The effect of vasodilator agents on the treatment of vascular complications associated with arterial hyaluronic acid embolism: Evaluation in the rat abdominal flap model

Hyaluronic acid(HA) fillers are the most commonly preferred nonsurgical procedures in aesthetic treatments. Although considered safe, unintentional arterial injection can result in complications such as skin necrosis, blindness, and cerebral ischemia. Hyaluronidase is the only treatment with a consensus on its efficacy in vascular complications. While some approaches suggest the addition of vasodilators to this treatment, it is proposed that vasodilators may exacerbate ischemia and could also be associated with the migration of filler to other angiosomes and systemic circulation. In order to test our hypothesis that vasodilators alone or in combination with hyaluronidase would decrease tissue survival and increase migration of HA particles to adjacent angiosomes in filler embolism, an experimental study consisting of eight groups (6 rats each) was planned. The experimental model was designed based on the bilateral superficial inferior epigastric artery(SIEA). The right SIEA was ligated in Group 1, whereas in Group 2, the right SIEA was embolised with filler. In the other groups, after filler embolisation, subcutaneous or intraarterial hyaluronidase and/or papaverine were administered. After indocyanine green angiography and photography on the 3rd day, the subjects were euthanised. The viable / total flap area was analysed from the photographs. In the tissue samples, presence of HA, SIEA recanalisation, the primary angiosome inflammation were evaluated. The rate of adjacent angiosomes containing HA were calculated. The highest survival rate was recorded with hyaluronidase and the lowest with papaverine and combined administration. The highest rates of adjacent angiosomes containing HA, were recorded with combined, followed by papaverine administration. This data indicates that vasodilators compromise tissue viability and enhance the passage of HA through vascular connections, particularly when used in conjunction with hyaluronidase. Keywords: filler embolism, hyaluron,dase, hyaluronic acid filler, vascular complication, vasodilator