Invited Discussion on: The Effect of Hyaluronidase on Depth of Necrosis in Hyaluronic Acid Filling-Related Skin Complica
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EDITOR’S INVITED COMMENTARY
Invited Discussion on: The Effect of Hyaluronidase on Depth of Necrosis in Hyaluronic Acid Filling-Related Skin Complications Jonathan Cook1 • Jason N. Pozner1,2
Received: 20 May 2020 / Accepted: 20 May 2020 Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. In their article, ‘‘The Effect of Hyaluronidase on Depth of Necrosis in Hyaluronic Acid Filling-Related Skin Complications,’’ the authors share their experience with ischemic complications caused by hyaluronic acid (HA) injection, adding to a growing body of the literature which supports immediate hyaluronidase injection as the mainstay of treatment [1]. This was a retrospective review of 16 ischemic complications that occurred from 2010 to 2019, out of a total of 841 facial HA injections performed by the senior author. These HA injections were performed in various facial areas (chin, glabella, infraorbital, lip, malar, nasolabial, and nose). The type of HA was not specified. The authors report that, owing to a lack of availability of hyaluronidase in their country, the initial 6 patients who experienced a complication were treated without hyaluronidase, while the remaining 10 patients were treated with a regimen that included hyaluronidase injection once a complication was recognized. Extrapolating from their experience, the authors conclude that: ‘‘although the necrosis observed in the patients who did not receive hyaluronidase treatment
& Jason N. Pozner [email protected] 1
Sanctuary Plastic Surgery, 4800 N. Federal Highway, Suite c101, Boca Raton, FL 33431, USA
2
Department of Plastic Surgery, Cleveland Clinic Florida, Weston, FL, USA
was smaller, the healing period lasted longer than those who received hyaluronidase treatment.’’ As with any study evaluating an infrequent event, it is important here to recognize the limitations of small sample sizes. Although the authors reviewed a large number of facial injections (841), and their series of complications (16) was indeed sizeable for a single institution, it is not possible to draw meaningful comparisons between their treatment groups. We did find the basis for this comparison to be interesting: the availability of hyaluronidase midway through the authors’ treatments essentially resulted in two distinct ‘‘treatment groups’’ (with and without hyaluronidase). This experimental approach would otherwise have been difficult to accomplish (and potentially unethical), since hyaluronidase has been so well established as a component of emergency treatment for HA complications [2–4]. We commend the authors for their openness in detailing their complications and for providing another account of the dangers of this ‘‘everyday’’ procedure. However, bas
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