Late Intervention Yet Successful Outcome with High-dose Pulsed Hyaluronidase for Forehead Filler Vascular Complication

Vascular complications following hyaluronic acid filler injections are rare but may lead to ischemia and necrosis. Effective management often relies on the early administration of hyaluronidase to restore perfusion and prevent long-term damage. However, delayed presentations pose unique challenges due to prolonged ischemia and increased risk of tissue necrosis. A 35-year-old woman presented 3 days after forehead filler injection with signs of vascular compromise. Initial treatment with 1800 U hyaluronidase failed. On presentation, she exhibited advanced ischemia with erythema, pustules, and livedo reticularis. A high-dose pulsed hyaluronidase protocol totaling 32,000 U for 4 days was initiated. Rapid improvement followed, with complete epithelialization by day 30 and near-complete recovery by day 90 without scarring. Despite delayed presentation, the high-dose pulsed hyaluronidase protocol successfully reversed ischemia and prevented necrosis, supporting its use in late-stage vascular complications.