Filler vascular occlusion: the warning signs and what to do now

What is filler vascular occlusion?

Filler vascular occlusion is a blockage of a blood vessel by dermal filler, either because filler has entered the vessel or because filler beside it is pressing it shut. The skin that the vessel supplies then receives too little blood. If blood flow is not restored, that skin can blister, break down and scar, and in rare cases filler that travels towards the eye can affect vision.

It can happen with any filler, in any area and in careful hands, which is why doctors who inject filler are trained to recognise it and act at once. Most filler treatments go smoothly, and in one large survey of dermatologists most of the occlusions reported left no long-term effects (Alam and colleagues, 2021).

• Arterial occlusion: filler inside or compressing an artery. It usually shows straight away, with pale skin and strong pain.
• Venous occlusion: typically pressure on a vein from outside. It tends to show later, with dull or little pain and dark discolouration (King and colleagues, 2020).
• Occlusion affecting the eye: filler reaching the artery that supplies the eye. It is rare and is the most serious form.

This guide covers the signs, what to do and how occlusion is treated. For other filler problems and how they are assessed, see filler correction at SkinRev Lab.

What are the signs of vascular occlusion after filler?

The signs of vascular occlusion after filler are skin that turns pale, white, mottled or dusky, pain that is severe or keeps rising, and, rarely, a change in vision. They usually appear during the injection or within minutes, but they can develop over the following hours. If any of them appear, go to an emergency department now. Published guidance describes a typical sequence (King and colleagues, 2020):

• Pale or white skin (blanching): often immediate, and it may come and go at first.
• Pain: usually severe and immediate, and sometimes felt away from the injection point. Numbing cream or anaesthetic in the filler can dull it, so little pain does not rule occlusion out.
• A lacy, net-like or mottled pattern: within minutes to tens of minutes, following the area the vessel supplies.
• Slow colour return: when the skin is pressed, colour takes longer than about three seconds to come back.
• Blue-grey or dusky purple skin: over tens of minutes to hours.
• Cool skin: the area can feel cooler than the other side.
• Skin breakdown: blisters, sores or a dark scab over the following days if blood flow is not restored.

Signs that involve the eye or brain are an emergency of their own: sudden blurring or loss of vision, eye pain, double vision, a drooping eyelid, weakness, numbness, difficulty speaking or a severe headache. Call 995.

Is it a bruise, normal swelling or vascular occlusion?

A bruise is dark from the start and stays where the needle went in, whereas vascular occlusion usually begins with pale skin and rising pain and then spreads in a mottled or dusky pattern. Bruising and swelling are common after filler and are not warning signs on their own. The table is a general guide; if you are unsure, treat it as urgent and go to an emergency department now.

For what is expected in the first days, see bruising after filler and filler swelling: what is normal.

What should you do if you suspect vascular occlusion?

If you suspect vascular occlusion after filler, go to an emergency department now, and call the doctor who injected you on the way. Published guidance says suspected occlusion needs an immediate review in person and that photos or messages are not an acceptable substitute (King and colleagues, 2020).

1. Go now. Skin turning pale, dusky or mottled, or severe or escalating pain, means an emergency department now. For any change in vision, weakness or difficulty speaking, call 995.
2. Phone your injecting doctor. Call while you are on the way, and do not wait for an answer before setting off. They know what was injected and where, can speak to the hospital team, and may be able to meet or treat you urgently.
3. Bring the details. The product name, the amount, the areas treated and the time of injection help the doctors act quickly.
4. Say the words. Tell the triage nurse, "I had dermal filler injected today and I am worried about a blocked blood vessel."

What not to do:

• Do not wait overnight to see whether it settles.
• Do not massage, squeeze or press on the area, or apply ice or heat, unless your doctor advises it.
• Do not cover the area with make-up before it has been examined.
• Do not rely on a message or a photo for reassurance.

SkinRev Lab is open daily from 11am to 8pm and is not an emergency department, so do not wait for a reply from us or from any clinic if urgent signs are present.

How common is filler vascular occlusion?

Filler vascular occlusion is uncommon, and in one large survey most of the occlusions reported left no long-term effects. That study surveyed 370 dermatologists who had together injected about 1.7 million syringes of filler (Alam and colleagues, 2021):

• With needles, the study measured one occlusion per 6,410 one-millilitre syringes injected.
• With blunt-tipped cannulas, it measured one occlusion per 40,882 syringes.
• For no type of filler did the risk exceed one per 5,000 syringes.
• About 85 per cent of the occlusions reported left no long-term effects.
• Doctors who had injected filler for more than five years reported lower odds of occlusion.

These figures come from experienced specialists reporting from memory, so they are an estimate and cannot give an exact risk for one person or one treatment.

Some areas carry more risk than others. Reviews point to the nose, the area between the eyebrows (glabella), the forehead and the fold beside the nose, where arteries connect with the blood supply of the eye, and to the lips and the base of the nostril for skin injury (Beleznay and colleagues, 2019; Funt and Pavicic, 2013). Area-specific detail is in our guide to nose filler complications.

How do doctors treat filler vascular occlusion?

Doctors treat vascular occlusion from hyaluronic acid filler by injecting an enzyme (hyaluronidase) across the whole affected area, in repeated doses, until blood flow returns. Published guidance describes relatively high doses repeated about every hour, continued until skin colour, colour return on pressing and pain have improved (King and colleagues, 2020).

