Treatment of steroid atrophy with Hyaluronic acid filler
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A 62-year-old woman presented for Mohs micrographic surgery of a biopsy-proven basal cell carcinoma of the lateral aspect of the left orbital rim. The final surgical defect measured 1.1 x 1.4 cm and was reconstructed with a rotation flap. At follow-up 2 months postoperatively, she was noted to have firmness of the superior aspect of the flap along thee orbital rim. The patient thought that this scar tissue created a subjective sense of pulling on her eyelid, although she had no ectropion of the lid. As a result, 0.3 mL of triamcinolone acetonide at 20 mg/mL was injected into the firm scar tissue just above the orbital rim at the superior aspect of the flap.

The steroid was injected under low pressure with a 25-gauge needle retrogradely. 6 weeks later, patient returned to the clinic and noted that the flap firmness had resolved with the intralesional injection. However, she complained of a new onset of a divot that measured approximately 1 cm and was several centimeters inferior to the injection site, with fat atrophy, skin thinning, and telangiectasias consistent with steroid induced cutaneous atrophy.

Clinical observation was recommended, but at her 6-month postoperative visit, the atrophic area was unchanged and troubling to the patient. Treatment options discussed included laser therapy, excision, and hyaluronic acid filler injection. She found the contour change most noticeable, so she opted for hyaluronic acid filler injection to restore normal convexity to the cheek. A total of 0.3 mL of Restylane Silk was placed intradermally and at the dermal-subcutaneous junction within the area of atrophy. Immediate improvement was noted in the appearance and contour of the atrophic area. At follow-up 2 months later, the patient noted stable improvement in the appearance of the atrophic area, with some persistent skin telangiectasias but return of normal contour. Steroid atrophy will often resolve with time, but patients may be understandably reluctant to wait for spontaneous resolution.

In summary, steroid atrophy is a common adverse effect of injected corticosteroids. There is the risk of intralesional steroid separating from the surgical scar and entering normal tissue, where steroid effects will be unwanted and significant compared with the response in the area of the scar, as occurred in this case. Ways to minimize steroid migration when injecting scars include injecting small amounts of steroid and injecting retrogradely, deep, and under low pressure.