Fast and easy treatment for reduction of the Tyndall effect secondary to cosmetic use of hyaluronic acid

Journal of Drugs in Dermatology, March, 2008 by Tracee Douse-Dean, Carolyn I. Jacob

Introduction

Evaluation of the aging face includes the assessment of volume loss due to thinning skin, fat atrophy, and fat pad descent and protrusion. Today's treatment options include a variety of filler substances. One common product that is used for facial contouring and rhytide correction are dermal fillers containing hyaluronic acid (HA). (1) These fillers are appropriately used for moderate to severe wrinkles, acne scars, and lipoatrophy. Hyaluronic acid is a natural hydrophilic mucopolysaccharide that holds 1000 times its weight in water. (2) It can be made from rooster combs or through a streptococcal fermentation product. This nonanimal derived stabilized hyaluronic acid (NASHA) can be found in products such as Restylane[R] Juvederm[R] and Captique[TM].

Although the goal of HA dermal filler products is to enhance one's appearance, there have been some adverse reactions that can occur. These reactions consist of local edema, erythema, tenderness, bruising, and the possibility of a herpetic outbreak. (3) More complex side effects have been rare, but can consist of focal necrosis and delayed onset of "angry red bumps," which are secondary to a foreign body reaction. (4) Patients may also present with bluish discoloration in treated areas. This result is caused by injections that are placed too superficially (or perhaps migrate superficially) and create discoloration. This discoloration can present as a bluish, grayish, or yellowish tint underneath the skin, which has been known as the Tyndall effect.

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Case Report

Case 1

A 50-year-old woman with type 3 skin was treated by another physician with HA injections for the improvement of melolabial fold rhytides approximately 2 months prior. A week after her treatment, the patient noted an undesirable blue/gray discoloration towards the medial portion of the melolabial folds, which was more apparent when the skin was made taut (Figure 1). The patient was displeased with the noticeable coloration but liked the overall effect of the softening of her melolabial folds.

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Case 2

A 53-year-old woman with type 2 skin complained of bluish discoloration along the marionette lines. She had undergone injections with HA a year before. The patient used makeup on the entire face for coverage of telangiectasias, and without makeup, the bluish areas were noticeable (Figure 2).

Case 3

A 45-year-old patient complained of bluish bumps on the vermillion border 2 weeks after injections with HA. She had multiple injections with HA to both lips in the past. An examination of the right upper lip showed 1-mm bluish papules at the vermillion border (Figure 3).

Methods

The areas were cleansed first with chlorhexidine and a topical anesthesia, if desired by the patient, was applied for 10 minutes. Using a surgical scalpel (#11 blade), a small 1-mm to 2-mm incision was made directly into the area showing the largest amount of blue/gray discoloration (Figure 4). Gentle pressure was applied using 2 opposing cotton swabs at either end of the stream of discoloration and then rolled towards the incision site; the material extruded easily (Figure 5). This procedure can be repeated, if necessary, until the superficial HA has been removed leaving behind a normal shade of skin with the exception of temporary erythema caused by the procedure.

The authors have found this to be the most consistent, inexpensive, and time efficient way to correct Tyndall effect discoloration due to HA. This simple extraction method for superficial placement of HA can be done immediately, or as long as 12 months or more after placement. The patients treated are pleased with the immediate resolution of the discoloration, and proper incision by the #11 blade does not leave any residual scarring. The HA injection can then be performed in the appropriate dermal depth for the correction of rhytides.

Discussion

The Tyndall effect is due to the absence or presence of scattering of light due to substances the light encounters. It is directly related to the depth of penetration of the wavelengths of white light. Blue light, with a wavelength of 400 nm, scatters more readily than red light, which penetrates at a greater depth. Small particles about 400 nm in diameter scatter blue light and pass the longer red wavelengths. (1) If an appropriately sized substance is injected too superficially or in too large of a pool-like quantity, the blue wavelengths will scatter leading to a bluish hue in the skin. This phenomenon can usually be avoided if the product is injected at the correct dermal level.

If the Tyndall effect occurs, there are a variety of treatments available that can reduce or remove the discoloration. Some surgeons advocate the use of hyaluronidase, a soluble protein enzyme that counteracts the unwanted effects of HA. Hyaluronidase is prepared from mammalian testes, usually ovine or bovine, then diluted with lidocaine or saline for injection. (5) Brody used intracutaneous hyaluronidase to alleviate a persistent granulomatous reaction to HA and to reduce the erroneous placement of periocular HA which dissolved in 5 days after 2 treatments. (6) Soparkar et al and Goldberg et al also successfully used hyaluronidase to dissolve some of the HA filler to reduce contour irregularities in the periocular area. (7,8) Adverse reactions to injections of hyaluronidase include edema, spread of local infection, urticaria, and angioedema. (9) There is also a potential for the diffuse destruction of any placed HA, leading to loss of the underlying aesthetic effect. In addition, hyaluronidase may not be readily available and it requires an additional (although nominal) cost to the provider. The 1064 nm Nd:YAG laser has also been used to induce increased HA turnover and shrinkage of the gel. (1) The simple #11 blade extraction method has been found to be a quick, easy, and inexpensive method for correcting superficially placed HA.