Superior Outcomes with Ultrasound-Guided Hyaluronidase for Impending Filler-Induced Facial Skin Necrosis: A Systematic Review and Pilot Meta-Analysis.

BACKGROUND

Hyaluronidase remains the mainstay treatment for impending filler-induced facial skin necrosis. Complete resolution of impending skin necrosis following hyaluronidase injection is estimated to be around 77.8%. Current practices are varied but most involve flooding 1500 international units (IU) of hyaluronidase into the suspect area. Image-guided hyaluronidase administration has shown improved outcomes with lower doses of hyaluronidase; however, no reviews have been conducted.

OBJECTIVES

To characterize and establish the proportion of patients treated successfully with ultrasound-guided hyaluronidase for impending filler-induced facial skin necrosis.

METHODS

This systematic review and meta-analysis queried four international databases from inception until September 2024 for sources including two or more patients receiving ultrasound-guided hyaluronidase for impending filler-induced facial skin necrosis. Random-effects (DerSimonian and Laird) meta-analyses were conducted. The primary outcome was the pooled proportion of complete scar resolution after ultrasound-guided hyaluronidase. The Joanna Briggs Institute checklists were utilized to assess intra-study risk of bias, and the certainty of evidence rated using the GRADE approach.

RESULTS

Four studies totaling 55 patients were included in the analysis. The pooled proportion of complete scar resolution after ultrasound-guided hyaluronidase is probably 94.6% (95%-CI 80.6-98.7%, 4 studies, 55 patients, p= 0.06, moderate certainty). Two of four studies utilized image-guided hyaluronidase after failure of conventional flooding with 1500 IU. There was no statistical difference between ultrasound-guided injection of hyaluronidase intra-arterially and into hyaluronic acid deposits (p = 0.36).

CONCLUSION

Ultrasound-guided hyaluronidase represents a compelling step forward for complete resolution of impending filler-induced facial skin necrosis. Clinicians may wish to consider ultrasound-guided hyaluronidase as a first-line intervention considering the significant increase in the proportion of patients with better outcomes compared to non-image-guided intervention. More studies and higher-powered analyses are required to further confirm our findings.

PROTOCOL REGISTRATION

CRD42024585657.

LEVEL OF EVIDENCE I

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