AESTHETIC SURGERY

Ischemic Oculomotor Nerve Palsy and Skin Necrosis Caused by

Vascular Embolization After Hyaluronic Acid Filler Injection
A Case Report
Seung Gee Kwon, MD,* Jong Won Hong, MD,* Tai Suk Roh, MD, PhD,* Young Seok Kim, MD,*
Dong Kyun Rah, MD, PhD,* and Sung Soo Kim, MDÞ

Initial physical examination showed chemosis, conjunctival

Abstract: Hyaluronic acid filler injection is widely used for soft tissue aug-
injection, and corneal edema. The patient also presented decreased
mentation. However, there can be disastrous complications by direct vascular
visual acuity of 0.3 Snellen, blepharoptosis, a dilated pupil, as well as
embolization. We present a case of ischemic oculomotor nerve palsy and skin
limitations of extraocular movement at medial, up and down gaze, and
necrosis after hyaluronic acid filler injection on glabellar.
exotropia. Ecchymosis and discoloration with swelling were noted on
Blepharoptosis, exotropia and diplopia developed suddenly after the
the forehead to the nasal dorsum along the angiosome of the supra-
injection, and skin necrosis gradually occurred. Symptoms and signs of ocu-
trochlear and angular artery in a reticular pattern (Fig. 1A). No re-
lomotor nerve palsy continuously improved with steroid therapy. Skin defects
markable findings were found on magnetic resonance imaging and
healed with minimal scars through intensive wound care.
computed tomographic angiography. Internal carotid artery and ver-
Percutaneous filler injection of periorbital areas should be performed
tebral artery angiography were performed to evaluate ophthalmic artery
carefully by experienced surgeons, and the possibility of embolization should
occlusion, and a decrease in the number of retinal and ophthalmic artery
be considered promptly if symptoms develop.
branches was reported (Fig. 2A). Retinal staining was observed on
Key Words: ischemic oculomotor nerve palsy, ischemic 3rd nerve palsy, fundoscopy around the optic disc, which indicated ischemia of retinal
ophthalmic artery embolization, arterial embolization with filler, artery branches (Fig. 2B).
hyaluronic acid filler Aspirin and nicegorline were initially administered along with
conventional eye drops. Systemic steroid pulse therapy was performed
(Ann Plast Surg 2013;71: 333Y334)
for 3 days, and then, oral pills were provided. The skin lesion was
dressed daily with epidermal growth factor spray and sodium hya-
luronate gel for 1 week. Hyaluronidase was injected subcutaneously to
S oft tissue augmentation with various filler injections is becoming
very popular, satisfying the needs of patients for inexpensive, safe,
simple, and minimally invasive procedures. Hyaluronic acid (HA)
the skin lesion. Afterward, topical antibacterial ointment was applied

filler is the most commonly used material. Although percutaneous

filler injection has many of distinct advantages and rarely presents
complications, critical disasters such as a visual loss, nerve or muscle
infarction, as well as skin necrosis caused by arterial embolization
could arise.1Y3
Herein, we report a case of ischemic oculomotor nerve palsy
and skin necrosis after HA (Juvéderm Ultra Plus; Allergan Inc., Irvine,
CA) filler injection for nose augmentation.

CASE REPORT
A healthy 20-year-old woman who underwent nasal dorsum
augmentation with HA filler at a private practice office, suddenly
experienced partial visual disturbance and orbital pain in the right
side of the eye, along with nausea, vomiting, and headache. The phy-
sician who performed the procedure felt bursting right after puncture
and injected the filler carefully while pulling out the needle. After a
few seconds, blepharoptosis, diplopia, and dizziness developed.

Received November 15, 2011, and accepted for publication, after revision, February 6,
2012.
From the *Department of Plastic and Reconstructive Surgery, Institute of Human
Tissue Restoration, and †Department of Ophthalmology, College of Medicine,
Yonsei University, Gangnam Severance Hospital, Yonsei University Health
System, Seoul, Republic of Korea.
Conflicts of interest and sources of funding: none declared.
Reprints: Young Seok Kim, MD, Department of Plastic and Reconstructive Sur-
gery, Yonsei University College of Medicine, Yonsei University Health Sys-
tem, Gang-nam Severance Hospital, 712 Eonjuro, Gangnam-gu, 135-720 Seoul,
Republic of Korea. E-mail: psyskim@yuhs.ac.
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 0148-7043/13/7104-0333
DOI: 10.1097/SAP.0b013e31824f21da
FIGURE 1. A day after the initial filler injection (A). Ecchymosis
and discoloration with swelling were initially noted on the
forehead to the nasal dorsum along the angiosome of the
supratrochlear and angular artery. Exotropia and blepharoptosis
were also observed. Six days after the procedure (B). Up to
1 week, the skin lesion worsened to necrosis. Thirteen days
after the event (C). Almost all of the skin defect was healed
with minimal scarring. D, After 12 weeks, exotropia and
blepharoptosis resolved, and the skin lesion was completely
healed, although some blemishing was still noted.

