New Case Submission - Location: Forehead
Submitter Credentials: MD
Case Variables:
Location: Forehead
Product: HA Filler
Sign: Pustules / Blistering
Onset: Immediate
Tx: Hyaluronidase (Tissue Flooding)
Outcome: Partial Resolution / Scarring
History & Presentation:
35-year-old healthy woman underwent cosmetic forehead HA filler injection (Juvéderm, Allergan, Inc.) using a blunt-tip cannula at an outside clinic. Needle/cannula gauge, injection depth, volume, and specific anatomical approach were not reported. Immediately post-procedure, the patient experienced severe pain but did not seek same-day treatment. By day 2, she noted discoloration extending from the nasal root to the scalp. She received two doses of 900 U hyaluronidase (1,800 U total) at the originating clinic without clinical improvement, and ischemia continued to progress. By day 3, she developed well-demarcated erythema, worsening discoloration, and pustules, prompting presentation to the treating clinic. Examination revealed a clear zone of erythema and livedo reticularis indicating advanced vascular compromise with impending skin necrosis.
Management Protocol:
High-Dose Pulsed Hyaluronidase (HDPH) protocol initiated on day 3 post-injection, with doses spaced approximately 1 hour apart:
Day 3 post-injection (Day 1 of HDPH): 1,500 U + 1,500 U + 3,000 U = 6,000 U
Day 4 post-injection: 5 doses × 3,000 U = 15,000 U
Day 5 post-injection: 3 doses × 2,200 U = 6,600 U
Day 6 post-injection: 2 doses × 2,200 U = 4,400 U
Total: 32,000 U over 4 days
Initial dose selection was guided by DeLorenzi guidelines, based on clinical severity and anatomical extent. Dose tapering was guided by daily resolution of ischemia signs (color return, warmth, resolution of pustules). Supportive care: cefcapene pivoxil (oral antibiotic), loxoprofen and acetaminophen for pain.
Clinical response timeline:
Day 7: Significant reduction in erythema and pustules; early epithelialization
Day 30: Complete epithelialization with minimal scarring
Day 90: Near-complete recovery with subtle textural changes only
Day 180: Barely perceptible scar; minimal residual effects
