Vascular occlusion (VO) is either not discussed at all, or is spoken in very hushed tones between us doctors because the last thing we want is for people to be afraid of filler treatments. By Dr Anushka Reddy
The reality is that while there are millions of filler or fat injections done every year, very few of them actually lead to serious complications. But be that as it may, we still feel that this is an important conversation to have – as is the discussion around how we can minimise the risks.
So, before your next filler appointment, best familiarise yourself with all the facts around VO to ensure that you make an informed decision before an injector injects your face with filler (that may potentially cause tissue death, or even worse, blindness).
Fact 1: Vascular occlusion is a rare but very real filler risk
A vascular occlusion, or compromise, occurs when a doctor accidentally injects filler into an artery, thereby blocking it and impeding the delivery of oxygen and nutrients to the tissue.
In some instances, the swelling of the hyaluronic acid gel can cause compression of a blood vessel, thus causing vascular compromise.
And while this is an unlikely scenario, there’ve been cases where compression has been cited as the source of vascular compromise. Yet, bear in mind that both of these causes will be treated in exactly the same manner: with high doses of hyaluronidase.
A published case study of 14,355 filler injections administered over a 10-year stretch found the incidence of vascular compromise to be 0.05%. Experts generally agree that the true rate among injectors at large is likely higher since complications commonly go unreported.
Having said that, you can be rest assured that despite the extensive network of blood vessels in the face, it is very hard to inject one and cause a blockage. In addition, choosing an injector who has extensive knowledge of facial anatomy will further ameliorate the risk of injecting a blood vessel.
Fact 2: Not all blood vessels are the same
A complex network of arteries and veins supports our facial tissues – some vessels supply the skin, others supply the eyes and brain. However, it is the vast interconnection between the skin, brain and eye blood vessels that carry the devastating consequences of a patient becoming blind or having a stroke should the filler be injected incorrectly.
When it comes to the skin, should it be deprived of blood then there’s the potential for skin loss and scarring if it’s not treated.
Nevertheless, this shouldn’t happen so long as it is detected early and treated appropriately. For this reason, every doctor injecting hyaluronic acid filler must have a few vials of hyaluronidase available in their office to quickly dissolve the filler in the event of a VO.
The good news is that HA fillers can be dissolved instantly and restore blood flow immediately – thus preventing skin damage.
The flip side of the coin is that in more serious complications where the filler is inadvertently placed in a blood vessel that communicates with the circulation to the eye, it can lead to permanent blindness and other ophthalmic issues.
But again, I need to reiterate that the likelihood of this occurring is exceedingly rare! Indeed, a 2019 publication in the Aesthetic Surgery Journal estimates the risk of filler-induced blindness to be 0.001%.
Fact 3: More riskier injection sites
The forehead, the glabella (or space between the brows), and the nose are the most notorious danger zones for filler. The temples and the nasolabial folds are also considered high-risk.
Some injectors will err on the side of caution and avoid filling ‘danger zones.’ This is the responsible thing to do. Then there are those doctors who are experienced in the use of sonar technology, thus enabling them to detect blood vessels during the injection.
They will also very likely offer other treatments, such as the non-surgical nose job (which is super-trendy right now).
No to the nose
Being mindful of the depth of the injection, the volume injected and the location of the nasal blood vessels under sonar guidance will substantially mitigate the risk of VO. Although, the nose which has been operated on before is a definite no-go for me, since surgery can change the normal location of blood vessels – ultimately making the risk of a VO incidence even higher.
I personally do not inject the glabella with filler as it is a watershed area for blindness. I refuse to perform this procedure, even when my patients ask me to. This is where I tell them that one of the highest risk of blindness comes from injecting into this area, which is why I’m hesitant to do it.
Needless to say, they are quick to change their minds as soon as I inform them about these risks.
However, with all that said and done, it must be noted that there is no actual ‘safe’ zone in the face (which is due to the extensive network of blood vessels). There may be ‘safer’ zones, but in reality, blindness can be caused from injecting the lips, cheeks or any part of the face.
Fact 4: How to reduce the risk
As a patient, it is vital to go to a doctor who knows and understands the facial vasculature anatomy and its variations. And as a doctor, it is incredibly important to not only know where the blood vessels are, but what plane they’re in, and to appreciate that in any given person, these vessels may not be exactly where they’re supposed to be.
Injection technique is equally crucial. It is critical to inject S-L-O-W-L-Y while constantly moving the needle tip. By reducing plunger pressure, it also prevents injecting a big bolus that theoretically could be inside a vessel.
Fact 5: Warning signs of a VO
One of the cardinal signs of a VO is skin blanching: that is when the overlying skin turns white. Sometimes blanching can be seen along the distribution of an artery, in which case the area should be quickly flooded with hyaluronidase. The enzyme works within minutes, but protocols advocate several treatments over a few hours to re-establish blood flow.
Severe pain can be another sign of trouble, as the pain associated with a VO is incredibly intense. And as the blockage worsens, the pain escalates to a throbbing, fiery, out-of-proportion agony. This may be associated with skin mottling and is usually seen within an hour or two.
Fortunately, an experienced doctor will be able to distinguish skin mottling from a bruise and can therefore act accordingly.
When a vessel feeding the eye is affected, expect excruciating pain around this area, along with blurry or lost vision. Sometimes blanching along the vessel leading to the eye is visible.
This tends to happen within seconds of injection, so it is of utmost importance that swift, immediate intervention is carried out.
In this case, retro-bulbar injections of hyaluronidase that is inserted behind or around the eyeball by an ophthalmologist are ideal. But on the other hand, please note that this treatment is a last-ditch rescue effort, with its efficacy being highly controversial as well.
Fact 6: Slow and natural does it
Slow filler transformations are the safest. When filler is injected slowly and over a long duration, it not only keeps you looking like yourself, but it significantly lowers the risk of complications.
Furthermore, when filler is layered and built up over time, it allows the product to integrate into the tissue more naturally while reducing the risk of the patient being ‘overfilled’ (which is usually seen in people who’ve had all their fillers done in one go). Lastly – and most notably – it reduces the risk of compressing or occluding blood vessels.
Take home message
As a last word to wannabe filler patients, I suggest looking at the injectables experience – but not as a before and after story – rather, as a journey of looking more rejuvenated where you’ll be safer and look more natural.
Written by Dr Anushka Reddy MBChB (Wits)
- Dr Anushka Reddy is the owner of Medi-Sculpt, Aesthetic & Anti-Ageing Solutions www.medisculpt.co.za
- President of the South African Association of Cosmetic Doctors (SAACD) www.cosmeticdoctors.co.za
Dr Reddy has regularly contributed to various publications such as A2 Aesthetic & Anti-Ageing Magazine, Woman and Home, Longevity, Elle and The Star. She has also appeared on TV programmes such as Carte Blanche Medical, Top Billing, Eastern Mosaic, Maatband, Hello Doctor as well as CNBC Africa.
A2 Disclaimer: This article is published for information purposes only, nor should it be regarded as a replacement for sound medical advice.
This article was written by Dr Anushka Reddy and edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine Summer 2021 Edition (Issue 39 – Dec 2021 to Mar 2022).
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