Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 32, Number 2, March/April 2021
REFERENCES
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FIGURE 2. (A, B) Leech was removed from the patient by forceps.
from natural sources is drunk or while swimming in rivers and lakes.
When leeches enter the body, they may attach to the mucosa of the
entire upper aerodigestive tract. They may rarely cause death in
extreme cases. If leeches are attached to the upper aerodigestive
tract, they can cause dyspnea, hemoptysis or hematemesis, bleed-
ing, or, and in rare cases, Globus sensation.5,7
Leech infestation is observed more in the upper respiratory tract
than in the upper digestive tract. Erdoğan et al8 presented the case of
the patient had leech infestation in the tongue base cause dysphagia.
Another case by Kantekin reported a case of acute Bleeding on the
Floor of Mouth Leech Infestation in a 10-year-child.5 All cases were
diagnosed by indirect endoscopic examination. The leeches were
removed with forceps indirect laryngoscopy under general/local
anesthesia. The removal of the leech should be performed with great
caution because it strongly attaches to the associated mucosa with
its anterior suckers.9 Because the parasite has a slippery surface,
there is a risk of rupture during an intervention. Furthermore, if it
ruptures during surgical intervention, bleeding may continue when
some parts of its mouth remain in the mucosa.10 Anesthesia during
the surgical procedure is very important because of the technique of
removing the parasite. Removal of leeches from the upper airway
being performed under general or topical/local anesthesia.8 If the
leech infestation area is near the lower airway such as the inter
arytenoid area or epiglottis, there is a risk of aspiration of the
parasite during general anesthesia. Uygur et al11 recommended
tubeless induction anesthesia with mask ventilation for the removal
of a laryngeal leech, whereas Alioglu et al10 preferred removal of
the parasite without local anesthesia to prevent the inhibition of
reflexes for aspiration. We removed the leech under topical anesthe-
sia because the gag reflex did not permit the surgical intervention.
CONCLUSION
A live leech in the hypopharynx region should be considered in the
differential diagnosis of patients presenting with dysphagia, sen-
sation of a foreign body, and bloody saliva. Rural areas and
contaminated or unfiltered spring water drinking are predisposing
factors for leech infestations in the upper airway. The surgeon and
the anesthesiologist should take the necessary measures to avoid
hazardous complications such as aspiration and even death during
the surgical procedure.
e120
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1. Zengin Y, Gündüz E, Içer M, et al. A rare cause of Epistaxis due to leech
infestation. JAEMCR 2014;5:197–199
2. Shitaye N, Shibabaw S. Severe anemia due to pharyngeal leech
infestation; a case report from Ethiopia. BMC Surg 2017;17:102
3. Oğhan F, Güvey A, Özkiriş M, et al. Oropharyngeal leech infestation
and therapeutic options. Turkiye Parazitol Derg 2010;34:200–202
4. Al-Hadrani A, Debry C, Faucon F, et al. Hoarseness due to leech
ingestion. J Laryngol Otol 2000;114:145–146
5. Kantekin Y, Sari K, Özkiriş M, et al. An unusual cause of bleeding on the
floor of mouth: leech infestation. Turkiye Parazitol Derg 2015;39:323–
325DOI: 10.5152/tpd.2015.4254
6. Adam R, Zakrzewski P. Therapeutic use of leeches. Univ Tor Med J
2001;79:65–67
7. Mekonnen D. Leech Infestation. the unusual cause of upper airway
obstruction. Ethiop J Health Sci 2013;23:65–68
8. Erdoğan O, Ismi O, Vayisoğlu Y, et al. An Unusual Cause of Dysphagia:
Live Leech in the Tongue Base. Turk Arch Otorhinolaryngol
2015;53:192–194
9. San T, Gürkan E, Karaaslan A, et al. An unusual cause of hemoptysis:
leech in the supraglottic region of the larynx. J Craniofac Surg
2014;25:531–532
10. Bulent A, Ilknur O, Beray S, et al. An unusual cause of hemoptysis in a
child: live leech in the posterior pharynx. Trop Biomed 2010;27:208–
210
11. Uygur K, Yasan H, Yavuz L, et al. Removal of a laryngeal leech: a safe
and 20 effective method. Am J Otolaryngol 2003;24:338–340
Clinical Management of Nasal
Skin Necrosis Caused by
Hyaluronic Acid Filler
Marcelo Germani Vieira, DDS,
Daniel Augusto Machado-Filho, DDS, MS,
Allan Rafael Alcantara, DDS, Adriana Mendonça, DDS,
Jun Ho Kim, DDS, MS,y
and Arthur Rodriguez Gonzalez Cortes, DDS, PhDyz
Abstract: Nose augmentation with Hyaluronic acid (HA) fillers has
been considered the preferred technique for minimally invasive
From the Pròspere Facial Institute, No. 300, Avenida Moema; yDepartment
Stomatology, School of Dentistry, University of São Paulo, No 2227,
Avenida Professor Lineu Prestes, São Paulo, SP, Brazil; and
zDepartment of Dental Surgery, Faculty of Dental Surgery, University
of Malta, Block A, Level 0, Mater Dei Hospital, Msida MSD, Malta.
