title: Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations.
abstract: Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Joel L
authors.initials: JL
authors.lastname: Cohen
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Brian S
authors.initials: BS
authors.lastname: Biesman
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Steven H
authors.initials: SH
authors.lastname: Dayan
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Claudio
authors.initials: C
authors.lastname: DeLorenzi
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Val S
authors.initials: VS
authors.lastname: Lambros
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Nestor
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Neil
authors.initials: N
authors.lastname: Sadick
authors.affiliation: Dr Cohen is an Associate Clinical Professor in the Department of Dermatology at the University of Colorado, Boulder, and an Assistant Clinical Professor in the Department of Dermatology at the University of California Irvine. Dr Biesman is a Clinical Assistant Professor in the Departments of Ophthalmology and Otolaryngology and the Division of Dermatology at Vanderbilt University Medical Center, Nashville, TN. Dr Dayan is a Clinical Assistant Professor in the Department of Otolaryngology at the University of Illinois, Chicago. Dr DeLorenzi is a plastic surgeon in private practice in Kitchener, Ontario, Canada. Dr Lambros is a Clinical Professor of Plastic Surgery at the University of California Irvine. Dr Nestor is a Voluntary Associate Professor in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, FL. Dr Sadick is a Clinical Professor of Dermatology at Weill Cornell Medical College, New York, NY. Dr Sykes is a Professor and the Director of Facial Plastic Surgery in the Department of Otolaryngology at the UC Davis Health System of the University of California Davis, Sacramento.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sykes
mesh_terms: D001241:Aspirin / Q000627:therapeutic use; D000067548:Dermal Fillers / Q000009:adverse effects*; D006801:Humans; D006820:Hyaluronic Acid / Q000009:adverse effects*; D006821:Hyaluronoglucosaminidase / Q000627:therapeutic use*; D008405:Massage; D009336:Necrosis / Q000139:chemically induced / Q000517:prevention & control*; D005996:Nitroglycerin / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D014665:Vasodilator Agents / Q000627:therapeutic use*; D055675:Viscosupplements / Q000009:adverse effects*
chemical_list: D000067548:Dermal Fillers; D010975:Platelet Aggregation Inhibitors; D014665:Vasodilator Agents; D055675:Viscosupplements; D006820:Hyaluronic Acid; D006821:Hyaluronoglucosaminidase; D005996:Nitroglycerin; D001241:Aspirin