• It is time-critical. The guidance says a skin test for allergy is not required first in this emergency, because delay causes harm. That differs from planned dissolving, which is covered in hyaluronidase side effects.
• The whole area is treated. The enzyme is placed throughout the pale or mottled skin and not only where the filler went in.
• Going late is still worth it. The same guidance reports cases in which skin loss was avoided even when this treatment began up to 48 hours after the filler was injected, so go even if hours have passed. Earlier is better, and no outcome can be promised.
• Other measures may be added. Doctors may use further medicines and supportive care to help blood flow; your doctor will advise what is needed.

If the filler is not hyaluronic acid, the enzyme cannot dissolve it. Some reviews still advise giving it, alongside other measures, and the hospital or treating doctor will decide (Funt and Pavicic, 2013). This is one reason to know exactly which product was injected.

Emergency treatment is different from a planned appointment to dissolve filler, which uses small, mapped doses.

Can filler vascular occlusion affect your eyesight?

Yes, rarely: filler that enters an artery connected to the eye's blood supply can block it and cause sudden loss of vision. This is the most serious filler complication and the hardest to reverse, which is why any visual symptom during or after filler needs emergency care immediately.

A review of the world literature found 48 new published cases of partial or complete vision loss after filler between January 2015 and September 2018 (Beleznay and colleagues, 2019):

• The areas injected most often were the nose (56.3 per cent of cases), the glabella (27.1 per cent), the forehead (18.8 per cent) and the fold beside the nose (14.6 per cent).
• The most common symptoms were vision loss, pain, difficulty moving the eye and a drooping eyelid.
• Skin changes accompanied 43.8 per cent of cases.
• Vision recovered completely in 10 of the 48 cases and partially in 8.

Published cases are a small number set against the very large number of filler treatments given worldwide, so the risk for one treatment is very low, but the review cannot give an exact rate.

What to do: call 995 or go to an emergency department at once for blurred, dim or lost vision, double vision, eye pain or a drooping eyelid after filler. Do not wait for the clinic to open or for a call back.

What happens after a vascular occlusion has been treated?

After a vascular occlusion has been treated, the skin is reviewed closely, at first as often as every day, until its colour and blood flow have settled. Guidance for doctors says patients should be followed until the occlusion has resolved and should have a number to call out of hours (King and colleagues, 2020).

• If blood flow returned early: the skin may recover with little or no mark, although this cannot be promised. Swelling and bruising from the enzyme injections are common for a few days.
• If some skin was injured: blisters, sores or a dark scab can appear over days. The area then heals from the edges inwards over days to weeks.
• Wound care matters: injured skin may need dressings, medicine if a doctor finds infection, pain relief and, for deeper injury, referral to a specialist.
• The filler result changes: the enzyme dissolves hyaluronic acid filler in the area, so the treated feature usually returns towards how it looked before.

Later on, once the skin has healed, a doctor can assess any mark, texture change or unevenness and discuss whether anything should be done. Whether and when filler can be placed again is an individual decision; see filler after dissolving for the general considerations. Your doctor will advise on timing.

Return to an emergency department if the skin darkens, pain rises again, or redness spreads with fever.

How can you lower the risk of vascular occlusion?

The most useful way to lower the risk of vascular occlusion is to have filler injected by a doctor who knows the anatomy of the area, can recognise occlusion and can treat it on the spot. No technique removes the risk completely, but these questions help you judge preparedness:

• Who is injecting, and are they a doctor trained in facial anatomy and in managing filler emergencies?
• Is the enzyme (hyaluronidase) kept on site, and is there a written plan for a suspected occlusion?
• What product is being used, and is it hyaluronic acid, which the enzyme can dissolve? Ask for the name and amount in writing.
• Is a needle or a cannula planned, and why? In one large study, cannulas were linked with lower odds of occlusion than needles (Alam and colleagues, 2021).
• How will you reach the doctor after hours if something looks wrong that evening?
• Is my area higher risk? The nose, glabella and forehead deserve a specific conversation.

Tell the doctor about previous filler, surgery or scarring in the area, since these can change where vessels lie. Ultrasound can show filler and nearby vessels before treatment; the ultrasound filler mapping video shows how.

A doctor who uses smaller amounts, injects slowly, or advises against filler in a particular area is often lowering this risk for you.

When can Dr Sin Yong help at SkinRev Lab?

Dr Sin Yong, medical adviser at SkinRev Lab, can assess the skin and any remaining filler once a vascular occlusion has been treated as an emergency, and can assess other filler concerns that are not urgent. SkinRev Lab is a clinic at CityLink Mall, open daily from 11am to 8pm, and is not an emergency department. If urgent signs are present, go to an emergency department now and do not message or wait for the clinic.

An assessment may include:

• A full filler history: products, dates, areas, amounts and what treatment was given for the occlusion.
• Examination of the skin at rest and in movement.
• High-frequency ultrasound, where useful, to map remaining filler, its depth and nearby vessels.
• A plain explanation of the options, including waiting and doing nothing.

What may be discussed, where appropriate: whether remaining hyaluronic acid filler should be dissolved in small, mapped doses, how healing skin can be supported, and when it is reasonable to consider further treatment. No outcome can be promised, and some marks improve only with time. Assessment and correction are priced at consultation.

It is also worth staying in touch with the doctor who treated you, as they hold your records. For related concerns, see filler lumps and nodules, filler migration and signs of too much filler.