Annals of Plastic Surgery & Volume 71, Number 4, October 2013 www.annalsplasticsurgery.com 333

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Kwon et al
FIGURE 2. Internal carotid artery angiography shows a decreased
branch of the retinal artery from the ophthalmic artery (A).
Upon fundoscopy, retinal staining besides the optic disc
(arrows) indicates ischemia of the retinal artery branches (B).
until the scab fell off naturally. Empirical intravenous antibiotics were
used to prevent infection and cellulitis for 2 weeks.
Two weeks later, visual acuity improved to 0.6 Snellen and
blepharoptosis resolved partially. Exotropia, diplopia, and limitations
of eyeball movement were improved but not completely. The skin lesion
worsened, and deepithelization developed within the first week (Fig. 1B).
However, after another week, the lesion was almost completely re-
epithelized except for focal minimal dermal defects (Fig. 1C).
Twelve weeks after the procedure, blepharoptosis, strabismus,
and eyeball movement were fully recovered. Only minimal and in-
termittent diplopia still remained but was resolved after 6 months from
the event. Skin defects completely healed leaving only a minimal
blemish (Fig. 1D).
DISCUSSION
The common complications with HA filler injection are nodule
formation, erythema, or inflammation. Vascular embolization and skin
necrosis are very rare.2 Cases of arterial embolization after HA filler
injection have been reported, but they resulted in only skin problems.4
However, a case of embolization after calcium hydroxylapatite filler
injection that resulted in oculomotor nerve palsy has been reported.5
Oculomotor nerve palsy by embolization from HA filler has not been
previously demonstrated.
Exotropia and blepharoptosis were presented in this patient,
indicative of oculomotor nerve palsy. Ischemia of the ophthalmic
artery resulted in oculomotor nerve palsy. We suppose that the emboli
of the HA filler enters the dorsal nasal artery and flows retrograde
to the ophthalmic artery and retinal artery. Angiographic and fundo-
scopic findings suggested direct embolization of the ophthalmic ar-
tery. Sudden infarction of the retina and oculomotor nerve was the
cause of visual loss, blepharoptosis, ocular muscle palsy, and exo-
tropia. Also present were the nasal dorsal artery and its terminal
branches at the glabellar region connecting with the distal portion of
the ophthalmic artery from the intraorbit. For this reason, even su-
perficial injection may be a source of emboli to orbital vasculature.
Juvéderm Ultra Plus has a high proportion of cross-linked HA and is
334 www.annalsplasticsurgery.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery & Volume 71, Number 4, October 2013
purportedly better for volumizing deep tissue than previously used
fillers.6 In this case, the injection plane was deeper than the dermal
layer, which may increase the possibility of direct puncture of vessels.
As it was impossible to remove the emboli, steroid therapy and
conventional conservative eye care were performed. LowYmolecular
weight heparin could be considered to prevent thrombosis.4,7 Hyal-
uronidase may have an effect on relieving edema or lumpiness but
not for lysis of emboli in vessels. If strabismus or blepharoptosis
persists, surgical correction may be necessary.
Blood circulation of the glabella is supplied by the supratro-
chlear and angular artery, which are terminal branches of the nasal
dorsal artery, without collateral circulation.7,8 Owing to embolization
of a proximal lesion of these vessels, skin necrosis developed, starting
with edema, ecchymosis, and then deepithelization. Minimal com-
plications after HA filler injection, such as erythema, nodules, or
discoloration, can be easily managed by conservative care or hyal-
uronidase injection.8Y10 On the other hand, if skin necrosis develops,
intensive wound care with appropriate materials is essential. Further-
more, if defects are deep, surgical intervention should be considered.
Once necrosis has occurred, intensive wound care should be
followed, including moisturizing the wound and preventing infection.
We initially used epidermal growth factor to accelerate reepithelization
and sodium hyaluronate gel to induce neovascularization and maintain
humidity.
To avoid direct infiltration of the fillers into the glabellar
area, precautions should be taken when infiltrating epinephrine locally,
using blunt cannulars, medially and superficially injecting a needle,
aspirating before injection and using a low volume in 1 session.7Y11
CONCLUSIONS
Although percutaneous HA filler injection is very simple to
apply, it should be carefully applied, especially in the periorbital area by
an experienced physician with a good understanding of the anatomy of
the facial vasculature and potential risk of embolization. If embolization
develops, steroid therapy may be helpful to control acute symptoms
and appropriate wound management is essential. Also, consultation
and cooperation with ophthalmologists are necessary.
ACKNOWLEDGMENT
Informed consent was received for publication of the figures in
this article.
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* 2013 Lippincott Williams & Wilkins