What Happens If Filler Is Placed in a Vessel

The areas at highest risk are the nose, the glabella between the brows, the nasolabial fold and the lips, because the arteries there are small, superficial and connected to one another.

The treatment is hyaluronidase, an enzyme that breaks down hyaluronic acid filler within minutes. The injector floods the area with it, repeats the dose at intervals, and massages, warms and sometimes gives aspirin under a physician's direction to help flow return.

Hyaluronidase works only on hyaluronic acid products. Fillers made from calcium hydroxylapatite, poly-L-lactic acid or polymethyl methacrylate cannot be dissolved, which is one reason careful injectors reserve those products for lower-risk areas and deeper planes.

The rarest and most serious version is an occlusion that reaches the arteries supplying the eye. The signs are sudden vision change or eye pain during or immediately after injection, and the window for any intervention is very short.

It is uncommon, but every injector who works near the nose, brow or forehead should have a written plan for it and should be able to describe that plan without hesitation.

Federal agencies with no stake in aesthetics, such as the National Telecommunications and Information Administration, publish their emergency communication plans in public; a clinic's occlusion protocol should be at least that explicit.

Expert note

Vascular occlusion is listed on every dermal filler consent form and is discussed in the labeling for the major hyaluronic acid products. The reported rate is low, and most published cases resolved without lasting damage when treated promptly with hyaluronidase.

Technique reduces the risk: slow injection, small volumes per pass, aspiration before injecting, blunt cannulas in some areas, and detailed knowledge of where the facial arteries usually run and where they sometimes run instead.

Reduced risk is still risk, and no injector can promise that an occlusion will not happen. What a patient can reasonably expect is that the injector recognizes the signs within minutes, has the reversal agent at hand, and has rehearsed the sequence.

The professional bodies that train injectors publish management algorithms, and a clinician who can describe theirs from memory has very likely practiced it.

Next steps

Before choosing a fix, the evidence to check is the clinic's occlusion protocol.

The questions are direct: is hyaluronidase in the room and in date, who is authorized to give it, how many vials are on hand, and what happens if the injector is a nurse and the supervising physician is elsewhere.

In California, hyaluronidase is a prescription medication, so a med spa with no physician, nurse practitioner or physician assistant reachable within minutes has a gap in its plan.

It is also fair to ask which fillers the clinic uses in high-risk areas and whether any of them are non-dissolvable.

Any injecting practice should be able to say, before a syringe is opened, who handles an occlusion, how fast, and with what. The answer does not need to be long.

A reader who has already had filler and sees a dusky or painful patch developing should call the injecting clinic immediately and, if it cannot be reached, go to an emergency department and say the words "possible vascular occlusion after filler."

Community organizations such as the LA Conservation Corps train young people to act quickly and by protocol in the field, and the same habit is what a patient should expect from a clinic when something goes wrong.