Emergency Care Copy

Emergency Care



What You Should Know about Necrosis 

 Necrosis is caused by a lack of blood and oxygen to the tissue. It may be triggered by chemicals, cold, trauma, radiation or chronic conditions that impair blood flow. There are many types of necrosis, as it can affect many areas of the body, including bone, skin, organs and other tissues.

One common type of necrosis is caused by damage from tissues after dermal fillers. Any time blood flow is blocked to an area, i.e. with filler or an area is so damaged that blood cannot flow to and from it, necrosis may be possible.

Injection necrosis is a rare, but important, complication associated with dermal fillers. Necrosis can be attributed to one of two factors—an interruption of vascular supply due to compression or frank obstruction of vessels by direct injection of the material into a vessel itself.

The Use of Hyaluronidase in Aesthetic Practice


There are several sources of hyaluronidase and they are generally divided into 3 subgroups (Meyer7), mammalian (obtained from the testis), hookworm/leech and microbial although recombinant human hyaluronidase is now available (Hylenex, from Halozyme Therapeutics, San Diego, California) which has a purity of 100 times higher than some currently used Bovine preparations8. There are no long-term data for this product yet but it is likely to have a lower proportion of allergic reactions.

This guidance refers to the use of Hyalase® (Wockhardt) which is readily available in the UK as a 1500 unit ampoule of powder for reconstitution and is of ovine (sheep) origin.


Off-label use of hyaluronidase

Although hyaluronidase is not licensed for the use in correcting problems with dermal filler injections and off-label promotion is not allowed by Article 87 of Directive 2001/83/EC, its use is allowed provided the patient’s best interest and autonomy are respected and forms part of the informed consent (MHRA, 2009).

What should be treated?

Vascular compromise as a result of hyaluronic acid filler injection should be treated immediately (refer to Aesthetic Complications Expert Group, Necrosis guidance). Signs of impending necrosis include pain, prolonged blanching (reticulated white or dusky appearance of the skin) and coolness of the skin. Hyaluronidase should be administered as soon as this complication occurs, there is good evidence that tissue necrosis will be prevented or be less severe the sooner the hyaluronidase is injected5.

The Tyndall effect refers to the scattering of light that may be seen in some patients after injection of hyaluronic acid resulting in a bluish hue of the skin (refer to Aesthetic Complications Expert Group, Tyndall’s effect guidance). It is often caused by injecting too superficially, placing large boluses of product in one area or using an inappropriate product for the area treated. It is most commonly seen in the sub ocular region. By degrading the hyaluronic acid using hyaluronidase, this problem can usually be corrected.

Overcorrection or misplacement of hyaluronic acid filler can be successfully treated with hyaluronidase although this is often caused by poor injection technique or poor choice of product for a particular area.

Lumps or nodules that may appear several months after the initial treatment may be amenable to hyaluronidase (refer to Aesthetic Complications Expert Group, Delayed Onset Nodules guidance). It is important to remember that hyaluronidase is used to help diffuse fluids intradermal and for hypodermoclysis so if the nodule is thought to be infective, it is important to administer antibiotics to prevent further spread of infection (refer to Aesthetic Complications Expert Group, Infection guidance).


Storage and reconstitution

It is recommended that hyaluronidase should be stored at cool temperatures (2-8oC) as this guarantees the quality of the product over a long period. If storage is at room temperature (25oC), the stability is only guaranteed for 12 months.

Hyalase® may be reconstituted with either saline or water for injection. Reconstitution with saline tends to produce less stinging so is recommended. Although local anaesthetics may be used to reconstitute the product, as the enzymatic action of hyaluronidase can be affected by pH, care should be made with diluents. Hyaluronidase is indicated to improve permeation of subcutaneous products so the injection of local anaesthetic as a diluent may lead to wider spread and increased systemic absorption. For this reason, this guidance does not advocate the addition of local anaesthetic.

Reconstitution instructions: Open a 10ml ampoule of saline and add 1ml of saline to the opened ampoule of Hyalase®, ensure the powder is fully dissolved (draw up and expel the syringe a couple of times to ensure complete mixing). Aspirate the 1ml of saline with the reconstituted Hyalase® and re-introduce it into the ampoule of saline. Agitate the ampoule to ensure the Hyalase® is mixed throughout the whole volume of saline. This now gives a concentration of 150 Units/ml. The reconstituted solution can now be drawn up in a 0.3ml or 0.5ml syringe with a 27G or 30G needle. Each 0.01ml graduation represents 1.5 Units.



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