Received May 14, 2020.
Accepted for publication June 1, 2020.
Address correspondence and reprint requests to Jun Ho Kim, DDS, MS,
Department of Stomatology, School of Dentistry, University of São
Paulo, Avenida Professor Lineu Prestes, 2227, Zip code: 05508-000, São
Paulo, SP, Brazil; E-mail: jun.kim@usp.br
The patient signed an informed consent to confirm her will to participate in
this report, the guidelines of declaration of Helsinki were followed in this
report.
The authors declare to have no conflicts of interest related to this study.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2020 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000006847
# 2020 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 32, Number 2, March/April 2021
cosmetic procedures. Despite severe complications related to HA
injection are rare, none of the existing treatment protocols has been
established as standard. The aim of this report is to present an
alternative approach to treat nasal skin necrosis related to HA
injection. A high dose of hyaluronidase – 6000 IU was applied
in the nose, for the purpose of reversing a necrotic process. The
present findings suggest that a high dose of hyaluronidase could be a
promising approach to treat severe nasal skin necrosis caused by
HA filler.
Key Words: Adverse effects, hyaluronic acid, injections, skin
necrosis
N onsurgical rhinoplasty with Hyaluronic acid (HA) fillers has
become one of the most common, safe, effective, reproduci-
ble, and preferred procedures for nose augmentation worldwide.1– 3
With the current popularity of dermal fillers in facial cosmetic
surgery, an increase in prevalence of related complications has been
expected.1,2
Despite complications are rare, detailed knowledge of anatomy,
clinical indications, and properties of the fillers is required to
achieve successful outcomes in nonsurgical rhinoplasty. Among
the recommended clinical approaches are: aspiration before injec-
tion, use of a blunt cannula to reduce the risk of accidental
intravascular fillers injection and/ or extravascular filler com-
pression, and slow speed of injection with small amount of fil-
lers.2 –5
The most severe complication in nonsurgical rhinoplasty is soft
tissue necrosis. It is caused due to interruption of the vascular
supply to the area by direct injury to the vessel or by externally
compressing the vasculature of the nose skin. Such situation may be
caused by excessive intradermal injection of fillers such as HA.3,4
To reverse undesirable effects of HA, hyaluronidase may be
used to dissolving peptide bonds in long-chain proteins within
HA.1–9 However there is no defined dose and use protocols of
hyaluronidase for treating nasal skin necrosis.
Thus, the aim of this article is to report a case of nasal skin
necrosis due to HA filler injection for nose augmentation procedure,
treated with a high dose of hyaluronidase.
PATIENT
A 21-year-old female patient presented with a history of persistent
pain following nasal injection of HA filler during cosmetic facial
therapy. The patient did not know the amount of HA used by the
dermatologist, who attempted to treat the aforementioned compli-
cation with low powered laser 5 days before patient’s initial
attendance at the clinic of this study.
In the first clinical appointment, initial anamnesis and photo-
graphic documentation were taken. A necrotic skin area of with
discoloration, tenderness, paresthesia and pain extended from the
FIGURE 1. Photographic documentation taken (A) 5 days after injection of HA.
A necrotic skin area of with discoloration, tenderness and pain extended from
the nose tip to the right upper lip. (B) 2 hours after hyaluronidase application.
(C) The patient returned with no symptoms and flesh nose skin aspect after six
days of procedure with hyaluronidase and postoperative prescriptions.
# 2020 Mutaz B. Habal, MD
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
nose tip to the right upper lip (Fig. 1A). A treatment protocol based on
administration of hyaluronidase was adopted, following previous
similar methodology.8 We used 2000 IU of hyaluronidase resulting in
a concentration four times higher than the described in the literature.
Accordingly, three doses of hyaluronidase were applied in the
same day (a total of 6000 IU) with cannula G22 under anesthesia of
the infratrochlear and external nasal nerve, as well as of the area
around the cannula with mepivacaine without adrenaline. Hyalur-
onidase was then applied at the nasal dorsum, with retro-injections
and rotating the cannula. Additional applications at the columella
and nasal spine region were also performed.
