Case Report

Cosmetic
Managing Complications of Submental Artery
Involvement after Hyaluronic Acid Filler
Injection in Chin Region
Martha Fang, Sp. KK, M. Kes*
Eqram Rahman, MS, MSc, PhD† Summary: Hyaluronic acid dermal fillers are becoming popular all over the world,
Krishan Mohan Kapoor, but due to the presence of many blood vessels in the face, there is always a small
MS, MCh, DNB‡ possibility of vascular complications. We present a case with the ischemic involve-
ment of chin and neck skin after accidental submental artery involvement after
hyaluronic acid filler injection for chin region. Impending skin necrosis on the
chin and upper neck on the right side was diagnosed quickly by observing the skin
changes in the immediate postfiller phase. Pain in the mandible and in the muscles
during swallowing due to possible ischemia of muscles supplied by submental ar-
tery was another crucial diagnostic feature. All parts of the affected zone were treat-
ed with high-dose pulsed hyaluronidase protocol using 4 pulses of hyaluronidase
injection in first 24 hours after filler injection. Complete resolution of cutaneous
ischemic changes and painful swallowing was achieved within days after treatment.
Knowledge of presenting features of postfiller vascular complications and the ex-
tent of vascular territory of the involved artery is quite helpful in quickly i­ nstituting
treatment leading to the near-complete recovery with minimal sequelae. (Plast Re-
constr Surg Glob Open 2018;6:e1789; doi: 10.1097/GOX.0000000000001789; Published
online 25 May 2018.)

H
yaluronic acid (HA) dermal fillers are becoming ­ revious history of 3 ml HA fillers injection in the chin
p
popular all over the world for facial treatments. area 2 months earlier and history of acne in chin area in
However, due to the presence of many blood ves- the past. There was no history of previous health prob-
sels in the face, there is always a small possibility of vas- lems, smoking, or any allergy. She was not on any systemic
cular complications because of accidental intraarterial treatments and not using any topical products.
injection. Although soft-tissue fillers have a very favorable Juvederm Voluma (Allergan Inc., Irvine, Calif.) filler
safety profile, adverse events can rarely happen even in that has a concentration of 20 mg/ml of HA and premixed
the hands of an experienced injector.1 It is imperative for with lidocaine was injected by an experienced injector, us-
aesthetic practitioners to promptly recognize the features ing the 27 G sharp needle in the supraperiosteal plane. In-
of post HA filler vascular occlusion, for management to jection on the chin apex was given in midline using 1.4 ml
begin immediately. of filler followed by 0.3 ml on each side of midline in the
anterior chin area after performing aspiration. The injec-
tion was given slowly and with minimal pressure. All in-
CASE REPORT
jections were given in supraperiosteal plane. Immediately
A 31-year-old Indonesian female patient was injected
after completing the filler injections, blanching of skin on
at a private hospital for chin augmentation. She had the
the right side of chin and upper neck areas was noted. The
From the *Department of Dermatology, Siloam Hospital, Bali, patient complained of excessive pain on the chin spread-
Indonesia; †Department of Anatomy, Institute of Medical and ing to the mandible and gingival area immediately after
Biomedical Education, St George’s University of London, United the injection. She also complained of severe pain during
Kingdom; and ‡Anticlock Clinic, Chandigarh and Department of swallowing. Ten minutes after completion of injections,
Plastic surgery, Fortis Hospital, Mohali, India. livedo reticularis/skin mottling was beginning to show
Received for publication November 11, 2017; accepted March 26, around the blanched skin patch extending from the men-
2018. tal crease to the upper cervical area with skin overlap on
Copyright © 2018 The Authors. Published by Wolters Kluwer Health, the left side across midline in some areas (Fig. 1). The
Inc. on behalf of The American Society of Plastic Surgeons. This decision to dissolve the HA filler material with high-dose
is an open-access article distributed under the terms of the Creative pulsed hyaluronidase was taken immediately. As adjoining
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the Disclosure: The authors have no financial interest to
work provided it is properly cited. The work cannot be changed in declare in relation to the content of this article. The Article
any way or used commercially without permission from the journal. Processing Charge was paid for by the authors.
DOI: 10.1097/GOX.0000000000001789

www.PRSGlobalOpen.com 1
 PRS Global Open • 2018

Fig. 1. Postinjection picture taken 15 minutes after filler injection in

the chin. Skin discoloration and demarcation of the ischemic area
visible in chin and neck.

