Ultrasound-Guided Targeted vs Regional Flooding: A Comparative Study for Improving the Clinical Outcome in Soft Tissue Filler Vascular Adverse Event Management

Background: Adverse vascular event management following hyaluronic acid-based aesthetic injections relies on the administration of hyaluronidase which is capable of enzymatically degrading the injected product and improving clinical symptoms. Two protocols are currently available to manage such complications: ultrasound-guided targeted and flooding. Objectives: The aim of this study was to compare the 2 protocols in terms of the volume of hyaluronidase utilized, and the onset and degree of clinical improvement. Methods: A comparative case series of 39 patients was retrospectively evaluated. The patients were initially treated with the flooding protocol and then treated with the ultrasound-guided targeted protocol due to no or little improvement. Results: The ultrasound-guided targeted protocol utilized a mean [standard deviation] total of 122.5 [34] IU of hyaluronidase, whereas the flooding protocol utilized 1519.4 [1137] IU, which represents a statistically significant reduced amount of injected hyaluronidase (P= 0.028). There was no clinical improvement in 92.3% and only little improvement in 7.7% of the treated patients following the first applied flooding protocol, but there was a 100% immediate improvement when subsequently treated with the ultrasound-guided targeted protocol. Ultrasound imaging revealed that the application of hyaluronidase restored normal blood flow both in the perivascular space and in the superficially located subdermal soft tissues. Conclusions: Despite its limitations in study design, this retrospectively evaluated case series revealed that the ultrasound-guided targeted protocol utilized less hyaluronidase and restored clinically visible symptoms faster. The effect of this protocol is best explained by the perforasome concept which will need to be investigated further in future studies.

Automated summary

This study compared the ultrasound-guided targeted and flooding protocols for managing adverse vascular events following hyaluronic acid-based aesthetic injections. The results showed that the ultrasound-guided targeted protocol utilized less hyaluronidase and restored clinical symptoms faster.