Two hours immediately after procedure, another application was
performed with cannula and needle to apply on superficial nasal
tissues. No pain was reported by the patient during this procedure,
facilitating needle application. No immediate changes in skin color
or symptoms were noted after the procedure (Fig. 1A and B), and
the patient was dismissed. Postoperative prescriptions and pro-
cedures were recommended to the patient as observed in Supple-
mentary Digital Content, Table 1, http://links.lww.com/SCS/
B636.6,8
Follow-up conditions were gradually improved. On the sixth day
of follow-up, the patient returned with no symptoms and flesh nose
skin aspect (Fig. 1C).
DISCUSSION
As observed herein, hyaluronidase therapy is useful to reverse skin
necrosis cause by excessive amounts of HA fillers.7 Despite previous
studies recommended to treat nasal skin necrosis early as possible,1,3
the present approach involving hyaluronidase was delayed due to an
interval of five days from the complication to the patient’s first
attendance. On the other hand, the favorable results observed herein
supports previous studies confirming that it is possible to reverse HA
related necrosis with hyaluronidase injection.
Furthermore, despite previous studies6,8,9 have described lower
doses of hyaluronidase (ie, from 150 IU to 1500 IU) as sufficient,
a higher dose of hyaluronidase (6000 IU) could also be used
efficiently to treat pressure skin necrosis. A high dose of hyalur-
onidase applied to compensate of treatment delay (5 days). As
observed herein, knowledge and familiarity with the prevention,
presentation, and immediate treatment of the adverse events is
essential for attaining the best possible outcome.
Within the limitations of the present report, our findings suggest
that nasal skin necrosis due to excessive amount of HA fillers can be
efficiently treated with high doses of hyaluronidase.
REFERENCES
1. Han J, He Y, Liu K, et al. Necrosis of the glabella after injection with
hyaluronic acid into the forehead. J Craniofac Surg 2018;29:e726–e727
2. Park TH, Seo SW, Kim JK, et al. Clinical experience with hyaluronic
acid-filler complications. J Plast Reconstr Aesthet Surg 2011;64:892–896
3. 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–e441
4. Bertossi D, Giampaoli G, Verner I, et al. Complications and management
after a nonsurgical rhinoplasty: a literature review. Dermatol Ther
2019;32:e12978
5. Beleznay K, Humphrey S, Carruthers JD, et al. Vascular compromise
from soft tissue augmentation: experience with 12 cases and
recommendations for optimal outcomes. J Clin Aesthet Dermatol
2014;7:37–43
6. Signorini M, Liew S, Sundaram H, et al. Global aesthetics consensus:
avoidance and management of complications from hyaluronic acid
fillers-evidence- and opinion-based review and consensus
recommendations. Plast Reconstr Surg 2016;137:961e–e971
7. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse
events and treatment approaches. Plast Surg Nurs 2015;35:13–32
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Brief Clinical Studies The Journal of Craniofacial Surgery
8. DeLorenzi C. New high dose pulsed hyaluronidase protocol for
hyaluronic acid filler vascular adverse events. Aesthet Surg J
2017;37:814–825
9. Robati RM, Moeineddin F, Almasi-Nasrabadi M. The risk of skin
necrosis following hyaluronic acid filler injection in patients with a
history of cosmetic rhinoplasty. Aesthet Surg J 2018;38:883–888
Assessment of Freestyle Local
Facial Perforator Flaps for
Coverage of Facial Defects
Mohamed A. Ellabban, MD, Ahmed M. Ibrahim, MSc,
Amr A. Gomah, MD, Omar Salah, MD,
Islam Abdelrahman, MD,y Ingrid Steinvall, PhD,y
Osama A. Adly, MD, and Ahmed M. Aboelnaga, MD
Objective: To assess local freestyle facial perforator flaps in the
reconstruction of small to medium-sized facial defects.
Materials and methods: In a case series, local freestyle perforator
flaps were used in Suez Canal University Hospital to reconstruct 28
facial defects in 26 patients between 2017 and 2019. Adequate
perforators were identified near those defects and flaps were
designed as propeller or VY advancement. Four scales from the
FACE-Q (satisfaction with facial appearance, satisfaction with the
outcome, psychological function, and appearance-related psycho-
social distress) and 2 scales from the SCAR-Q (Appearance scale
and Symptom scale) were used as well as the observer part of the
Patient and Observer Scar Assessment Scale. The mean follow up
period was 10 months.
