How to Handle Vascular Occlusion After Filler Injection

Vascular occlusion is a rare but serious complication that can occur after dermal filler injections. It is caused by unintentional injection into or near an artery, resulting in restricted blood flow, leading to tissue ischemia and even necrosis. This serious complication can happen even to experienced injectors. It is extremely important that this condition be recognized and promptly treated to minimize complications.

Recognizing the Signs of Vascular Occlusion

Key signs and symptoms include:

  • Severe, persistent pain at the injection site. Pain is usually not evident on the day of injection. Pain typically develops one to two days after the occlusion occurs.
  • Blanching or whitening of the skin, often with a lacy or net-like appearance.
  • Color changes in the affected area, starting as banching, and progressing to  erythema and dusky or purple discoloration if untreated. Reticulate erythema can usually be seen by one day post-occlusion.
  • Decreased temperature will usually be noted soon after the occlusion.
  • Slow capillary refill will typically be seen soon after the occlusion.
  • Blistering, pustules and peeling may be seen a few days after the occlusion.
  • Necrosis may be evident by day three after the occlusion.

As time passes (day 4 to 7), pain will typically decrease and erosions may appear as the skin breaks down. Secondary infections may occur.

Awareness and vigilance are crucial, as early intervention can often reverse the issue and minimize damage.

Prevention Strategies

Careful technique, a thorough knowldge of anatomy, and adherence to best practices can reduce the risk of vascular occlusion:

  • Know the anatomy: Understand the vascular anatomy, especially in high-risk areas such as the nasolabial folds, glabella, and forehead.
  • Use smaller needles or cannulas: Cannulas can reduce the risk of vessel puncture, and smaller-gauge needles can help with controlled, superficial placement.
  • Inject slowly and in small increments: Fast or high-volume injections increase the risk of  occlusion.
  • Aspirate before injecting: Aspiration can provide a warning if blood is drawn back into the syringe, but it is not always a reliable indicator.

Immediate Management of Vascular Occlusion

If vascular occlusion is suspected, follow these steps quickly and methodically:

Stop the Injection Immediately

Discontinue the injection as soon as vascular occlusion is suspected.

Administer Hyaluronidase

Hyaluronidase is crucial for dissolving hyaluronic acid-based fillers. Inject the enzyme immediately in and around the affected area in multiple points to break down the filler and relieve the occlusion. High-dose hyaluronidase  may be necessary depending on the extent of the filler material. It is important to treat the entire surrounding erythematous area. 40-50 IU per square centimeter is advised. Use at least 500IU for the lip and 1,000 IU for the nose. Treat every 60 minutes until tissue reperfusion is acheived. Follow-up daily and inject further hyaluronidase if needed.

Apply Warm Compresses and Massage the Area

A warm compress can promote vasodilation, encouraging blood flow. Gently massaging the area may also help to disperse any filler near the vessel, reducing pressure and promoting reperfusion.

Apply Nitroglycerin Paste (if Available)

Nitroglycerin paste, when applied topically, can aid in vasodilation. Use it sparingly and observe closely, as it may cause side effects like headache or low blood pressure.

Consider Hyperbaric Oxygen Therapy

In cases where tissue ischemia persists, hyperbaric oxygen therapy (HBOT) may support healing by enhancing oxygen delivery to affected tissues. It is particularly useful in severe cases and may be coordinated with a specialized facility.

Home Care

At home management may include aspirin (325 mg/day), oral antibiotics, continued warm compresses and massage, and prednisone. If erosins occur, topical antibiotics should be applied.

Aftercare and Follow-Up

Patients who experience vascular occlusion should have close follow-up care to monitor recovery and assess for any signs of tissue damage or scarring. Ensure they understand signs of delayed ischemia, such as increasing pain or skin discoloration, and encourage them to contact your office immediately if they experience any concerning symptoms. Provide at home care as described above. Culture any pustules that may develop and treat accordingly. Monitor for infection. Once the acute situation is resolved, CO2 laser can be used to treat any scarring.

Conclusion

Though vascular occlusion is rare, preparedness is key to managing this potential complication.

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