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spasticated

What kind of scars are these, and is there anything I can do about them at home? Vascular Occlusion Necrosis from Filler Injection - Artery / Vein

Both of these scars are from cysts. They are very noticeable when light hits from certain angles because they are sunken spots on my skin. Are they rolling scars? Will TCA Cross method work on these scars? Or are these the type of scars that I will have to do subcision + filler to see results with? I am hesitant to go the subcision route because it costs a couple thousand in my area. If there is any hope to treat them at home I would be open to ideas.

Currently I've been doing:

TCA Peels once a month
Derma rolling once a month
Tretinoin

Been doing this all for about 5 months now. The scar on my upper cheek is 2 years old. The scar on the bottom is 6 months old.

Any help is appreciated, thank you.

20180829_192938.jpg

Edited by spasticated

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I would not bother with a bunch of at home stuff. Why you have straight forward rolling scars. Subcision and filler will help them. Can be affordable if you do one treatment a year.

If you wish you can try retin-a/tretinorin/differin nightly when not treating, and perhaps some light peels like glycolic. Dermastamping them is another option. You will get the most improvement with the above.

BA

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Super easy fix.  Also agree, just go straight to subcision and fillers.  This shouldn't take more than one session to fill.   The rest of your skin is excellent.

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3 hours ago, beautifulambition said:

 

Thank you for the responses. I am going to get a consultation tomorrow for a subcision. On the phone the lady told me that a subcision would be ~$800 and filler (hyaluronic acid) would be another ~700. Do these prices sound right? I am in Canada.

Also what would be better: 2x treatments of subcision without filler ($1600) OR 1x treatment of subcision with filler ($1500) 

Edited by spasticated

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@spasticated Depends on where you live, ... get 3 consultations in CAN to be sure.

You can do one treatment of sub with no filler and the 2nd and 3rd do filler if you wish, ... see if they will save half of the syringe for the next treatment. Treat over time, ... derms push quick treatment. They need to subcise this area of deficiency.  

If Filler is not affordable, ... get it once a year and save up.

BA
 

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Hi guys I went through with the surgery. I am going to upload some pictures of the progress. I am worried that one of the areas is infected though and it's a holiday weekend so nothing is open at the moment. Can anyone let me know what they think? 

Immediately after the subcision:
5bbb967c243dc_Day0.thumb.png.8f9b86d8e35aa8f53733f4f5b1de9a51.png

Here is the area I am concerned about after 2 days. The thing that concerns me is the white pimples that are surrounding the area, there are 3 of them on day 2 and more on day 3:5bbb966c09b98_after2days.png.0bc85bdb2842d418ccdbbd0aeb8ae0d6.png


Here is day 3 (today):
5bbb9670f2a28_after3days2.png.34e5cab601591ce486f49ef824cde75a.png5bbb966e2e4e0_after3days.png.564e4695cd1a2d4d3cbc74763fc6e8bd.png


It's not too clear in the last picture but there are several little white pimples all over the cut, probably 8-10. Is there cause for concern? The procedure was just subcision + hyaluronic fillers after 

Also I've been putting polysporin on the areas, is that okay? It wont interact with the filler or anything and affect the scar healing process will it?

Edited by spasticated

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This is 100% arterial occlusion over the branch of the angular aa. Hylase ASAP , add the usual Aspirin, Nifedipine, etc... should heal in time. This is a medical emergency. White pustulation = sterile neutrophils. Seen many of these before. HA is in the end branches of the angular aa., a major branch of the facial aa. You will NOT go blind, but your skin compromised, with the correct wound care, it will be OK, move immediately. Keep us posted. I wish you well. 

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@beautifulambition @Obi wan

Thank you for your replies. I figured something was not right. I am going to the clinic at 2PM to get it treated. When they inject hyalase into the arterial area will it dissolve filler in the other parts of my face too?

Also, just out of curiosity, how come you are certain that I will not go blind? Is it because the arteries that connect to the eye are deeper than this one?


Edit: I went to the clinic and the Doctor injected hyalase and explained what happened and that it was only the 2nd time in her 25 year career that it's happened. She said she is going to give it 6-8 weeks to heal completely then she will do whatever needs to be done on any remaining scars.

