle, WA 98122, USA.
authors.forename: James
authors.initials: J
authors.lastname: Ridgway
authors.affiliation: Beckman Laser Institute and Medical Clinic, University of California Irvine, 1002 Health Sciences Road East, Irvine, CA 92612, USA.
authors.forename: J Stuart
authors.initials: JS
authors.lastname: Nelson
authors.affiliation: 999 North Tustin Avenue, Suite 117, Santa Ana, CA 92705, USA.
authors.forename: Nelson
authors.initials: N
authors.lastname: Lowe
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, University of California Irvine, 101 The City Drive, Bldg. 56, Suite 500, Orange, CA 92868, USA; Beckman Laser Institute and Medical Clinic, University of California Irvine, 1002 Health Sciences Road East, Irvine, CA 92612, USA.
authors.forename: Brian
authors.initials: B
authors.lastname: Wong
mesh_terms: D000328:Adult; D001672:Biocompatible Materials / Q000008:administration & dosage / Q000009:adverse effects*; D002610:Cheek / Q000473:pathology*; D017886:Durapatite / Q000008:administration & dosage / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007267:Injections; D055171:Nasal Cartilages / Q000473:pathology*; D009336:Necrosis / Q000209:etiology; D014947:Wounds and Injuries / Q000209:etiology / Q000473:pathology / Q000628:therapy*
chemical_list: D001672:Biocompatible Materials; D017886:Durapatite
keywords: Calcium hydroxylapatite; Complication; Injectable filler; Nasal alar necrosis; Tissue necrosis