skin units of the chin and upper neck were involved, 1,000
U of hyaluronidase was injected using a 30 G needle at
chin and neck area, which became demarcated after filler
injection, was injected and 1 cm beyond the demarcated af- Fig. 2. Picture taken immediately after first high-dose pulsed
fected zone was also injected. Within minutes, reperfusion ­hyaluronidase (HDPH) treatment showing reperfusion in the isch-
was noted in most of the involved area (Fig. 2). After 60 emic zone with a small area of blanching (shown by an arrow), still in
minutes, some patches of mottling were still seen in affect- the middle of the ischemic zone.
ed area along with persistence of painful swallowing and a
further 1,000 U of hyaluronidase was injected using a 27
G cannula, passing both in deep and superficial planes. A
cannula was used to avoid the possibility of any additional
bruising. Immediate reperfusion was again noted in resid-
ual mottled skin patches and pain during swallowing also
reduced markedly. The patient was also put on oral Cefix-
ime 200 mg twice daily and acetylsalicylic acid 75 mg once
daily along with topical Mupirocin ointment for 5 days.
During the post-hyaluronidase injection period, there
was no increase in the size of the involved area. After 6
hours, the affected area was injected again with the third
pulse of 1,000 U of hyaluronidase. The patient was sent
home after treating physician was satisfied with perfusion
status of skin. The patient was reviewed after 24 hours of
filler injection, and though most of the areas were well
perfused with some residual pain, the patient was injected
with the fourth pulse of 1,000 U hyaluronidase using a 27
G cannula.
Continuous maintenance of good capillary refill and
improvement in pain in the affected area were considered
the endpoint of hyaluronidase treatment after the fourth
pulse. Forty-eight hours after filler injection, the patient had
developed multiple small pustules over the whole territory.
On the fifth-day postinjection, pustules on the chin started
to dry, leaving some crusts (Fig. 3). Pain in the chin apex Fig. 3. Five days post-hyaluronidase, with skin changes like pustules
and during swallowing was minimal. On the seventh day­ and crusting around the mental crease, extending to the chin apex.

2
Fang and Rahman • Managing Complications of Submental Artery Involvement

and levator labii inferioris and anastomoses with the in-

ferior labial artery. The deep branch passes between the
muscle and the bone, supplies the lip and periosteum of
the mandible, and anastomoses with the inferior labial
and mental arteries.10
The presenting feature of pain during swallowing could
be explained as a sign of ischemia in the arterial branches
to digastric, mylohyoid and platysma muscle, and pain in
mandible and gingiva could be due to ischemia in peri-
osteal arterial branches. Livedo reticularis in this patient
extending from the mental crease down to the upper cervi-
cal area with skin overlap on the left side across midline in
some areas showed that vascular interruption happened in
the territory supplied by the submental artery.
In this case, probability of intraarterial injection is
higher compared with external compression, because of
following features: (1) appearance of immediate blanch-
ing within seconds and livedo in 10–15 minutes; (2) ab-
sence of strong facial bands in the area of injection, which
may cause acute compartment syndrome; (3) immediate
Fig. 4. Cadaveric dissection, demonstrating the course of the sub-
mental artery and its branches and its relationship (shown by an
muscle pain at a site quite distant from point of injection
arrow) to chin injection points. (Picture credits: Krishan Mohan Ka- but within vascular territory of involved artery; (4) devel-
poor). opment of pustules such as lesions in affected skin, possibly
due to micro skin necrosis secondary to microcirculation
involvement.
postinjection, pustules had healed without any residual scar-
Hyaluronidase is very important for managing cutane-
ring, and there was no pain in the chin apex and during
ous complications secondary to intravascular HA filler in-
swallowing. However, some hyperpigmentation and ery-
jection. The dose of hyaluronidase is estimated depending
thema around the mental crease were noted that improved
on the number of adjoining areas affected. The recom-
markedly in next 2 weeks.
mended dose of a minimum of 200–300 units of hyal-
uronidase and up to 1,500 units have been mentioned in
DISCUSSION literature if needed.10 The fine 30 G needle was used for
This case is being presented for injectors to learn very superficial injection, as it is easier to inject superficial-
about the possibility of intraarterial injection in the chin ly with very fine needle, while a 27 G needle was used for
area during filler injection and its management. The chin deeper injection. An estimate of 1,000 units for 2 adjoin-
region is considered a safer area, as very few cases of post- ing areas of chin and neck, as recommended in high-dose
filler vascular complications have been reported in the pulsed hyaluronidase protocol, was used in this case for
literature.2 The presence of submental artery and its com- each pulse. This protocol has proven to be very success-
munication with inferior labial artery and mental artery ful over past 2 years in managing vascular complications
could be basis for a more extensive territory involvement related to filler injections.11
during inadvertent intravascular injection of filling sub-
stance.3 Although vascular complications can be avoided
mostly through detailed knowledge of vascular anatomy,4 CONCLUSIONS
injectors must also learn to recognize the presenting fea- This case report describes successful management of
tures of such complications quickly to institute hyaluroni- impending skin necrosis resulting from the involvement
dase-based treatment protocols.5,6 of submental artery after HA fillers injection. The sub-
The submental artery is the largest branch of the facial mental artery presents a potential risk factor for the vascu-
artery in the neck with an average diameter of 1.69 mm7 lar accident during chin filler injections. Quick diagnosis
(Fig. 4). The average size of the territory supplied by sub- of vascular obstruction and identification of involved arte-
mental artery is significant and measures 45 ± 10.2 cm.8 rial territory was helpful in managing the ischemic zone
The facial artery gives origin to the submental artery successfully with hyaluronidase-based treatment protocol.
behind or at the superior edge of the submandibular Krishan Mohan Kapoor, MS, MCh, DNB
gland.9 The submental artery runs antero-medially below #1508, Sector 33 D
the mandible and then runs superficial to the mylohyoid Chandigarh-160022
muscle to reach the chin. It gives off some branches to the India
submandibular gland and perforating branches to the pla- E-mail: [email protected]
tysma and mylohyoid muscles. The terminal branches of
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