Severe vascular adverse events, such as occlusion, can occur after treatment with dermal fillers in the glabellar and nasolabial regions. The author proposes that late onset vascular occlusion may be caused by hyaluronic acid expanding and compressing underlying arteries after injection. To treat impending necrosis from filler-induced vascular occlusion, the author recommends higher than normal doses of hyaluronidase, intravenous steroids, and other measures to increase blood flow and oxygen delivery. While most adverse reactions are mild and transient, practitioners must understand vascular anatomy and have protocols in place to promptly treat more serious complications like vascular occlusion.

1. Reversal of a
dermal filler
induced
facial artery occlusion
Patrick Treacy discusses the factors to consider to avoid adverse
events after the use of a dermal filler as well as the best methods of
treating complications, including steroids and hyaluronidase
ABSTRACT
Soft tissue augmentation with
dermal fillers has become an
integral part of most aesthetic
practices. Fortunately, adverse
reactions are usually mild and
transient. However, significant
adverse events such as
vascular occlusion also occur.
Vascular compromise occurs
Keywords
Localised adiposities, topical
slimming treatment, botanical
extracts, ultrasonography, in vivo
assessment
because of embolisation and/
or compression material into/
onto the vasculature. In this
article, the author theorises
that late onset vascular
occlusion may occur not
only due to embolisation but
because hyaluronic acid (HA)
expands due to its hydrophilic
action and compresses the
facial artery or its branches.
He proposes that intravenous
steroids should be added to the
accepted reversal protocol. His
goal is not to promote this as
a definitive measure but rather
to establish a discussion on
treatment protocols that may
be helpful to other physicians
in the future.
Within the past 15 years,
facial soft-tissue augmentation
has become very popular in
aesthetic clinics around the
world. Although most
biodegradable-type products
are considered safe, adverse events do occur that are
time-limited. The products have been observed to
have severe, persistent, and recurrent complications.
Histological examinations in these cases, often show
the presence and persistence of the filler1. Dermal filler
complications are divided into ‘early’ and ‘delayed’ in
terms of time of occurrence and ‘minor’ and ‘major’ in
terms of severity1, 2. Minor complications occurring
immediately or hours to days after injection include
injection site reactions, such as bruising, erythema,
pain and tenderness, swelling, and itching. These
events usually resolve within a week without
sequelae3, 4. Severe vascular adverse events have been
reported in the glabellar and nasolabial regions after
treatment with both biodegradable and non-biodegradable
injectable fillers5.
Although rarely reported in the literature,
complications related to interrupted blood supply to
the nose can occur with nasolabial fold dermal
injection. The exact mechanism of this event is
unknown, however it is widely accepted that vascular
compromise is a function of compression and/or
embolisation of material into the vasculature. It has
Patrick Treacy, Medical
Director, Ailesbury Clinics Ltd
and Ailesbury Hair Clinics Ltd,
Dublin, Cork, London, and
Middle East
email: ptreacy@gmail.com
been theorised that, as injected hyaluronic acid (HA)
expands because of its hydrophilic action, the facial
artery, angular artery, or its branches, become
compressed. the facial artery runs in an oblique
direction over the mandible toward the nasal sidewall.
It passes under the zygomaticus muscles, crossing the
nasolabial fold. It turns to run in the alar crease and
along the lateral nasal wall, where it terminates in the
angular artery, which continues toward the medial
orbital rim6.
There are several important factors that may lessen
the occurrence of adverse events. Before injecting any
dermal filler, a thorough medical history including
medication (especially blood thinners), allergies, and
scarring history (e.g. tendency for keloids) should be
taken. The injector should be well trained in injection
technique and know which filler to implant at which
depth. Understanding the anatomy, limitations of the
filler and proper technique can reduce the risk of adverse
effects. When complications occur, the practitioner
should understand how to manage them from
observation to surgical intervention7.
Preventing side-effects
The best way to handle side-effects is to prevent them8.
For optimum outcomes, aesthetic physicians should
have: a detailed understanding of facial anatomy; the
individual characteristics of available fillers; their
indications, contraindications, benefits, and drawbacks;
and ways to prevent and avoid potential complications9.
Hyaluronic acid dermal fillers are the most widely used
injectables to augment facial volume without surgery.
They are popular because of their ease of
administration, predictable effectiveness, good safety
profile, and quick patient recovery10. Since its
reformulation in mid-1999, the biologically engineered
hyaluronic acid filler Restylane (Medicis
Pharmaceuticals, Scottsdale, AZ, USA) elicits less than
one allergic reaction in 1600 treatments. Skin
peer-review | Dermatology |
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❚ September 2014 | prime-journal.com

