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.

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