Cosmetics Challenge By Hema Sundaram, MD Curing the Blues: Resolution of the Tyndall Effect Through Removal of a Misplaced NASHA Filler with Hyaluronidase Implantation of NASHA fillers too superficially can produce the Tyndall effect. Besides aesthetic elegance, longevity after injection and an excellent safety record, a significant advantage of NASHA fillers is that they are reversible when misplaced.
ne of the most fulfilling aspects of lants, non-steroidal anti-inflammatory sis. The large particle NASHA was being a dermatologist is the daily drugs (NSAIDs) or other medications injected into the nasolabial folds, the ver- Oopportunity to tangibly help that might predispose her to extensive or milion lips, the perioral frames, and the patients by improving upon what they prolonged ecchymosis. At my first con- midface. The small particle NASHA was can see. This opportunity is enhanced sultation with this patient one month injected alone into the rhytides on the within the subspecialty of cosmetic der- after the filler injections there was focal cheeks, into the periorbital frame, the matology, where visual harmony is all. It elevation, induration, and patchy bluish vermilion borders, and the philtral is usually more challenging to restore that discoloration of an area on her left lower columns, and layered over the large par- harmony through the correction of sub- cheek surrounding rhytidosis of superfi- ticle NASHA in the nasolabial folds. optimal results from an injectable treat- cial and moderate depth. She had ment than it is to perform treatment de Fitzpatrick Type I skin with rhytidosis at Discussion novo. However, I find this corrective work rest. This patient's skin discoloration, associ- immensely satisfying, by dint of its being ated with induration and elevation of the ultimate distillation of the injector's Treatment the injected area, was consistent with art-and also because it provides substan- The area of discoloration on this placement of NASHA filler too superfi- tial improvement in quality of life for the patient's left cheek was injected with cially. NASHA fillers are transparent patient. The anticipation of the easy fix is ovine hyaluronidase (Vitrase, ISTA and may be particulate gels (e.g. especially alluring, as in the case present- Pharmaceuticals): 0.375ml of a stock Perlane and Restylane) or nonparticu- ed below. solution of Vitrase (200 USP units/ml) late and thus non-gels from a scientific was diluted with 1.5ml of 1% lidocaine point of view (e.g. Juvéderm and Case Presentation with epinephrine. A total of 0.5cc dilut- Juvéderm Ultra Plus, Allergan). Large A 57-year-old white woman from ed Vitrase was injected into the epider- particle NASHA (Perlane) is FDA California presented complaining of per- mis and superficial dermis within the approved for implantation into the sistent bruising on her left cheek which area of skin discoloration and elevation, deep dermis to superficial subcutis for had appeared the day after the area was 0.1cc being injected via a 30G needle at the correction of moderate to severe injected with a large particle non-animal each of five sites. facial folds and wrinkles, such as stabilized hyaluronic acid (NASHA) At follow-up 14 days later the skin nasolabial folds. Perlane is my mainstay filler (Perlane, Medicis). She had dis- discoloration, elevation, and induration for lifting, contouring and global volu- cussed her concern by telephone with had resolved completely. The patient mization of the face and for correction the injector and had been advised that reported that she was completely satisfied of moderate to deep rhytidosis. I the bruising would resolve with time. with the results and no longer felt social- implant Perlane into the deep dermis, She stated that she felt very unhappy ly embarrassed. She subsequently the subcutis, and also supraperiosteally about the outcome of her filler injec- received injections of small and large par- where appropriate to optimize the tions and that it was impairing her social ticle NASHA filler (Restylane and extent and longevity of aesthetic life. She reported extensive sun exposure Perlane, Medicis) and botulinum toxin A improvement, such as in the superior throughout her lifetime and was a non- (Botox, Allergan) for nonsurgical facial midface and prejowl regions. Small par- smoker. She was not taking anticoagu- lifting and improvement of her rhytido- ticle NASHA (Restylane) and nonpar-
28 Practical Dermatology May 2009 Cosmetics Challenge
Left: 57-year-old woman one month after injection of large particle NASHA (Perlane) into the left cheek. Note Focal area of bluish skin discoloration, induration and elevation (ringed). Right: Same patient 14 days after injection of 20 units ovine hyaluronidase (Vitrase). Note complete resolution of skin discoloration, induration and elevation. ticulate NASHA (Juvéderm Ultra and 700nm. Therefore, the superficially suboptimal results following filler injec- Juvéderm Ultra Plus) are indicated for implanted filler material scatters blue tions, the bluish skin discoloration that mid to deep dermal implantation. I light about ten times more strongly than occurs after implantation of NASHA inject Restylane alone for correction of red light. This scattered blue light then filler too superficially may persist for superficial and moderate facial rhytido- traces a visible path back to the skin sur- months to years unless corrective meas- sis and for volume restoration to the face. The resultant bluish appearance of ures are taken. In contrast, ecchymosis periorbital frame,1 and I layer Restylane the skin is an example of the Tyndall following injection of a NASHA filler over Perlane to fine-tune