This Filler Risk May Be Rare, But It Can Lead To Skin Necrosis And Blindness

‘In case of emergency’ is a concept we’ve all come to be familiar with and, with any aesthetic decision, we have to be cognizant of the risks. While the majority of 'tweakments’ are deemed safe and effective — they're low risk and high reward — no aesthetic procedure is without side effects and complications, some of which can be severe.

Case in point: hyaluronic acid (HA)-based filler. HA fillers are known to cause temporary swelling and bruising at the injection site, but did you know that there is a risk (however rare) of vascular occlusion and, subsequently, skin necrosis and even blindness if the filler is injected into or near a blood vessel. So, what do you do in case of this emergency? The AEDITION spoke with two top plastic surgeons to break down the warning signs, risks, treatment options, and more.

What Is Vascular Occlusion From Filler?

Vascular occlusion is a rare but potentially serious complication of hyaluronic acid filler injections. It results from accidental injection of the product into an artery, and it can also be due to compression of the artery from surrounding filler. “In certain circumstances, when filler is injected near or into the blood vessel, they become occluded due to the pressure,” says Jason Roostaeian, MD, a board certified plastic and reconstructive surgeon in Los Angeles. “If the pressure is above a certain level, the vessels are compressed and blood flow is limited, which is what causes the damage.”

To put it plainly, the artery or capillary is constricted due to pressure of the filler or injected with filler. As a result, it is unable to function properly. The lack of blood flow causes the skin to suffocate and thereby can be damaging to both vision and skin (more on that below). “When something causes the artery or vein to be blocked, it’s like a heart attack caused by filler, and the affected area is the skin,” explains Amir Karam, MD, a double board certified facial plastic and reconstructive surgeon.

Risk of Vascular Occlusion

Yes, the chances of vascular occlusion occurring are quite low. A December 2020 study in JAMA Dermatology found that the risk of vascular occlusion is “exceedingly low” — one in 6,410 syringes via needle and one in 40,882 via microcannula injector — when injected by a board certified dermatologist.

Even so, it shouldn’t be taken lightly. “This complication, if left untreated, can lead to blindness in rare circumstances,” Dr. Jason explains. The reason? “Any vessels around the eyes, such as the nose, the glabellar region, the vessels in the temples, those vessels do not have valves,” Dr. Karam shares. “Therefore, the blood flow can go back towards the eye and cause blindness.”

But blindness isn’t the only risk. Vascular occlusion can rapidly progress to tissue necrosis if not identified and treated quickly. Symptoms of skin necrosis include skin blanching, change in tone, intense pain, and bruising. When the vessel is blocked, “there is no blood flow to that segment of the skin,” Dr. Karam notes.

Those familiar with post-filler bruising know what it looks like on them and should be able to identify the normal from the atypical, but newbies may want to pay closer attention. “Bruising from filler does not hurt,” Dr. Karam explains. And it tends to be localized. “Discoloration of the skin that goes beyond the area of injection is a tell-tale sign of vascular occlusion,” he adds.

So, how soon after injecting do the effects of vascular occlusion start to show? Depending on the case, it can happen immediately and be treated on the spot. But Dr. Jason notes that it can also occur after you’ve left your injector. Likely, the skin will begin to blanch due to the lack of blood flow and other symptoms will follow. “Usually, you see it happen in the first 24 hours, but the symptoms don’t always happen right away,” he cautions.

To further complicate matters, it can be difficult to diagnose. “It can devolve over six to 12 hours, and many might confuse it for a bruise,” Dr. Jason explains. “That’s why it takes a trained professional to know what they are looking at in case there is a risk of tissue damage.”

Vascular Occlusion Treatment Options

If you feel that you are experiencing a complication from your filler injections, our experts recommend seeking out your injector first. To dissolve the filler and prevent further damage, they will administer hyaluronidase — an enzyme that breaks down hyaluronic acid — followed by an aspirin regimen and, in some cases, warm compresses. As it relates to the latter remedy, Dr. Jason notes that the warm compress may be added to help boost blood flow but admits that the jury is still out on whether warm or cold compresses are best.

We’ve focused this article around HA filler, but, if the filler in use is not formulated with HA, dissolving with hyaluronidase is not an option. “Other measures include using aspirin to thin the blood and adding nitroglycerin to the area of the skin until the area has been relieved of its occlusion,” Dr. Karam shares.

As studies suggest, the best way to prevent vascular occlusion is to be treated by a skilled injector who has a deep understanding of the anatomy of the area you are looking to treat — but, even in the most well-trained hands, Dr. Jason acknowledges that it’s somewhat of a numbers game. “There are certain areas where it is more prevalent when there’s one main source of blood flow to the area, but it can still happen to any injector,” he explains.

With that said, there is no substitute for expertise when it comes to reducing the risk of this complication. “There are certain measures, such as understanding where the blood vessels are located and having a good understanding of vascular anatomy, that can help prevent this,” Dr. Karam notes. Additionally, he says that injection technique is a factor, too. “Using a microcannula or using the fanning method before the deployment of filler can decrease this risk,” he adds.

With skin necrosis, the first course of action will be to let the area heal. From there, the damage can be assessed, Dr. Jason says. Some patients who experience complications from vascular occlusion swear off filler for good. But, for those interested in returning to the office again, Dr. Jason notes that a new approach will likely be necessary. “Some people have a higher likelihood to have this occur again, and the injector would likely stay away from that area in particular,” he says.

The Takeaway

One of the most difficult parts of treating vascular occlusion is how easily it can go undetected. When detected early, however, long-term damage is often preventable. The early warning signs manifest as bruising and sensitivity. So, while they may blend in with the discoloration and soreness that can be expected from the treatment, any abnormalities shouldn’t be overlooked. In case of emergency, always seek help from your injector immediately.