Thanks again for the reply you guys, especially Obi Wan, I didn't know how serious it was until I read your post. Edited by spasticated

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 5bbd1022c8b54_afterhyalaseinjection.png.10e9fad14ce231e56197a9517028127d.png

Here is a picture of the area a couple hours after receiving hyalase injections. The swelling has gone down substantially. Do you guys think there will be any permanent damage from this?

Edited by spasticated

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@spasticated Obi Wan is saying because of the Vein/Artery you should be fine to not go blind, he knows his anatomy and how the wound looks (reaction). But you should get it dissolved. I give Obi Wan all the credit for making you aware of the severity here.

Injectors make mistakes, even the top ones, Lim did this once also I recall. When you do thousands of patients it can happen... anatomy can vary slightly - person to person. What's good is we caught the issue early and Obi Wan made yo aware of it's serve nature.  I

Signs of breached your Vein/Artery you displayed to give you proper care with dissolving the HA, Nitropaste, and antibiotic / stimulation.

As Obiwan said you can use blood thinners such as Asprin, spices, meds under your Dr's care. Sounds like she already addressed this.

There are tell tale signs to look for when injecting and this is a classic example why one cannot just subcise them-self (anatomy) or just have someone who injects anywhere. Again I am very sorry this happened to you. It should fully resolve with time (healing), and (optional - you may not need) antibiotic therapy.

In the future, I would do filler again (more experience can use techniques to breach the artery even with a standard needle, or if you wish or cannula injection (Less prone to breach artery). I still think this (flller) is the right solution to your situation if you can hang in there, things will resolve fully.  If you wish to get rid of the lingering redness or PIE / inflammation quicker vascular laser can be used to help or wait for it to naturally resolve.

No other areas need to be reversed as they did not breach veins/arteries - no reactions. 

No you will heal fully, thanks for the pic, it will just take some weeks, you can use some concealer like dermablend - concealer used post surgeries sold at derpartment stores if you wish during the process to hide the PIE.

Sounds like she the DR will now take care of the mistake.

BA



Note: Please note the below is for reference, these are only the major arteries and veins (there are many more) ... everyone's anatomy can vary slightly and is not exact to model, goto a board certified physician who can deal with this.

Arteries of the Face and Neck | Plastic Surgery Key

Thanks to Dr Steven Weiner Florida for this expert protocol to treat Vascular Occlusion after filler. 

 

What is Vascular Occlusion or Vascular Compromise from Dermal Fillers?

Dermal fillers of becoming the fastest growing area of aesthetic enhancements. In general, the procedure of injecting the filler is safe, with very little downtime, and with visible results. However, there is a rare, but extremely significant potential risk, that patient’s, medical staff, and providers need to always be aware of: Vascular Occlusion or Vascular Compromise.

What is Vascular Occlusion or Vascular Compromise? This is caused when the dermal filler is either injected into an artery or around an artery to the point that the blood flow is reduced or completely stopped. The area of skin or other tissues that are supplied by the affected vessel will start to die without the necessary blood supply. Almost always, if this complication occurs, there will be an immediate blanching (paleness, tissue turns white) when the blood flow is interrupted, often in areas far away from the actual injection. Recognition is key to a favorable outcome. If this occurs, the injector must stop immediately and take measures to resolve the problem. Pain is usually associate with vascular occlusion. There have been cases reported that occurred 12-24 hours after being injected but almost always it occurs immediately.

If no treatment is initiated to improve the vascular flow, the skin will start to appear dusky, a bluish tint, with fine reticulations (lace like) to areas WELL BEYOND THE SITE OF INJECTION. This occurs within 24 hours. If still no therapy is done, the skin will start to die, turning black, and sometimes there is an associated infection. At this point, scarring will likely occur and surgery is often needed to remove dead tissue and/or to close the wound.
If there is a recognized vascular event, several steps should be initiated.
 
  1. Hyaluronidase, an enzyme that dissolves Hyaluronic Acid, should immediately be injected in the area, and into the vessel if possible. Some doctors advocate using hyaluronidase even if the filler is not an HA filler because it will dissolve the naturally occurring hyaluronic acid hopefully improving blood flow.
  2. Massaging the area will help mostly if the filler is externally pushing on the vessel. This might move the filler away from the vessel to re-establish flow.
  3. Blood thinners will allow the blood to flow thru a smaller vessel or to go around a blockage. Aspirin and possibly heparin are recommended by most physicians.
  4. Vasodilators such as nitroglycerin are also recommended by most physicians. There is a question as to whether this might allow the blockage to travel further down the vessel.
  5. For severely vasacular compromised tissue, hyperbaric oxygen treatments are beneficial.
Administering dermal fillers with blunt tip cannulas will minimize the chances of a vascular event. The fact that the ends of the cannulas are rounded, makes it very difficult to enter a vessel, particularly with the larger cannulas. To the author’s knowledge, there have been no reported events of vascular occlusion with cannulas larger than a 27g. There is still the possibility of causing external pressure on vessels, but this seems to be a low risk, and mainly associated with fillers that expand, like the HA fillers.

