Use of Liquid Concentrated Growth Factor in the Management of Necrotic Tissue After Facial Vascular Complications Induced by Hyaluronic Acid Injection

Xin Wang, MD; Qiming Zhao, MD; Xiaoping Chen, MD; Xiaowei Wang, MD; Miao Wang, MD; Xiaoxiang Huang, MD; Xiaohui Long, MD; Yue Chen, MD


Wounds. 2022;34(11):263-268. 

In This Article

Abstract and Introduction


Introduction: HA fillers may induce facial vascular embolism. The resulting tissue ischemia and necrosis are severe iatrogenic complications for which no effective treatments are available.

Objective: This single-center case series studied the use of liquid CGF in the management of facial tissue necrosis due to HA injection.

Methods: All 12 patients with facial tissue necrosis (2 mild, 3 moderate, 7 severe) were previously treated with hyaluronidase injection in outside hospitals. They received a routine injection of hyaluronidase (dose of 400–1500 U) at the site of ischemia immediately after admission to the authors' hospital, but CGF was also injected. CGF injection was repeated once weekly until wound healing. Efficacy was assessed at 4 weeks (mean, 24.08 days).

Results: No patient experienced wound expansion or aggravation or infection at the sites of necrosis. A complete healing rate of 91.67% was noted at the 4-week follow-up. No scarring was evident in patients with mild to moderate necrosis. Those with moderate necrosis exhibited varied degrees of scarring after recovery, and scarring was evident in those with severe necrosis. No severe adverse effects occurred.

Conclusion: CGF promoted the healing of ischemic and necrotic tissue wounds induced by facial vascular embolism following injection of HA fillers. CGF should be considered as a nonsurgical treatment method for vascular embolism following HA filler injection.


Facial rejuvenation is a cosmetic procedure for which HA has been gaining in popularity among those seeking beauty treatments. In 2018, nearly 2.7 million HA filler injections were performed in the United States.[1] As the number and complexity of dermal fillers increase, the incidence of vascular occlusions will likely increase as well. The overall incidence of vascular adverse events is reportedly 1%.[2] Among these complications, vascular complication-induced local skin ischemia and necrosis, blindness, and cerebrovascular accidents are the most severe.[3–5]

The clinical presentations of facial vascular embolism following HA injection mainly include severe pain and map-like discoloration in the region of the embolism. The damaged or necrotic skin tissues and dermal cells may slough off 48 to 72 hours after ischemia, followed by ulceration. The characteristics of skin damage manifestations, including hyperemia, edema, cyanosis, map-like discoloration, sporadic pointed pustules, necrosis, and ulcer, may vary according to wound depth.[6] Ischemic skin wounds caused by vascular embolism after HA injection are similar to skin flap damage induced by blood flow obstruction; the clinical treatment of these wounds is rather difficult.

Studies have demonstrated that the application of various growth factors, including VEGF, bFGF, and keratinocyte growth factor, substantially increase ischemic flap survival.[7–10] However, most growth factors have pleiotropic effects and a short half-life, which limits the clinical applications of a single growth factor in managing the ischemic damage to skin flaps.[11]

CGF is a platelet concentrate comprising various growth factors, platelets, leukocytes, CD34 cells, and fibrinous matrix.[12–14] It accelerates wound healing, and CGF has been applied in clinical practice to promote healing of refractory wounds.[15–17]

In the current case series, liquid CGF was applied in the management of necrotic facial wounds caused by vascular embolism following HA injection. This is a newer nonsurgical method for treating tissue necrosis caused by facial vascular embolism after injection of dermal fillers.