A 10-point plan for avoiding hyaluronic acid dermal filler-related complications during facial aesthetic procedures and algorithms for management

Figures & data

Table 1 A 10-point plan for avoiding filler complications

Abbreviations: HA, hyaluronic acid; IV, intravenous; SLR, single-lens reflex.

Table 2 Algorithm for early and delayed hypersensitivity reactions

Hypersensitivity reactions
Early	Delayed
Check vital signs	Cold compresses
Resuscitation measures: Adrenalin IV access Fluids	H1-receptor antagonists
	H2-receptor antagonists
	Leukotriene synthesis inhibitors
	Oral corticosteroids
	Propranolol
	Ibuprofen

Abbreviation: IV, intravenous.

Table 3 DeLorenzi’s HDPH dosage and protocol

High-dose pulse hyaluronidase
Dosage	Standard dosage	500 IU per area
	Lip, nose, and forehead	Act as multipliers
	Two areas	1,000 IU per hour
	Three areas	1,500 IU per area
Protocol
• Inject at least every 60–90 minutes until skin color has normalized and capillary refill time has normalized
• Massage to increase embolus contact with the hyaluronidase by propelling the HA distally into thinner-walled arterioles
• Aim to complete treatment within 72 hours of onset for complete resolution
• Keep patient in clinic for observation and treatment until the capillary refill has improved (usually three sessions over 3 hours) • Do not apply nitroglycerin paste until the offending HA has been dissolved (day 2 or 3 of treatment) as dilation of adjacent nonobstructed vascular pathways can lead to the propagation of the embolus toward the orbit

Abbreviation: HA, hyaluronic acid; HDPH, high-dose pulse hyaluronidase.

Table 4 Algorithm for single or multiple late-onset nodules

Single nodule			Multiple nodules
Inflammatory		Noninflammatory	Consider systemic diseases
Fluctuant	Nonfluctuant	Encapsulated hematoma	If biofilm or granuloma
Abscess	Biofilm or granuloma	Wait	Topical immunosuppressants
Puncture + drain	Hyaluronidase + antibiotics	Puncture + drain
Antibiotics	Intralesional steroids	Antibiotics	Antibiotics for example:
		Hyaluronidase	Ciprofloxacin 500–700 mg bd (2–4 weeks)
			Clarithromycin 500 mg bd + Moxifloxacin 400 mg bd (10 days)
			Minocycline 100 mg/day (6 months)
			Levofloxacin (3 weeks) followed by additional clarithromycin (3 weeks)
			Hyaluronidase + antibiotics
			Colchicinea

Note:

a Unpublished data.

Abbreviation: bd, twice daily.