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Vascular Compromise and
Alopecia After Hyaluronic Acid
Filler Injection in Temple Region
Congying Li, MD,, and Wei Zhang, MD
Abstract: Hyaluronic acid filler injection is widely applied in
facial shaping and facial filling. Although hyaluronic acid in-
jection is thought to be relatively safe and effective, there are still
incidents being reported occasionally. The authors report here a
case of alopecia at vascular compromise area after receiving
hyaluronic acid filler injection in the left temple region, skin
necrosis, and alopecia were well recovered with the treatment of
hyaluronidase and external application of minoxidil.
Key Words: alopecia, hyaluronic acid filler injection, hyaluronidase,
temple region, vascular compromise
Hyaluronic acid injections are popular nonsurgical cosmetic
procedure. Although the safety profile is favorable, adverse re-
actions can occur.1,2
The common complications of hyaluronic acid filler injection
include vascular infarction and compromise; inflammatory re-
actions; nodules, granulomas.3
Alopecia is an extremely rare adverse reaction, and hereby we
describe a case of alopecia at vascular compromise area after
receiving hyaluronic acid filler injection in the left temple region.
CASE PRESENTATION
A 50-year-old woman presented with rash and pain after in-
jection of hyaluronic acid on the left side of the temple.The
patient underwent Hyaluronic Acid (HA) filler injection at a
plastic surgery clinic for bilateral temple augmentation.
However, the brand name of hyaluronic acid filler and in-
jection dose is unknown. The patient stated that no significant
pain or other immediate discomfort after injection. Ice com-
press was applied to the bruise area immediately after in-
jection for 10 minutes. No other special treatments were given.
However, several hours after the injection, mild swelling and
red bruise appeared on her left forehead, temple region and
periocular area, accompanied by painful and numb feeling.
Afterwards, aggravated rash and pain, with the development
of large area of map-like red and purple bruise and excessive
swelling, occurred on the same area of her face in left fore-
head, temple region, and periocular area. The bruise failed to
fade by pressing and caused severe pain. In such a situation,
the patient visited our hospital on the third day after injection.
On examination there is swelling, map-like red and purple
bruise, and tenderness in left forehead, temple region, and
periocular area (Fig. 1A). Physical examination did not reveal
other abnormalities.
When considered the possible consequence of vascular
embolization at the injection site, we injected hyaluronidase into
her embolism area immediately, gave oral antibiotics, and
applied Qingpeng ointment to the rash area. In addition, we
required the patient to use hot compress on the affected area
and kept a regular follow-up.
The pain was relieved after the treatment, and rash stopped
evolving and gradually darkened, ruptured and crusted. One
week after the treatment, the patient stated that pain was
basically disappeared. Large areas of dark fuchsia stain and
crust formation could be observed at her left forehead, temple
region, and periocular area. Two weeks after treatment,
scattered crust, and erythema after crust sheded were observed
at her left forehead and temple region. Rash at periocular area
were basically subsided. However, alopecia occurred along the
path of embolism in upper forehead area where the crust shed.
Hair follicle was observed in alopecic area. There existed large
area of hair loss occurred in hair growth area where rash
occurred (Fig. 1B). After 2 months of external application of
minoxidil to alopecic area, the rash subsided and new hair
grow (Fig. 1C).
DISCUSSION
The patient’s embolism area distributed along superficial
temporal artery. Alopecia occurred after ischemic skin injury,
possibly due to local compression, tissue hypoxia, and hair
follicle dystrophy. The patient received active treatment after
complications and recovered well.
Superficial temporal artery ascends in anterior-superior
region of auriculotemporal nerve, and mostly divides into the
frontal and parietal branches from 4 cm above the zygomatic
From the Department of Medical cosmetology, Shanghai Skin Diseases
Hospital, Shanghai, China.
Received May 12, 2022.
Accepted for publication May 20, 2022.
The authors report no conflicts of interest.
Address correspondence and reprint requests to Congying Li, MD,
Department of Medical Cosmetology, Shanghai Skin Diseases
Hospital, Shanghai 200050, China; E-mail: licongyinglcy@qq.com
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Copyright © 2022 The Author(s). Published by Wolters Kluwer
Health, Inc. on behalf of Mutaz B. Habal, MD.
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000008865
Brief Clinical Studies The Journal of Craniofacial Surgery Volume 34, Number 2, March/April 2023
e128 Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.
arch. The frontal branch of superficial temporal artery passes
through superficial temporal fascia, reaches the forehead
through temple region. There it extends down to posterior
orbital branch and finally converges to supratrochlear artery.
Besides, the frontal branch in subcutaneous tissue converges
to supraorbital artery at frontalis muscle.4
Temporal fossa depression not only affects the beauty of
upper facial profile, but also some people in China thought it
related to “physiognomy.”Therefore, people with love for beauty
preferredtochooseinjectiontofill temporal fossa. Considering
relatively high density of blood vessels in the temporal fossa
region, injection staff should be familiar with anatomical
structure, bypass import blood vessels, operate normatively, and
be suggested to inject horizontally into periosteum.
