CE: R.R.
; SCS-17-0306; Total nos of Pages: 2;
SCS-17-0306
BRIEF CLINICAL STUDIES
Demarcative Necrosis Along
Previous Laceration Line
After Filler Injection
Jong-Lim Kim, MD,y Jin Yong Shin, MD,y
Si-Gyun Roh, MD,y and Nae-Ho Lee, MD, PhDy
Abstract: In recent years, fillers have been widely used for soft
tissue augmentation. Although they are generally considered to be
safe, many complications have been reported to date. Nose and
nasolabial fold augmentations with fillers can lead to an imple-
mentation of nasal skin necrosis, possibly caused by intravascular
embolism and/or extravascular compression. Herein, we present a
case of a successfully treated patient who experienced skin necrosis
after an injection of dermal fillers into the nasolabial fold. Inter-
estingly, we discovered that the patient had experienced a laceration
8 years ago around the area in which the filler was injected.
Key Words: Filler, necrosis, previous laceration
A n injection of dermal fillers is one of the most commonly
performed procedures in cosmetic surgery. The process is
relatively simple, with a high patient satisfaction, which can lead
to a cavalier attitude toward fillers. However, it is important to
recognize its association with serious complications.1 –3
Herein, we present a 41-year-old woman who experienced skin
necrosis after an injection of dermal fillers into the nasolabial fold.
The skin and soft tissue necrosis extended up to the tip of nose and
left alar nasi, along the previous laceration line, without crossing
over the previous laceration line.
CLINICAL REPORT
A 41-year-old woman underwent dermal filler injection by general
physician at a local clinic for soft tissue augmentation of the
nasolabial folds. Immediately after the injection, she felt an erythe-
matous change on her left nasolabial fold, alar nasi, tip of nose, and
glabella. The patient contacted the physician who injected the
dermal filler 2 days after the injection to complain about her side
effects. Soon thereafter, she was given 2 injections of hyaluroni-
dase. However, she still experienced swelling, tenderness, and
multiple vesicle formation on her face.
On the following day, she visited our outpatient department with
a referral from the local plastic surgery clinic. After taking her
medical history, we found that she had experienced a laceration to
the left upper lip, philtrum, collumella, and contralateral alar nasi
From the Department of Plastic and Reconstructive Surgery, Medical
School of Chonbuk National, University; and yResearch Institute of
Clinical Medicine-Biomedical Research Institute of Chonbuk National,
University Hospital, Jeonju, Republic of Korea.
Received February 9, 2017.
Accepted for publication March 6, 2017.
Address correspondence and reprint requests to Jin Yong Shin, MD,
Department of Plastic and Reconstructive, Surgery, Chonbuk National
University Medical School, 20, Geonji-ro, Deokjin-Gu, Jeonju-si,
Chonbuk 561-712, Republic of Korea; E-mail: psjyshin@gmail.com
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000003791
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
FIGURE 1. (A) The patient had a laceration on the left upper lip and
contralateral alar nasi 8 years ago. (B) After filler injection, skin and soft
tissue necrosis occurred, which was extended to the tip of the nose and left alar
nasi along the previous laceration line. (C) The patient healed with minimal
asymmetry of nostrils after 4 months.
8 years ago, which potentially compromised her vascular network
(Fig. 1A).
She presented with erythematous change and multiple vesicle
formation on the left side of her face. She was started on an aspirin
regimen (1 pill of 100 mg daily for 10 days) to prevent further
clot formation. Moreover, intravenous administration of antibiotics
(ciprofloxacin and clarithromycin) was started and continued for
10 days. She was treated with warm saline wet dressing with
antibiotic ointment (bacitracin) for 16 days.
The skin and soft tissue necrosis was extended to the tip of the
nose and left alar nasi, along the previous laceration line, without
crossing over the previous laceration line (Fig. 1B). The wound
was demarcated and surgically removed on the 13th day after the
injection. The patient healed with minimal skin defect in the left
nostril and alar base. The patient has been followed for 4 months
with minimal asymmetry of nostrils (Fig. 1C).
DISCUSSION
Soft tissue augmentation with filler agents is in higher demand
in large part because of increased public awareness to these
products and increasing confidence that these agents provide a
safe and consistent means of facial rejuvenation. Despite the
impressive safety profile of these products, complications still
do occur.4
There are several reports on necrosis of the glabella and alar
areas upon injection of dermal filler.1,3,5– 7 Injection necrosis is a
rare but clinically important potential complication.
Moreover, many injection technical tips and treatments for skin
necrosis owing to dermal filler injection have been proposed.3,4,6,7
However, too much focus on these could possibly result in neglect-
ing patient history.
The suggested contraindications in the literature for use of
dermal fillers are known sensitivities to filler material, history of
severe allergy or anaphylaxis, and bleeding disorders. Injection
should be deferred until infection or inflammation has been
controlled or resolved.8–12
We emphasize that previous scar formation and history taking
of injury should be checked around the injection site before
dermal filler injection. Because laceration may compromise the
vascular network so that the possibility of injection necrosis
increases.
In conclusion, the case we present highlights that thorough
physical examination and history-taking are the most fundamental
aspects in preventing complications caused by filler injection.
REFERENCES
1. Schanz S, Schippert W, Ulmer A, et al. Arterial embolization caused
by injection of hyaluronic acid (Restylane). Br J Dermatol 2002;
146:928–929
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Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

2. American Society of Plastic Surgeons, 2014. Plastic Surgery statistics
Report. Available at: https://www.plasticsurgery.org/news/plastic-
surgery-statistics/. Accessed October 20, 2015.
3. Grunebaum LD, Bogdan Allemann I, Dayan S, et al. The risk of alar
necrosis associated with dermal filler injection. Dermatol Surg
2009;35:1635–1640
4. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of
dermal filler complications. Aesthet Surg J 2011;31:110–121
5. Inoue K, Sato K, Matsumoto D, et al. Arterial embolization and skin
necrosis of the nasal ala following injection of dermal fillers. Plast
Reconstr Surg 2008;121:127e–8e
6. Kang MS, Park ES, Shin HS, et al. Skin necrosis of the nasal ala after
injection of dermal fillers. Dermatol Surg 2011;37:375–380
7. Hanke CW, Higley HR, Jolivette DM, et al. Abscess formation and local
necrosis after treatment with Zyderm or Zyplast collagen implant. J Am
Acad Dermatol 1991;25:319–326
8. Sun ZS, Zhu GZ, Wang HB, et al. Clinical outcomes of
impending nasal skin necrosis related to nose and nasolabial fold
augmentation with hyaluronic acid fillers. Plast Reconstr Surg
2015;136:434e–441e
9. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating
dermal filler complications. Plast Reconstr Surg 2006;118:
92S–107S
10. Lafaille P, Benedetto A. Fillers: contraindications, side effects and
precautions. J Cutan Aesth Surg 2010;3:16–19
11. De Boulle K, Heydenrych I. Patient factors influencing dermal filler
complications: prevention, assessment, and treatment. Clin Cosmet
Investig Dermatol 2015;8:205–214
12. United States Food and Drug Administration; Center for Devices and
Radiological Health; Office of Device Education. Executive Summary–
Dermal Filler Devices. Silver Spring, MD: United States Food and Drug
Administration; Center for Devices and Radiological Health; Office
of Device Education; GPO; 2008. Available at; https://www.fda.gov/
ohrms/dockets/ac/08/briefing/2008-4391b1-01%20-%20FDA%20
Executive%20Summary%20Dermal%20Fillers.pdf. Accessed March
27, 2017

2 # 2017 Mutaz B. Habal, MD

Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.