Alessio Redaelli 1, Melania Battistella 2

¹ Cosmetic Department, Visconti di Mondrone Medical Center, Milan, Italy

² Aesthetic Practitioner, Rome, Italy

Case Report

A 34-year-old female patient, that received a surgery for an open rhinoplasty on May 27^th 2011, had been injected on the 22^nd of February 2018 to project the tip of the nose. The doctor referred to have used a hyaluronic acid filler (HA) with a concentration of 20 mg/mL (Perfectha Deep®) for a total amount of 0.1 mL with a 27 G needle and very low pressure. He was perfectly aware that the nose is considered an area with a very high risk of vascular compromise. The needle was inserted with a 25 degree angle directly on the tip of the nose without local anaesthesia and with a negative aspiration test result. The patient had not felt sensation of discomfort or pain during the injection and the doctor had not seen blanching of the injected area or of the surrounded ones as shown in Figures 1 a and b.

Fig. 1a + b: Blanching around the injected area.

Fig. 2: Light erythema overall the tip of the nose, the lateral walls and the dorsum.

Fig. 3: Patient at day 2 after procedure.

The patient went home. The following day, when the doctor contacted her for routine check, she complained about redness on the nose. Consequently, she was asked to send immediately a picture and to come back to the clinic. She looked like in Figure 2 with a light erythema over all the tip of the nose, the lateral walls and the dorsum.

At this time the doctor started an anti-inflammatory therapy with deflazacort 30 mg orally for 5 days. At the second day after the procedure (Fig.3), the doctor discussed the case with other colleagues experienced in filler procedures and they interpreted it like an infection because of the peeling 4 days before. Therefore, the patient was advised to use clindamycin 600 mg two times a day for 7 days and levofloxacin 400 mg for 10 days, but no hyaluronidase was mentioned at that moment. At the third day after the injection the redness got more intense and spread on the surrounding areas as shown in Fig. 4 (a) and (b).

Fig. 4a + b: Third day after the injection, redness got more intense and spread on the surrounded areas.

Fig. 5a, b, c: At day 4 development of necrotic areas.

At day 4 after the injection the patient looked as in Figure 5 (a-c) with development of necrotic areas. No sign of improvement could be noted but an extended necrosis over both alar cartilage areas appeared instead.

Fig. 6: Patient at day six.

Fig. 7: Highlighted pattern of PRP-treatment to repeat weekly.

At day 5 (Fig. 6), a consultation with other doctors began after a literature research was started. The doctor came to the conclusion of a vascular compromise of the treated area probably due to a compression of a vessel.

The team in place had no hyaluronidase at that time; therefore, the consulting doctors suggested to proceed as follow:

• Immediate platelet-rich plasma (PRP) in the affected area to repeat weekly (0.4 cc) with the highlighted pattern shown in Figure 7,
• Daily hyperbaric chamber until the healing of the necrotic area would have been achieved.
• Continuation with oral antibiotics.
• Pain killer each 12 h in case of need.
• Topical nitroglycerine paste Nitroderm® TTS 5 (suspended 3 days later because of referred side effects).
• Antibiotic dressing and wound healing ointment without debridement in order to avoid scars.

Fig. 8 a, b, c: Patient one month after the adverse event.

Fig. 9: Patient after 45 days.

Fig. 10 a, b, c: Almost complete healing after 4 months.

The patient was observed on a daily basis and treated with local ointment and dressing.

At day 6 after the injection, hyaluronidase was obtained, and the patient was injected with 1.500 U.Figure 8 (a – c) demonstrates the clinical features one month after the adverse event with the presence of necrotic tissue areas on the nose tip.

The healing was still incomplete after 45 days (Fig. 9).

At the fourth month, even if an almost complete healing could have been achieved (Fig. 10 a, b and c), the patient still had a small depression area on the tip of the nose (Fig. 11).

Fig. 11: After 4 months only a small depression is left.

Fig. 12: After daily application of Kelocote®.

This was probably where the major vascular damage occurred. Topical Kelocote® and a thin silicone layer were applied every night. Within two weeks it had been substituted by a red spot of granulation as shown in detail in Fig. 12.

Fig. 13 a + b: Patient after receiving a monthly session of PRP.

Fig. 14 a, b, c: Patient after 10 months of treatment.

She received a total of 22 sessions of hyperbaric chamber, weekly PRP and local care every day so far.

From July up to September 2018, the patient received a monthly session of PRP and at 18^thof October she looked like in Fig. 13 (a and b), with a little depression on the affected area and a smaller and flattened red spot, that disappeared at the 10^th month after the adverse event (Fig.14 a, b and c).

A fractional CO₂ laser was suggested to restore the damaged tissue and make the scares less visible.

The patient’s attitude, discipline and trust in the doctor had been very important for obtaining this result.

Disclosures:

Alessio Redaelli is trainer and KOL for Filorga and Ipsen company.