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Reprint Address: Kenny Banh, md, Department of Emergency Medicine, University of California San Francisco-Fresno, 155 N Fresno St., Fresno, CA 93701-2302
Affiliations
Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, California
A 48-year-old woman presented to the Emergency Department (ED) with the complaint of her face turning blue and gray (Figure 1). Earlier that day, her plastic surgeon had administered injections of the hyaluronic acid Restylane® (Medicis Aesthetics Inc., Scottsdale, AZ) in her face to reduce expression lines around her mouth. She had no significant allergic reactions in the past and was on no medications. Approximately 8 h later she noticed an acute progressive graying and now bluish hue in the areas of her lips, cheek, and nose without any pain or other symptoms. After discussing the case with her surgeon, we applied topical nitroglycerin to her face and placed her in our hyperbaric chamber, resulting in complete resolution of her symptoms (Figure 2).
Figure 1Ischemia of the lip face and nose after lip injection earlier that day.
Injection of hyaluronic acid (HA) fillers is the fifth most common non-surgical procedure being performed in the United States, after injection of botulinum toxin, laser hair removal, chemical peels, and microdermabrasion (
). HA injections reduce lines and wrinkles by replacing lost subcutaneous volume in the skin, as opposed to botulinum injections, which reduce the pull on the skin by facial muscles. Hyaluron is a naturally occurring glycosaminoglycan that exhibits neither species nor tissue specificity. It is an essential non-immunogenic component of the extracellular matrix of all animal tissues and is highly hydrophilic. Hyaluronic acid is known by the trademarks Zyderm® and CosmoDerm® (Allergan, Fremont, CA), Zyplast® and CosmoPlast® (Inamed Corp., Fremont, CA), Hylaform® and Captique® (Genzyme Corp., Cambridge, MA), Juvederm® (Pringy Corp., Pringy, France) and Restylane®, which mainly differ in how the hyaluronic acid is derived (plant vs. animal).
Common injection-related reactions to hyaluronic acid injections do occur, such as redness, swelling, pain, and itching; but only about 1 in 2000 people will have a true hypersensitivity reaction. These range from granuloma formation to generalized anaphylactic reactions, but injection site and distal tissue ischemia and necrosis may occur from unknown etiology. A review of the Adverse Event Reporting System database found only 13 cases of tissue necrosis in more than 400,000 patients (
). A single dive of hyperbaric therapy is not an established therapy for complications of HA injections, but is described in case reports and is a mainstay of treatment for ischemic wounds (
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