Earlobe vascular occlusion case study learning points
Think vascular occlusions only happen in lips and noses? Think again, as Dr Tim Pearce dives into a very interesting case study involving a vascular occlusion in the earlobe.
In this blog Dr Tim shares a brief round-up of his conversation with Canadian registered nurse Victoria Pond. He talks to her about the time she was treating a patient with dermal filler in the earlobe but had to promptly diagnose and treat a vascular occlusion (VO). This is such an unusual case – Dr Tim has never seen a VO in the earlobe – so we think you will agree that it presents a great learning opportunity for all aesthetic clinicians.
You can watch the full interview on earlobe vascular occlusion with Dr Tim Pearce and Victoria Pond as part of the Aesthetic Mastery Show.
Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>
Is earlobe treatment with dermal fillers commonplace?
It is safe to state that there are next to no training courses in the UK which specifically teach aesthetic practitioners the injection techniques for dermal filler treatment in the earlobe.
It seems relatively straightforward, and some clinicians may be lucky enough to learn from a fellow practitioner who has chosen to master the skill, or see it demonstrated at a conference, but it is far from the norm for dermal filler training in the UK.
Why and how would you treat an earlobe with dermal filler?
Victoria delved into the details of the case and explained that her patient had stretched her earlobes with spacers as a teenager, but as an adult, she was no longer comfortable with the appearance of her earlobes. During the consultation, they discussed the use of dermal fillers to replace lost volume and reduce the size of the hole in the earlobe.
Victoria admits it was the first time that she had attempted to treat an earlobe with dermal filler but did all she could to further research the procedure. This was despite a lack of available training courses or detailed earlobe anatomy literature, especially in relation to the vasculature of the ear. Victoria went on to focus on reviewing content from other trusted aesthetic clinicians around the world who demonstrated the treatment technique.
Yet, she still needed more information, so she thought back to first principles and her medical training. Understanding that ears can get hot and cold, and demonstrably so, it was safe to note that there must be some vasculature, and that it resides near the surface. There is no palpability of vessels in the ear, and we regularly pierce ears and earlobes due to their cartilaginous nature. Victoria concluded that it was a relatively safe area to inject with dermal filler.
As this was still unknown territory, she chose her product well, deciding to use a soft hyaluronic acid-based product that would dissolve quickly if required in an emergency.
The technique used to treat involved retrograde linear threading for support with multiple injections parallel to the earlobe, alongside micro-boluses near the opening in the lobe from the piercing to attempt to close the space using multiple injections at a 45-degree angle, placed around the hole. In total, Victoria used approximately 0.3-0.4ml of filler per earlobe.
Dr Tim highlighted that multiple entry points for multiple injections, at different angles, targeting an irregular shape, may have contributed to the outcome of a vascular occlusion in this case, and could be a lesson when considering earlobe treatment techniques.
What was the first sign of a vascular occlusion in the earlobe?
Victoria explained that the VO occurred in the first earlobe she had treated, which she observed had bled the most out of the two. The first sign she noticed was thought to be the formation of a haematoma adjacent to the piercing hole in the earlobe. Initially there were no concerns about capillary refill, the ear was not more engorged that the one on the other side, and the patient did not complain of pain, thus she went home.
Two days later the patient got in touch with Victoria and noted that one ear was much more swollen than the other, with a feeling of fullness in the ear that was uncomfortable but not painful. Upon seeing a photograph, Victoria asked her to return to clinic and it became obvious that the outcome was not normal, and action was required.
Upon assessment and examination, it was apparent that the earlobe was much more swollen and discoloured than the other treated side. The lobe was purple in colour and a webbed whiteness had started to track up into the main part of the ear. A capillary refill test showed that there was no refill whatsoever to the lobe, so a diagnosis of vascular occlusion was made.
How did you treat and reverse the vascular occlusion in the earlobe?
When approaching the problem, Victoria noted that the earlobe is small, localised, and the vascular occlusion was likely affecting a small artery, thus cannulating would be difficult. The protocol used was to flood the area (extra-vascularly) with hyaluronidase (1500 units per ml), apply heat, massage, and reassess before repetition.
You can download Dr Tim’s emergency dermal filler reversal protocol alongside a downloadable template for a hyaluronidase consent form which is useful to help you to explain the risks to your patients.
On the first day of reversal treatment, six rounds of hyaluronidase were repeated into different planes of the tissue at different angles to try to resolve the problem. When capillary refill showed signs of returning and everything looked improved, the decision was taken to leave the ear to recover for a few hours before re-evaluation. Later that day, the signs were good, and the patient was sent home, with a return planned for the following morning. However, on the second day, it was noted that discolouration had started to form behind the ear and onto the neck.
Victoria was understandably nervous and sought to evaluate what she was looking at – was this just old red blood cells sitting in the tissue that had been pushed out after treatment the previous day or was something deeper happening in the anatomy? The latter being the most likely answer when she considered the location of the temporal and carotid arteries and their anastomoses in relation to the ear, and the potential worst-case scenarios involved.
During assessment, she further checked the capillary refill behind the ear, yet all was functional. The decision was taken to apply several more rounds of hyaluronidase to the earlobe and subdermally behind the ear, resulting in five more vials. That is eleven vials of hyaluronidase in total.
You might like to read Dr Tim’s blog on vascular occlusion: how much Hyalase (Hyaluronidase) do you really need?
On evaluation on the third day, the capillary refill to the earlobe was fully functional, and although discolouration persisted behind the ear, it had improved, and continued to do so in the following days.
What have you learnt about treating earlobes and vascular occlusions from this experience?
Concluding, Dr Tim was keen to hear what Victoria has learnt from what was a traumatic experience for both her and her patient. She explained that a healthy amount of fear has been transformed into safety protocols, and thorough patient consenting.
Victoria explained that she is open and honest with her patients following the experience, noting that it happened and could happen with any case, but that she is more than prepared to manage such a complication after this experience. She noted that patients are often reassured that she successfully dealt with this case and feel confident that they are in safe hands were something to happen in future.
Victoria concluded that she has not let the fear of the event hinder her practice but has channelled it into taking extra steps when treating for improved patient safety, because there are no safe areas, just lower risk areas, when injecting filler.
She will never know if she was just unlucky, if there was a variation in anatomy, or whether it was her technique, or a combination of everything, but it can happen, and you must be prepared to deal with the complication. Approaching treatment in future, Victoria may consider using a cannula, albeit a small one, to treat the earlobe, alongside pre-evaluation of vessels with ultrasound. She maintains that aspiration and small volumes is also key to treating this area.
Dr Tim praised Victoria for sharing this case study as a tool for education for all, and pointed out the lack of anatomical understanding, particularly in relation to the vasculature of the ear, and how different shapes to earlobes may impact of the entry point of vessels, we simply do not know – one for more studies he encouraged.
Is your worst nightmare causing a VO?
If you want to be a great injector then you need to get over your fear of complications. Register here for the next webinar to help you overcome your complications anxiety >>
Aesthetics Mastery Show
Earlobe Vascular Occlusion Case Study
In this episode, Dr Tim discusses the case with nurse Victoria Pond. They discuss diagnosis, treatment and how to avoid necrosis. Watch the full Aesthetics Mastery Show here.
Read more and join in the debate on our YouTube channel.
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In addition, browse our FREE downloadable resources on complications.
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