Introduction

Dermal fillers have become increasingly popular in aesthetic medicine for their ability to restore volume, smooth wrinkles, and enhance facial features. While generally considered safe when performed by trained professionals, complications can occur, one of the most serious being vascular occlusion. Vascular occlusion is a rare but potentially severe complication that can lead to tissue ischemia, necrosis, and even blindness if not promptly recognized and treated. This article will explore the causes, signs, prevention strategies, and management options for vascular occlusion following dermal filler injections.

What is Vascular Occlusion?

Vascular occlusion occurs when a blood vessel is blocked, preventing blood flow to the tissues that it supplies. In the context of dermal fillers, this can happen when filler material is inadvertently injected into a blood vessel or when pressure from the filler compresses a vessel externally. The resulting lack of blood supply can lead to tissue ischemia, where the affected tissue does not receive enough oxygen and nutrients, potentially causing tissue death (necrosis).

Causes of Vascular Occlusion

Vascular occlusion can occur due to several factors, primarily related to the injection technique, the type of filler used, and the anatomical area being treated.

  • Injection Technique: The technique used by the injector is crucial in preventing vascular occlusion. Incorrect placement of the needle or cannula can inadvertently enter a blood vessel. Additionally, using excessive force or high volumes of filler can increase the risk of compressing nearby vessels, leading to occlusion.  

Please see my blog on The importance of finding the right practitioner

  • Filler Type: Different types of fillers have varying viscosities and characteristics, which can influence the risk of vascular occlusion. Hyaluronic acid-based fillers are most commonly used and are generally safe because they can be dissolved with hyaluronidase if an occlusion occurs. However, fillers that are more viscous or non-dissolvable carry a higher risk of complications.

At Radiant, we use only Juvederm which is a hyaluronic filler produced by Allergan.

  • Anatomical Area: Certain areas of the face are more prone to vascular complications due to their complex vascular anatomy. High-risk areas include the glabella (between the eyebrows), the nasolabial folds, and the nose. These regions have critical blood vessels that, if occluded, can lead to significant complications such as skin necrosis or, in severe cases, blindness if the retinal artery is affected.

At Radiant we would never inject into the glabella (area between the brows) and that despite being trained in this area, we choose to not perform non surgical rhinoplasty (nose filler). For us, these areas are too high risk.

Signs and Symptoms of Vascular Occlusion

Recognizing the signs and symptoms of vascular occlusion early is essential for prompt treatment and minimizing tissue damage. Common signs include:

  1. Pain: Sudden, intense pain during or after the injection is one of the first signs of vascular occlusion. This pain is usually localized to the area of occlusion and is more severe than typical post-injection discomfort.
  2. Blanching: The affected area may become pale or white due to the lack of blood flow. This is known as blanching and can be a critical early sign of occlusion.
  3. Discoloration: As the condition progresses, the skin may become blue or purple, indicating the development of tissue ischemia and the potential for necrosis.
  4. Cool Skin: The skin over the occluded area may feel cooler to the touch due to reduced blood flow.
  5. Delayed Capillary Refill: A delayed capillary refill time (the time it takes for color to return to the skin after pressing) can indicate compromised blood flow.
  6. Visual Disturbances: If the occlusion affects the blood supply to the eye, the patient may experience visual disturbances, including partial or complete loss of vision, which requires immediate medical attention.

Prevention of Vascular Occlusion

Preventing vascular occlusion is paramount in aesthetic procedures involving dermal fillers. Several strategies can be employed to minimize the risk:

  1. Thorough Anatomical Knowledge: A deep understanding of facial anatomy, including the locations of major blood vessels, is essential for any injector. This knowledge helps in planning safe injection sites and avoiding high-risk areas.
  2. Proper Injection Technique: Using the correct injection technique is critical. Injectors should use a slow, controlled injection with minimal pressure to reduce the risk of inadvertently entering a blood vessel. Aspiration before injection (pulling back the plunger slightly to check for blood) is a commonly recommended technique, although its effectiveness is debated.
  3. Cannula vs. Needle: In some cases, using a blunt-tipped cannula instead of a sharp needle can reduce the risk of vascular occlusion. Cannulas are less likely to pierce blood vessels and can be used to deposit filler more safely in certain areas.
  4. Use of Hyaluronic Acid Fillers: When possible, choosing hyaluronic acid-based fillers is advisable because they can be dissolved with hyaluronidase if an occlusion occurs. This allows for rapid intervention to restore blood flow.

At Radiant, we use only Juvederm which is a hyaluronic filler produced by Allergan.

  1. Patient Assessment: A thorough assessment of the patient’s medical history, including any previous aesthetic procedures, is important. Patients with a history of vascular issues or who are on medications that affect blood clotting may be at higher risk.
  2. Small Volume Injections: Injecting smaller amounts of filler at a time and massaging the area gently to distribute the filler evenly can help reduce the risk of compression-related occlusion.

Management of Vascular Occlusion

Despite best efforts, vascular occlusion can still occur. Prompt recognition and management are crucial to prevent long-term damage.

  1. Immediate Cessation of Injection: If vascular occlusion is suspected, the injection should be stopped immediately.
  2. Massage and Warm Compresses: Gentle massage of the area and the application of warm compresses can help to increase blood flow and alleviate the early stages of occlusion.
  3. Hyaluronidase Injection: If hyaluronic acid-based filler has been used, hyaluronidase should be injected as soon as possible to dissolve the filler and restore blood flow. The dose and number of injections will depend on the severity of the occlusion and the amount of filler present.

Hyaluronidase is a Prescription only medicine which can only be prescribed by a medic.

  1. Aspirin: Administering aspirin can help reduce clot formation and improve blood flow, although this should be done under medical supervision.
  2. Hyperbaric Oxygen Therapy: In severe cases, hyperbaric oxygen therapy may be recommended to enhance tissue oxygenation and promote healing.
  3. Referral to a Specialist: If the occlusion involves critical areas such as the eyes, or if there is significant tissue damage, immediate referral to a specialist, such as an ophthalmologist or plastic surgeon, is essential.

Radiant is a member of Save Face, Aesthetics Complications Expert Group and the JCCP. Each of these registers are only available to medical practitioners.

If you do choose to have a non surgical rhinoplasty/glabella filler, we would advise that you ask whether the injector has access to an Ophthalmologist who would be available to offer emergency advice on a vascular occlusion.

  1. Close Monitoring: After initial treatment, close monitoring of the affected area is necessary to assess the response to treatment and to detect any signs of worsening.

Radiant is always available 24/7 for emergencies and after care advice.

Conclusion

Vascular occlusion is a serious complication of dermal filler injections, but with proper knowledge, technique, and prompt intervention, the risks can be minimized, and outcomes can be significantly improved. It is essential for practitioners to stay informed about the latest prevention and management strategies to ensure patient safety and the successful use of dermal fillers in aesthetic medicine.