The areas prone to vascular events are areas of the face that are called “watershed areas”. These are areas where there is poor collateral blood supply. These areas are:
  1. Glabella
  2. Under the eye
  3. Nose and around the nasal ala (nostrils)
  4. Nasolabial folds
  5. Upper lip
The catastrophic complication of blindness from dermal fillers is also a form of vascular occlusion. This is when a bolus of dermal filler is injected into an artery in such a way that it travels back to the vessels supplying the retina. Not only does the injector have to be within an artery, but he/she has to exert a force of injection that overcomes the blood pressure (retrograde flow) in the vessel. This is an extremely rare occurrence but unfortunately is almost universally irreversible.

Prevention is key to avoiding a vascular event with dermal fillers. The safest fillers are the HA fillers which can readily be dissolved with hyaluronidase. Cannulas should be used in all high risk areas in the author’s opinion. If using needles, aspiration to see if the tip is within a vessel should be done before all injections in these areas. Careful counseling of patients and staff is needed to recognize a potential event early to get the best possible outcome.

Here is a story of a similar situation (Vascular occlusion / Necrosis) and pictures below source: https://www.skinintegrity.com.au/_blog/Skin_Integrity_Blog/post/cosmetic-disasters/

download.jpgnecrosis%20of%20nose.png

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That is a very good write-up from Dr Steven Weiner. The one thing I did immediately notice on the Friday when I had the fillers done is that a section of my skin was colourless (white).. I just assumed it was because she went under that area when she did subcision. But it turns out that is the telltale sign of arterial obstruction (along with all of the little white pimples surrounding the area). The day after is when it bruised and swelled immensely. I wonder if the pressure eventually forced some of the hyaluronic acid out of the way so that just enough blood flow could get through to keep the skin alive, because I didn't get it treated until today and it didn't turn black. That is 72+ hours after the HA blockage. It's unfortunate because I had this all done on the Friday and then it was a long weekend here in Canada and so Monday was a holiday. I had to wait until today to get back to the clinic. 

Hopefully no permanent scarring results from this, but the doctor told me that she will be working with me to ensure that everything looks as it should. She said they will do the appropriate procedures if there are any scars or abnormalities - free of charge. I'm not upset at the doctor as it does seem to be a freak incident, but hopefully she learns from this and recognizes the signs of immediate occlusion. 

Again I want to thank the both of you immensely for everything that you do on these forums. If it was not for your responses I don't know that I would have been in such a rush to get this looked at. I initially thought it was just an infected cut and that it would heal as long as I kept it clean and lubricated with polysporin. 

I will continue to update this thread with my progress. Cheers. 

 

Edited by spasticated

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@spasticated I surmise when you had Nokor or normal needle Subcision. Veins/ Artery was chopped up (this is normal), when filler was administered directly after this occurred the HA went into the venus system. This is why many Dr's are doing subcision with a blunt cannula now instead of the scapel of a nokor or a normal needle. Where she (Dr) went wrong is you do not inject post Nokor subcision or or normal needle (right away) because of excess swelling and chopped up veins. You wait for the swelling to go down and things to heal (there was a risk here), even if she aspirated the needle, everything was raw and open. 

I think you should be fine with no scarring, ... just more filler needed. The recent pic looks very good, just some minor swelling, it will take time. 

Thank you for helping others learn. 

Happy late Thanksgiving - to the CAN's.

