Concerned about vascular occlusion? Here’s what you need to know.

Concerned about vascular occlusion? Here’s what you need to know.

As the demand for dermal fillers has soared, so has the number of underqualified cosmetic injectors—and, regrettably, poor filler results. One of the most undesired outcomes of filler injection is vascular occlusion, a condition that has gained recent notoriety due to reality TV star Lilly Ghalichi’s harrowing filler experience

Though it is a very rare occurrence, vascular occlusion can cause a number of unwanted side effects, ranging from mild and temporary to severe and permanent. The potential severity of this condition has caused some patients to ask whether or not filler injections are worth the risk.

What is vascular occlusion?

When injected incorrectly, facial fillers pose the risk of entering the bloodstream or blocking arteries and cutting off oxygen and nutrients to the skin—a condition called vascular occlusion. Vascular occlusion is typically mild, resulting in skin redness (erythema) or bruising around the injection site. However, if vascular occlusion is not treated quickly and properly, patients may experience skin death (necrosis) and even blindness, as facial fillers can migrate retrogressively to the orbital area. 

A clinical review in the Journal of Clinical and Aesthetic Dermatology found that just 0.05 to 0.01% of filler injections resulted in vascular occlusion.

How common is vascular occlusion?

Though they are not well documented, the frequency of adverse vascular events is extremely rare; a clinical review of 12 cases published in the Journal of Clinical and Aesthetic Dermatology found that just 0.05 to 0.01% of all cosmetic injections resulted in some degree of vascular occlusion. Additionally, the majority of vascular occlusion cases are minor and can be resolved without scarring or other lasting injuries.

Signs of vascular occlusion

Vascular occlusion can present in a multitude of ways, including:

  • Blanching is the whitening of the skin due to a lack of blood flow and is usually the first indication vascular occlusion has occurred. This shouldn’t be confused with temporary blanching, which may occur after filler injection if the filler is mixed with a local anesthetic, such as lidocaine, or if a patient was given a vasoconstricting medication to prevent bruising. Temporary blanching is non-threatening and will resolve on its own.
  • Bruising may occur if an artery or blood vessel has become blocked due to filler injection. Bruising may range from a blue discoloration to a dusky purple-grey appearance.
  • Swelling is likely to occur in and around the injection site if vascular obstruction is present, and may range from mild to severe. Some swelling is normal after dermal filler injection, and an experienced surgeon will be able to differentiate between normal and abnormal swelling.
  • Blackening of the skin is indicative of skin necrosis, or dead skin. Though skin necrosis is irreversible, surgical excision, diligent wound care, and the application of dermabrasion or laser resurfacing can help reduce potential scarring.

What to do if vascular occlusion is suspected

If vascular occlusion is identified early enough, hyaluronidase can be carefully injected into the filler region to break down hyaluronic acid (HA)-based fillers. As hyaluronidase’s enzymes digest the filler, blood supply should return to the skin, ameliorating any bruising or discoloration. Note that hyaluronidase is not effective at reversing fillers that are not made of HA, including calcium hydroxylapatite, poly-L-lactic acid, polymethyl-methacrylate, and fat. 

In addition to hyaluronidase, a combination of the following may be used to reverse the effects of vascular occlusion: 

  • Massage can encourage the resupply of blood to the area.
  • A warm compress can also encourage the resupply of blood.
  • Aspirin can help prevent blood clotting within a partially occluded blood vessel.
  • Topical nitroglycerin paste can relax blood vessels, increasing circulation.
  • An oral steroid, such as prednisone, can help reduce inflammation.

Areas to avoid or use extra caution when injecting

The areas listed below are often referred to as “danger zones” by cosmetic surgeons, and should either be avoided completely or seriously considered when injecting fillers:

  • The glabella complex. Although the glabella complex is the number one area for BOTOX® and other neurotoxin injections, it is the most dangerous area for dermal fillers and should only be treated by an experienced, board-certified facial cosmetic surgeon. This area consists of the brow and the area between the eyebrows and includes a number of very small arteries with limited circulation. Occlusion in these arteries can affect vision, as they are connected to the ophthalmic artery in the eye.
  • The medial canthus. This is the small depression between the inner corner of the eye and the upper nasal bridge. Since the medial canthus is the meeting point for the ophthalmic artery and the dorsal nasal artery, nasal skin necrosis and blindness are potential risks; therefore, extreme caution should be taken when injecting filler in this area. Additionally, a cannula is recommended for medial canthus injections.
  • The dorsal nasal artery. The nose is an increasingly popular facial feature to enhance using dermal fillers, a procedure called “liquid rhinoplasty.” Liquid rhinoplasty has a high patient satisfaction rating and can be performed safely and with beautiful results; however, a surgeon must be careful not to inject filler into the dorsal nasal artery, a branch of the ophthalmic artery that runs down the nasal bridge. Injecting into the dorsal nasal artery could cause tip necrosis (skin death of the nasal tip), impaired vision, or blindness. Great care should be taken when injecting fillers in and around the nose.
  • The angular artery. This is the terminal branch of the facial artery and runs alongside the nose downwards from the medial canthus. Since the angular artery supplies blood from the eye to the bridge of the nose, injecting filler into the angular artery could cause obstruction in both of these areas, as well as in the mid-face. An experienced surgeon can avoid the angular artery by injecting one full finger-width away from the edge of the nose.

While there are many areas of the face at risk of vascular occlusion, an experienced facial cosmetic surgeon will have the skill and training required to safely inject around these areas. 

Choosing a board-certified facial cosmetic surgeon will help ensure safe and beautiful filler injections.

Prevent vascular occlusion by choosing an ABFCS surgeon

The number one way to avoid vascular occlusion is to choose a facial cosmetic surgeon certified by the American Board of Facial Cosmetic Surgery (ABFCS) for your filler injections. Doing so will ensure he or she has a thorough understanding of facial anatomy and extensive experience performing cosmetic injections. An ABFCS surgeon will also take the following steps to help make sure your injections are performed safely:

  • Use a cannula vs a needle. An ABFCS surgeon will understand that a blunt-tip cannula will spread filler out more evenly beneath the skin and reduce the risk of injection into an artery or blood vessel. This not only enhances safety but provides better results.
  • Aspirate their cannula. ABFCS surgeons often choose to aspirate their cannulas before injecting filler. Aspirating is when a surgeon pulls back the plunger of a cannula after it is inserted below the skin to check for blood. If blood is drawn into the cannula, a surgeon knows they have hit a blood vessel or artery, and they will choose a different area to inject.
  • Avoid deep bolus injections. Large or “bolus” injections of filler can place excessive pressure on nearby blood vessels and cause them to become constricted. A skilled surgeon will use radial fanning or a similar disbursement technique for areas of the face requiring larger amounts of filler to improve safety and enhance filler results.

Looking for a board-certified facial cosmetic surgeon near you?

If you are seeking dermal filler injections to enhance your face, make sure you choose a facial cosmetic surgeon who is certified by the American Board of Facial Cosmetic Surgery. An ABFCS surgeon will use the techniques and knowledge discussed in this blog to ensure you receive safe and beautiful cosmetic injections, every time. To find a board-certified facial cosmetic surgeon near you, browse our surgeon directory.