Results: Complete reconstruction was achieved in all cases with a
high rate of patient satisfaction which was assessed by FACE-Q and
SCAR-Q. Moreover, observer assessment by Patient and Observer
Scar Assessment Scale score showed high patient satisfaction with
the scars with a mean (SD) 15.5 (3.4) and there was a positive
correlation between subjective and objective: results (r2 from 0.27
to 0.41, P < 0.01). Regarding complications, bulkiness occurred in
2 flaps, congestion in 2 flaps, dehiscence in 1 flap, and tip necrosis
in 5 flaps. Accordingly, secondary intervention in the form of
medicinal leech therapy was used in 3 flaps, delayed closure for
the dehisced flap and debulking for 1 flap.
From the Plastic and Reconstructive Surgery Unit, Surgery Department,
Suez Canal University, Ismailia, Egypt; and yDepartment of Hand
Surgery, Plastic Surgery and Burns, and Department of Clinical and
Experimental Medicine, Linköping University, Linköping, Sweden.
Received May 14, 2020.
Accepted for publication June 1, 2020.
Address correspondence and reprint requests to Mohamed A. Ellabban, MD,
Suez Canal University Hospitals and Medical School, 4.5 Ring Road,
Ismailia, Egypt; E-mail: mohamed.ellabban@med.suez.edu.eg
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2020 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000006848
e122 # 2020 Mutaz B. Habal, MD
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 32, Number 2, March/April 2021
Conclusions: Local freestyle perforator flap reconstruction is one
of the recommended techniques for small to medium-sized
facial defects which gives a high aesthetic outcome and patient
satisfaction.
Key Words: Face-Q, facial perforators, facial reconstruction,
POSAS, SCAR-Q
T he use of perforator flaps evolved extensively in reconstructing
different body defects using fasciocutaneous flaps with preser-
ving the underlying muscles after the description of more than 274
perforators in the body by Taylor and Palmar.1 In 1989, Koshima
and Soeda2 introduced the concept of perforator flaps followed by
Mardini et al3 who introduced freestyle free flaps for the first time in
2003. In 2005, Hofer et al4 introduced facial artery perforator flaps
for reconstructing facial defects by using a hand-held Doppler to
detect the perforators and then design the flap in the form of either
advancement or propeller.
Given the abundance of perforators in the face and after studying
the angiosomes by Taylor et al,5,6 defects in any facial subunit can,
in theory, be covered by using nearby perforators in designing
freestyle local perforator flaps especially for reconstructing check,
nasal, peri-nasal regions, preauricular and periorbital defects.
Freestyle local perforator flaps give the advantage of like with
like reconstruction in addition to a versatile vascular perforator
supplying the flap giving its free mobility and avoid the two-staged
reconstruction using pedicled flaps.7 In recent years, new tools have
been introduced to assess patient satisfaction after facial defects
reconstruction such as the FACE-Q8,9 and SCAR-Q.10
The aim was to evaluate local freestyle facial perforator flaps in
the reconstruction of different facial defects focusing on the aes-
thetic outcome and psychological aspect after the operation using
subscales of the FACE-Q and SCAR-Q, and the observer part of the
Patient and Observer Scar Assessment Scale11 (POSAS).
METHODS
In a case series, we performed local freestyle perforator flap
technique to reconstruct 28 facial defects in 26 patients (Supple-
mentary Digital Content, Table 1, http://links.lww.com/SCS/B650)
between September 2017 and February 2019. Follow up period was
6 to 18 months with mean (SD) 10.0 (3.7) months. All patients who
presented with small to medium-sized facial defects were included
in the study, regardless of their age or comorbidities.
We have been provided permission to use FACE-Q and SCAR-Q
in our nonfunded research. The FACE-Q is a validated instrument to
assess patient-reported outcomes after reconstruction of the facial
defects. The instrument is composed of numerous independently
functioning scales of which the scales used in our study were
Satisfaction with Facial Appearance, Satisfaction with Outcome,
Psychological Function, and Appearance-related Psychosocial
Distress Each Face Q scale has its series of questions that evaluate
one central concept. Scar Q10 was used for scar satisfaction
evaluation. It is formed of 3 scales; Appearance scale, Symptom
scale, and Psycho-Social scale. Scales used in the study were the
Appearance and Symptom scale. Each scale was converted into a
score from 1 to 100 (Rasch score), the higher the score the greater
the satisfaction, except for the score Appearance-related Psycho-
social Distress where higher values represent greater severity of
psychosocial distress. Each scale is independent and has its own
total score.
The observer scale of the POSAS was used also, where three
specialists in plastic surgery (at least 5 years experience) made the
assessment of the following items; the scar including; vascularity,