2. | Dermatology | peer-review
Severe vascular
adverse events have been
reported in the glabellar and
nasolabial regions after
treatment with both
biodegradable and
non-biodegradable
injectable fillers.
prime-journal.com | September 2014
❚ 23

3. review | Dermatology |
Anzeige_peer-reactions, including granuloma formation with poly-
L-lactic acid (Sculptra/formerly New Fill, Dermik
Laboratories, Berwyn, PA, USA) is considerably less
likely if a greater dilution and deeper injection
technique are employed11. Inflammatory nodules are
likely to be caused by a low-grade infection maintained
within a biofilm surrounding the hydrophobic silicone
gel and the combination gels. Aquamid gel may prevent
formation of a biofilm through its high water-binding
capacity, explaining why late inflammatory nodules
are not seen after injection of this polyacrylamide
hydrogel product11, 12. All gels act as foreign bodies. Host
response ranges from a few macrophages to an intense
foreign-body reaction with fibrosis, depending on gel
type. For polymer gels the filling effect stems from their
volume. For combination gels it stems from the
intended host foreign-body reaction to the
microparticles. Infectious nodules must be treated with
antibiotics. Granulomas must be treated with a
combination of both steroids and antibiotics or
excision12.
Case study
Patient was a 37-year-old woman who received HA
injection to the left nasolabial fold. She had an
uneventful procedure but reported back to the clinic
with an erythematous reaction and some pain in the
nasolabial and malar area the next day. In view of the
vascular compromise she was immediately treated
with 150 units of hyaluronidase and nitropaste to the
reticulated area. Because the patient presented 24
hours post-procedure she was given 100 mgs of
cortisone IV and commenced on 4 mgs of
Dexamethasone PO. It was also considered appropriate
to inject 0.2 mls of a dilute solution of 50%
dexamethasone 40 mgs/ml into the area where the
hyaluronic acid was initially injected.
The patient became hypotensive during treatment
and was temporarily referred to the emergency room
until stable. This was considered secondary to the
nitropaste gel. The hospital was willing to allow the
patient to come back to the clinic for further steroid
Figure 1 Images demonstrating
management of a patient over
7 days with impending necrosis
owing to complications
secondary to hyaluronic acid
dermal filler injection
Figure 2 Branching patterns of facial artery
FB
LNA
IAA
SLA
ILA
Branching patterns of facial artery according to its termination (ILA, inferior labial
artery; SLA, superior labial artery; IAA, inferior alar artery; LNA, lateral nasal artery;
FB, forehead branch
24
❚ September 2014 | prime-journal.com

