Vascular compromise resulting from hyaluronic acid dermal fillers: More than skin deep

(Image Credit: AdobeStock/anatoliy_gleb)

Reviewed by Steve Yoelin, MD

The use of soft-tissue fillers became widespread in the 1980s with the introduction of bovine collagen. The administration of these fillers is the second most popular type of nonsurgical aesthetic procedure in North America behind only botulinum toxins. Steven Yoelin, MD, who is in private practice in Newport Beach, CA, described complications associated with the use of these products at the Hawaiian Eye meeting in Maui.

These injected products generally are characterized by early, mild, self-limited side effects, including injection-site reactions of bruising, swelling, and erythema. Rare adverse events include infections, development of nodules, hypersensitivity, and vascular compromise.

Vascular compromise is the most ominous early adverse event that can occur when a filler is unintentionally injected into a blood vessel, according to Yoelin. Vascular compromise is rare, with an incidence of about 0.001%, but may be underreported. Some practitioners are now injecting fillers deeper into the face, which is associated with a higher risk of vascular occlusive events.

The soft-tissue fillers currently used are hyaluronic acids, calcium hydroxylapatite, polymethyl methacrylate, poly-L-lactic acid, and fat, all of which can cause vascular compromise.

The mechanisms by which vascular compromise occurs are not understood completely.

Preventing vascular compromise

Yoelin advised that physicians who inject dermal fillers should understand the underlying anatomy. In addition, the use of smaller bore needles, a slow injection technique, smaller boluses, cannulas, and lidocaine with epinephrine are advised. Importantly, the high-risk areas (i.e., the glabella, forehead, and nose) should be approached with caution.

Signs of vascular compromise

Yoelin advised that physicians be alert to skin blanching, which is the first indication of vascular compromise after filler injections. Other signs and symptoms include patient discomfort, bruising, and discoloration. He pointed out that the blanching often may be too subtle to notice. However, over the next several days, tissue necrosis will often take place if treatment is inadequate or is not instituted.

In order to prevent this complication, Dr. Yoelin advised, “Choose a reversible hyaluronic acid filler, exercise caution when injecting into high-risk areas, consider aspiration before injecting, use low volumes of the product, and consider using a cannula, rather than a needle.”If a vascular occlusion does occur, hyaluronidase is the cornerstone of treatment for occlusions that are induced by hyaluronic acid dermal fillers. Other treatment options include the administration of oral enteric-coated baby aspirin, possible oral steroids. antibiotics, and hyperbaric oxygen.

Yoelin discussed a novel way to treat hyaluronic acid dermal filler occlusions that involves the direct injection of the facial artery with hyaluronidase at the mandible during his presentation.

Vision loss

Blindness is an unlikely but dreaded complication of vascular compromise that can be induced by hyaluronic acid dermal fillers.

The mechanism by which this occurs is unclear.

“There is not consensus on how best to address hyaluronic acid-induced vascular occlusions. There is a desperate need to identify a way to reverse this life-changing adverse event,” Dr. Yoelin concluded