facial volume effect, the phenomenon by which an tends to resolve in one to two weeks, restoration, lifting and contouring. invisible beam of light becomes visible unless the patient is taking anticoagu- Based on this treatment paradigm, when it passes through non-homoge- lants, NSAIDs or other medications that Restylane implanted into the mid to neous material, in this case, a zone of prolong the extent and duration of deep dermis would have been a more skin containing boluses of filler. The ecchymosis. The quality and pattern of appropriate first-line choice than Tyndall effect is also the reason that the this patient’s skin discoloration and the Perlane for correction of the superficial sky appears blue although it is, in reality, associated skin elevation and induration and moderately deep rhytidosis of this colorless; again, this is due to stronger were consistent with the presence of filler patient’s cheeks. scattering of blue light than red light. material within the epidermis and/or the A NASHA filler that has been inap- The sun appears red at sunrise and sun- superficial dermis, rather than with pro- propriately implanted into the epidermis set because there is more scattering of longed ecchymosis. The strategy or superficial dermis may cause light blue light away from an observer’s eyes employed for correction of this problem beams that penetrate the skin surface to when the sun is low in the sky. The was to remove the misplaced large parti- be dispersed in many different direc- Tyndall effect is more accurately cle NASHA filler from the left cheek via tions—a physical process known as light described as Rayleigh scattering, since enzymatic digestion with hyaluronidase scattering. The intensity of the scattered the phenomenon was discovered and and to replace it during a subsequent light is proportional to the fourth power elucidated mathematically by the nine- treatment session with appropriately of the frequency of the light waves. Blue teenth-century English scientist and placed small particle NASHA. I prefer to light has a shorter wavelength (400nm) Nobel Laureate, Lord Rayleigh.2 dilute hyaluronidase with lidocaine with and thus a higher frequency than red In my experience, based on patients epinephrine for reasons of patient com- light, which has a wavelength of about who have consulted me for correction of fort and to reduce the rate of localized
May 2009 Practical Dermatology 29 Cosmetics Challenge
skin hypersensitivity, which was reported in one study to occur in 25 percent of patients receiving injections of undi- luted hyaluronidase.3 As an alternative to hyaluronidase injec- tion, NASHA filler that has been injected into very superfi- cially into the epidermis may be simply extruded after punc- ture of the skin with a 26-gauge needle. I believe that follow up of patients two to four weeks after injection of dermal fillers or botulinum toxin is essential in order to optimize results. This is even more important when the patient reports a complication. In this case, the patient expressed her concerns by telephone to the injector but she was not advised to return to the office for follow up. Had she followed up, it might have been apparent at that time that her skin discoloration was due to misplacement of filler rather than to persistent bruising as she believed, and appro- priate action could have been taken to resolve the problem. Services Include Filler injections may result in aesthetically undesirable outcomes or in other adverse effects if inappropriate Dermatology Practice Start-ups injectables are selected or if inappropriate injection tech- Practice Management Consultation Services niques are used.4 In this case, Perlane, an FDA approved, Coding Presentaions large particle NASHA filler, was injected too superficially into the cheek. I prefer to use NASHA fillers for facial vol- HIPAA Support ume replacement because they have a proven track record OSHA Compliance of safety and can be injected via small gauge needles with slow, controlled technique to minimize tissue trauma.5 Bi-Monthly Newsletter Additionally, NASHA fillers possess the significant advan- Lectures on Practice Management Issues tage that they have excellent longevity after injection, par- Insurance Credentialing Services ticularly when full volume correction is achieved, yet they are reversible within a few days through the injection of hyaluronidase to enzymatically digest them. This affords Book Store the clinician a safety level and a comfort zone that are not present with other types of dermal filler which are irre- Dermatology Nursing and Medical Assisting Manual versible and therefore not correctable when misplaced, Medical Office Response to Emergency except through passage of time. ■ E/M Documentation Package Dr. Sundaram has served as an Advisor, Clinical Investigator, Consultant, Speaker and/or Trainer for Medicis Pharmaceutical HIPAA Security Compliance Manual Corp. and ColBar Life Science Ltd. and has performed media work HIPAA Privacy Compliance Manual for Allergan, Inc. She has no stocks, shares or other financial interests in these or any other pharmaceutical or medical device companies. Risk Management for Physician Offices
1. Sundaram, H. Techniques for Minimally Invasive Rejuvenation of the Periorbital Audit Tools Region. Medscape Aesthetic Medicine CME/CE Interactive Lecture and Case Series. May 2008. http://cme.medscape.com/viewprogram/14656 Employee Policy Manual 2. McLinden, C. Rayleigh Scattering. Observations of Atmospheric Composition from NASA ER-2 Spectroradiometer Measurements. Getting Paid! http://www.ess.uci.edu/~cmclinden/link/xx/node20.html
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