4. Anzeige_Aesthetic_Prime_0814.indd 1 18.08.14 15:07

5. treatment and commencement of Chiroxy oxygenating
skin cream (Auriga international, Belgium). Chiroxy
oxygenating skin cream is designed to increase the
oxygen content of your skin by delivering O2 via
nanosomes. Her symptoms and signs disappeared
within a 5 day period and 2 weeks later there was no
evidence of any residual vascular deficit.
Discussion
For the moment, there is no ideal dermal filler as they
have widely varying properties, associated risks, and
injection requirements that contribute to adverse
events for the patient. The majority of adverse reactions
are mild and transient, such as bruising and oedema
secondary to trauma or the physical characteristics of
the material itself.
However, although serious adverse events are rare,
vascular complications either arterial or venous can
occur that are related to volume of filler used and the
technique of placement in the region of terminal
vessels. It is possible that injected HA expands because
of its hydrophilic action and the underlying facial artery,
angular artery, or its branches, become compressed.
This results in vascular compromise that can lead to
skin necrosis unless it is immediately treated. The
author proposes that intravenous steroids and anti-histamines
should be given to all these patients.
There are also issues related to the recent use of
adjunctive lidocaine in fillers that may make vessels
more exposed to accidental infiltration. Lidocaine
significantly decreases pain during injection and
post‑injection with corresponding increased patient
satisfaction13. The efficacy and safety profile of the
original filler may be compromised.
Rare complications with HA fillers include vascular
compression during or after the event which results in
reticulation some hours later and the author postulates
the use of intravenous steroids in these patients. These
patients normally show no evidence of vascular
compromise during injection. The protocol outlined by
Glaich et al14 calls for a coherent, sequential treatment
for vascular compromise resulting from injections of
hyaluronic acids. This protocol elaborates a sequence
of events that use topical nitroglycerin, hyaluronidase,
and other modalities to minimise the damage from
impending necrosis. Other authors have also published
guidelines for the treatment of impending necrosis
following soft tissue augmentation following injections
of hyaluronic acid15,16. Based upon the experience with
hyaluronic acid occlusion, treatment for particular
fillers that occlude vascular structures should seek to
increase blood flow to the affected areas. This may be
accomplished by decreasing pressure in the anatomic
compartment (using corticosteroids and hyaluronidase),
increasing blood flow (with sildenafil or similar drugs,
aspirin, and nitroglycerin paste), and increasing the
oxygen content to the affected tissues (hyperbaric
oxygen)17.
Regarding reversal of a hyaluronic acid induced
embolus, the author recommends starting at higher
Table 1
Author’s HLA
reversal protocol
Discontinue injection of
HLA immediately
Massage the affected area
immediately
Apply warm packs of gauze
to area (microwave)
Apply nitro-paste or 10 mgs
transderm-nitro patches
(Novartis) for a period of
up to 12 hours
Mix 300 units of hyalase
(0.2mls) with 0.2mls
(Wockhardt UK) of 2%
lidocaine and adrenaline
(Astra Zeneca)
Inject hyalase in 5–8 lots of
75u to occluded area
Hydrocortisone 100mg
IV stat
Dexamethsone 4mgs daily
PO X 3/7
peer-review | Dermatology |
Figure 3 Effects of a large filler bolus
Angular
artery
Distal
branches
Supratochlear artery
Dorsal nasal artery
Ophthalmic
artery
Facial artery
External
carotid artery
Internal
carotid artery
When a large bolus of filler material enters a small- or
medium-sized vessel, the material may flow retrograde to the
blood flow’s normal direction after it has filled in the distal
segment, because there is nowhere else for the filler to go. If
the filler bypasses a tributary during its retrograde flow, it may
enter this particular pathway and be carried to distant areas.
This is probably the pathophysiology responsible for injury
sites distant to the original injection site
Figure 4 Effects of a small filler bolus
Usually carried
downstream by
blood flow. May
cause limited
obstruction that
can be bypassed
via abundant
collateral vessels.
The problem is
in a region with
restricted
collaterals (eg,
the glabellar
region). Effect
depends on the
presence or
absence of
enough
collateral
circulation in the
target tissues
Micro volume
of filler does
not
completely
obstruct
blood supply
Distal
branches
Collateral
flow
Proximal
branches
For the
moment, there is
no ideal dermal
filler as they have
widely varying
properties,
associated risks,
and injection
requirements that
contribute to
adverse events for
the patient.
Table 2 Typical complication progression after
accidental intra-arterial injection of hyaluronic acid
Clinical findings Timing
Blanching: invariably immediate, usually seen during Lasting seconds to tens of
the actual injection seconds
Livedo pattern or immediate reactive hyperaemia Minutes: sometimes up to
if insufficient material injected to occlude the artery tens of minutes
Blue-black discolouration Tens of minutes to hours
Blister/bullae formation Hours to days
Skin breakdown, ulceration, demarcation, slough Days to weeks
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❚ September 2014 | prime-journal.com

6. levels of hyalase, possibly in the region of 150 to 300 iu,
and then treating repeatedly until the circulation
returns. Repeated treatment, massage, and the other
recommendations to promote vasodilation are
continued. It is probable as the material starts to break
down, it flows further downstream, where it probably
opens collateral vessels, or it can flow further past these
and obstruct a slightly different area. When it gets to the
precapillary arterioles, it gets permanently stuck, unless
it is bathed in more hyaluronidase (HYAL) and is
hydrolysed.
There are so many variables in a typical case that it is
impossible to be specific, since the manner of
manipulation of the area, the quantity and nature of the
filler within the vessel, and the actual location of the
emboli all factor into the equation. The absolute
quantity of hyaluronidase is probably irrelevant during
an acute event, it’s the results that count.
Declaration of interest None
Figures 1 © Dr Treacy, 3-4 original artwork © Claudio
De Lorenzi redrawn for Prime Journal © Kevin February
| Dermatology | peer-review
Key points References
One of the most
significant adverse events
associated with injections
of soft tissue
augmentation products is
vascular occlusion
Vascular complications
with HA fillers include
embolism or compression
during or after the event
which results in
reticulation some hours
later
The author postulates
the use of higher doses of
Hyalase than the normal
protocols and the uses of
intravenous steroids in
these patients
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prime-journal.com | September 2014
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