Resolution of Vascular Compromise From Liquid Rhinoplasty Using Hirudo medicinalis Therapy

Hyaluronic acid (HA) fillers are a relatively safe and effective means of cosmetic treatment for the face; however, as the numbers of both patients and injectors continue to rise, reports of adverse events (AEs) and ischemia are increasing. Although visual complications and stroke are the most-feared AEs, skin and underlying tissue necrosis is far more common and can be catastrophic. HA can be dissolved with hyaluronidase, but this does not always resolve ischemia. In some instances, including the case presented here, conventional interventions are inadequate to reverse the progression of ischemia and restore blood flow. In this case study, HA injection of the nasal sidewall resulted in ischemia and impending necrosis of the nasal tip. Following failure of standard-of-care measures to reverse the progression of ischemia and restore blood flow, Hirudo medicinalis therapy was successfully used as an adjuvant treatment. To our knowledge, this is the first report of H. medicinalis therapy for treatment of ischemia and necrosis from aesthetic filler injection. Based on experience here, this approach should be considered for patients who are out of therapeutic options, or as a helpful adjunct to speed resolution of vascular occlusion. In addition, the success of H. medicinalis therapy, which acts locally on the microvasculature, may inform our understanding of the mechanism of vascular occlusion with fillers.