A Potential Treatment Protocol for Vascular Occlusion Due To Dermal Fillers Injections

Vascular occlusion secondary to dermal fillers is a rare but potentially catastrophic risk of any dermal filler injection. Careful technique, a thorough knowledge of facial anatomy and a conservative approach keep the risk low. If an occlusion does happen, recognizing the signs early allows prompt diagnosis and treatment, and that is what limits the damage.

The first step is to dissolve hyaluronic acid gel filler with hyaluronidase (Hydase, Wydase, Vitrase, etc.). Do not inject a large volume in order not to add more pressure to the compartment. Do not add epinephrine when diluting the hyaluronidase.

The next goal is to limit the damage from the occlusion. One way is to dilate the blood vessels with 2% nitroglycerin paste applied liberally to the affected area. The authors recommend application of nitroglycerin paste 2 to 3 times daily provided that the patient does not develop symptoms such as headaches or light headedness.

Corticosteroids are indicated to diminish the inflammatory component of the injury, which can further inflame the compartment and lead to more vascular compromise. Oral corticosteroids in doses ranging from 40 to 60mg of prednisone are recommended for the first 2 to 3 days after occlusion. A taper over the first week is then initiated. Alternatively, use of a methylprednisolone dose pack is also reasonable.

Dilation of the blood vessels should be maximized with the use of drugs designed for the treatment of erectile dysfunction.9 These drugs, including sildenafil (Viagra), tadalafil (Cialis, Lilly USA, LLC), and vardenafil (Levitra, Bayer Pharmaceuticals Corporation) are selective inhibitors of cyclic guanosine monophosphate (GMP) specific phosphodiesterase type 5. Nitric oxide, which is released during normal activities, activates guanylate cyclase, which, in turn, increases cyclic GMP. Increases in GMP cause smooth muscle relaxation, dilation of the vascular wall, and increased blood flow. As with the use of these drugs in any patient, caveats regarding heart disease and other contraindications are still pertinent. Combination of such medications with Nitroglycerine can lead to significant side effects.

Aspirin is used to block platelet aggregation and has moderate anti-inflammatory properties. If the vascular injury from the particulate filler has not entirely occluded the vessel, aspirin may be able to help blood flow by inhibiting platelet aggregation and blood clotting. Keeping any aspect of the vessel patent will help to increase the viability of any tissue that relies on it for circulatory support. Doses of 81mg/day should be effective in decreasing platelet aggregation, and in the acute setting, aspirin may be placed sublingually.

Hyperbaric oxygen has the potential to deliver oxygen deep into the skin and may help to keep oxygen-dependent tissues viable. Its use in flaps, grafts, and other skin that has potential vascular compromise is controversial. However, if a facility exists that can provide hyperbaric oxygen to a patient with impending necrosis, it may be reasonable to attempt a course of this treatment.

In the cases the authors reported, clinical signs of impetigo appeared after a few days. In both patients, cultures for bacteria as well as for virus were negative. Despite the negative cultures, the patients were placed on cephalosporin antibiotics as soon as the honey-colored crust appeared. It is possible that this crust represented an exudate from a compromised epidermal barrier. However, in the event that a crust forms following vascular occlusion, it is prudent to use oral antibiotics while the cultures are pending.

In summary, catastrophic outcomes are rare, but when an occlusion happens, quick diagnosis and treatment on several fronts at once give the best chance of limiting them.

Reference:
J Clin Aesthet Dermatol. 2012 May; 5(5): 44–47.
A Treatment Protocol for Vascular Occlusion from Particulate Soft Tissue Augmentation
Kenneth Beer, MD, Jeanine Downie, MD, and Jacob Beer

Frequently Asked Questions

What is vascular occlusion from dermal filler?

It happens when filler blocks or presses on a blood vessel and cuts off part of the blood supply to the skin. It is a rare complication, but it can be serious, so it needs to be recognized and treated quickly.

Can hyaluronic acid filler be dissolved if something goes wrong?

Yes. Hyaluronic acid fillers can be dissolved with an enzyme called hyaluronidase, and dissolving the filler is the first step in treating a vascular occlusion. The Naderi Center keeps hyaluronidase on hand in both of its offices.

How is a vascular occlusion from filler treated?

Treatment starts with dissolving the filler with hyaluronidase. Depending on the case, physicians may also use nitroglycerin paste and other medications to open the blood vessels, corticosteroids to reduce inflammation, and aspirin to help blood flow. Hyperbaric oxygen is sometimes considered when tissue is at risk.

How can the risk of vascular occlusion be reduced?

The risk is kept low with careful injection technique, a thorough knowledge of facial anatomy and a conservative approach. At The Naderi Center, all filler injections are performed by physicians.