Though unavoidably filler injection may induce complica-
tions, the most severe complications related to vascular in-
juries and embolization in general. Prognosis of embolism is
highly related to location of embolism, the exent of vascular
injury, filler material and whether timely and effective treat-
ment is applied. Hyaluronidase can be used to reverse hya-
luronic acid fillers. Even though the probability is relatively
low that location of hyaluronidase injection is identical to that
of vascular obstruction, hyaluronidase injected in the ischemic
area still yields certain curative effect.5Early-stage and mid-
dle-stage embolism may be mostly well recovered with timely
and proper treatment.3
Alopecia occurred after receiving hyaluronic acid filler in-
jection may be well recovered with timely and proper treat-
ment. After recognition of vascular complications we suggest
immediate injection of hyaluronidase, and regular follow-up is
required. In addition to improving techniques to maximize
safety during filler injections, the ability to deal with compli-
cations should be more valued.
ACKNOWLEDGMENTS
The authors would like to thank the patients for cooperating with
follow-up and allowing the authors to publish this case.
REFERENCES
1. Gan SD, Itkin A, Wolpowitz D. Hyaluronic acid-induced alopecia: a
novel complication. Dermatol Surg 2013;39:1724–1725
2. Yang Q, Qiu LH, Yi CG, et al. Reversible alopecia with localized
scalp necrosis after accidental embolization of the parietal artery with
hyaluronic acid. Aesthetic Plast Surg 2017;41:695–699
3. Signorini M, Liew S, Sundaram H, et al. Global aesthetics consensus:
avoidance and management of complications from hyaluronic acid fillers-
evidence- and opinion-based review and consensus recommendations.
Plast Reconstr Surg 2016;137:961e–971e
4. Kleintjes WG. Forehead anatomy: arterial variations and venous
link of the midline forehead flap. J Plast Reconstr Aesthet Surg
2007;60:593–606
5. Landau M. Hyaluronidase caveats in treating filler complications.
Dermatol Surg 2015;41:S347–S353
Arthroscopic Disk Repositioning
After Failed Open Disk
Repositioning
Wenhao Zhang, MM,*Yi Luo, RN,*
Ahmed Abdelrehem, PhD,
†
Xiaohan Liu, MD,*
Minjie Chen, MD,*Chi Yang, MD,*Chuangqi Yu, MD,*and
Fang Wang, MD*
Purpose: Open disk repositioning has been long achieving ex-
cellent functional and stability outcomes. However, still remains
some relapses for whom a second open surgery is often
challenging. This study aimed to evaluate the effectiveness of
arthroscopic disk reposition as an alternative surgery for
unsuccessful cases of anterior disk displacement (ADD) after an
initial open disk repositioning.
Materials and Methods: This retrospective study included all
patients who underwent secondary arthroscopy for disk re-
positioning of the relapsed ADD after an initial open surgery
between January 2012 to June 2017. The redo arthroscopic disk
repositioning and suturing procedure was the primary predictor
input variable in this study. Outcome evaluation was based on
both clinical (visual analog scale and maximal interincisal
opening) and magnetic resonance imaging data.
Results: Twenty-seven joints fulfilling the inclusion criteria
were included. A significant improvement was detected at
24-month postoperatively compared with the baseline visual
analog scale. The maximal interincisal opening showed a
statistical improvement from 25.07 mm preoperatively to
38.44 mm at 24-month postoperatively. Twenty-six joints
maintained a stable disk position with only 1 joint relapsed to
ADD without reduction.
Conclusion: Arthroscopic disk reposition and suturing technique
is a reliable and effective repeat surgery after failed initial open
disk repositioning for management of ADD.
Key Words: arthroscopic, disk repositioning, failed open disc
repositioning, temporomandibular joint disk displacement
From the *Department of Oral Surgery, Shanghai Ninth People’s
Hospital, Shanghai Jiao Tong University, School of Medicine,
Shanghai, China; and †Department of Craniomaxillofacial and
Plastic Surgery, Faculty of Dentistry, Alexandria University, Alex-
andria, Egypt.
Received May 9, 2022.
Accepted for publication May 23, 2022.
W.Z. and Y.L. equally contributed to this work.
This study was supported by Fundamental research program funding of
Ninth People’s Hospital affiliated to Shanghai Jiao Tong university
School of Medicine (JYZZ158), Science and Technology Commis-
sion of Shanghai Funding/Supporting (16411960900), Shanghai
Municipal Science Research Project (SHDC12017101), Shanghai
Summit and Plateau Disciplines, and General Project of Shanghai
Health and Family Planning Commission (201740168).
The authors report no conflicts of interest.
Address correspondence and reprint requests to Fang Wang, MD,
Department of Oral Surgery, Shanghai Ninth People’s Hospital,
Shanghai Jiao Tong University, School of Medicine, No. 639,
Manufacturing Bureau Road, Huangpu District, Shanghai 200011,
China; E-mail: winfred1130@163.com
Supplemental Digital Content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal's website, www.jcraniofacialsurgery.
com.
Copyright © 2022 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000008867
The Journal of Craniofacial Surgery Volume 34, Number 2, March/April 2023 Brief Clinical Studies
Copyright © 2022 by Mutaz B. Habal, MD e129
Copyright © 2022 Mutaz B. Habal, MD. All rights reserved.