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All top injectors will get at least 2 of these per year. Its an odds game. So here is the theory behind WHY this happens so frequently to acne scar patients. Facial anatomy is not normal in acne scar patients. The arteries lie below the fat layer, so one has a buffer. Now, in acne scar patients the abnormal collagen 'picks up the artery. The artery caught up in all the scar tissue - the auriculotemporal aa.  Scar attachments are deep. Now in acne scar patients the artery is very superficial, as fat and dermal atrophy occurs. So even the most inexperienced injectors in the World would know what level to inject, but they do not know the level of the artery, This is why good injectors who perform this procedure will always give their mobile numbers to patients if they cross the facial artery, no matter how superficially they inject. Sterile pustulation precedes total necrosis, so it is good you got it in time. The good news is that this will heal without sequelae, add gentle vascular treatments in 2-3 weeks time as you will experience reactive hyperaemia (redness), if you can see a dermatologist who has done many of these 'salvages' as the pulse duration and energy settings need to be gentle. Silicone patche or liquid can also help. Wish you well. 

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5bbe1eedae220_1dayafterhyalaseinjection.jpg.a7bb7b6a9e30a457345cd26e6801053d.jpg

Here is an updated picture of the area 1 day after my hyalase injection. Still a little swollen and bruised but it looks far better than it did yesterday.

@Obi wan You said that I will experience reactive hyperaemia, is that for sure? When does that usually happen? Is it just a persistent redness that stays even after the bruising disappears? I will talk to my dermatologist about this. Thanks for the response again.

Edited by spasticated

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In some cases you will get reactive blood vessels around the area. The pathology behind this is that collateral vessels will help salvage your skin, much like creeks feeding around a dam (thats HA) blocking the flow of blood vessels. If you get the necrosis early, as you did because there were no necrotic areas (black bits), you may get away with minimal redness. Looking at your area of compromise, you did well by going to the doctor ASAP as suggested. So, stick with your silicone dressing, and I will not interfere with your doctors management as I am not qualified to give medical advice. My suggestion is that gentle remodelling such as Vascular laser should be used at week 3-6. This will 1. Aid in any scarring  2. Decrease Blood Vessels and redness 3. Stimulate collagen remodelling. NOTE the word gentle- hence low power, low fluency, long pulse duration. 
Post again in 8 weeks, and the community will see that if treated early and appropriately there will be no long term complication. Take care. 

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I am curious to know what you guys think on this: is it possible that the edema from the occlusion leads to adipose atrophy much like what happens when you get a cyst? I.e will the skin sink down in the area it was inflamed in? like what happened with the rolling scars that I was initially trying to treat

Edited by spasticated

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@spasticated Without a recent pic hard to determine. I can say your last pic looked good like you would heal. Obi was saying to do V-beam to deal with persistent redness in weeks 3-6. 

If the area was already atrophied aka the scar that was filled, ... the filler is gone, and it will need to be filled again. Your practitioner seems attentive and will fix the problem including filling it when things heal up. Those with scars have extra veins in strange places as the tissues are damaged, so things like this can happen. 

I would not worry about this too much right now unless you see serious concerns, please share and tell your practitioner. Healing is slow. 

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Here is an update about 4 weeks after my last. 

My concerns at the moment are that the nasalfold region is still swollen and creates a noticeable line compared to my other side. It's not that noticeable in this picture but in certain lighting it is. Is it possible that there is still swelling and that it will go down more? Or maybe that there is still filler in there which is what is causing it to be a little swollen? I am going to schedule a meeting with the dermatologist in a week or so. 5be1ca06a2f13_november6th20182.jpg.d9646888456471f27b28ea3dce1afc28.jpg

Edited by spasticated

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Reschedule the appointment. Still swollen. Saves you time to have him or her look at you and say everything is OK.  Here is some advice :

1. Massage the area twice a day, use Vaseline or some ointment like White soft paraffin. Moderate to hard massage around the whole area. 3 minutes twice a day. 

2. Keep going for 4 weeks. Swelling will go down. 

3. Swollen due to  all that has happened including compromised lymphatics, by simple massage this will settle. If you could repost in 4 weeks, this will be great. It can take up to 3 months for swelling to decrease. DO not have any treatments during this time. You do not have reactive redness, so no need for vascular lasers. By adding lasers, or microneedling you can improve blood flow, but swelling is due to LYMPHATIC flow, so- old fashioned massage over lasers. If you have access to a Low Level Diode - 810-830 Heal Lite, it can speed things up, but massage is the way to go. 

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On 11/12/2018 at 1:32 PM, Obi wan said:

 

Thank you sir, I didn't end up scheduling anything as I figured it was still swollen, but you confirmed what I was wondering. I will post another update in a month or so. Thanks again!

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