Vascular complications have always been a major concern for the practitioners who inject dermal fillers. The ongoing research in this area has helped us learn about the pattern and behavior of these complications. Learn from the experts in the field during this discussion panel course about this topic.
- Dr. Babak Maleki, MD (FRCSC, Ophthalmologist and Oculopastic surgeon) bio
- Dr. Reza Akef, MD (CCFP-EM, Aesthetic Physician) bio
Complications of dermal fillers these days are not common because the main fillers that we are using are hyaluronic acid (HA) fillers, complications, especially vascular complications are rare. This is a thing that none of us wants to see at practice. Even one vascular complication may have a very serious result that can be irreversible such as blindness. So that’s why we really want to be sure that whoever is practicing aesthetic medicine or doing injections know about these vascular complications.
Vascular complications usually happen for three causes. You may injure an artery or a vein directly by a needle or cannula so you might have a bruise or hematoma which is not a big deal but some patients are so scared of even a bruise. Vascular complications can happen due to intravascular injections, the chance of you doing an intravascular injection while using a needle is higher than cannula so a cannula is safer for high-risk areas. The third cause is the compression effect. Some experts believe that the compression effect does not exist especially for the facial arteries because they have a lot of elasticity so Compartments syndrome will not happen in the face. We think it still can happen especially around small arterioles or small capillaries if you inject a large amount of HA filler. With that being said most of the vascular complications that we have are due to intravascular injection.
We know that blindness mostly occurs in the areas that we have a significant anastomosis between internal and external Carotid arteries. The sites with most anastomosis are dorsal lateral sides of the nose (Angular & Dorsal nasal), Forehead (STA & Supraorbital), Temples (Deep Temporal & Lacrimal), Lateral Zygoma (TFA & Zygomaticofacial). We divide the face into 4 groups based on the risk of blindness, for example, Nose, Glabella, and Forehead are very high risk and Jaw line and chin are low risk. In 2009 most of the blindness cases were because of Glabella injection, but nowadays Nose has the highest risk of blindness due to filler injection. We have so many HA filler injections these days so we see most of the blindness cases in these patients.
Knowing anatomy is the first and the most important way to prevent vascular complications. You must have a deep understanding of 3D anatomy and places. You have to know the proper injection technique, how to use a cannula, how to inject deep, how to inject superficial etc. Otherwise, you are going to get complications. You also have to understand the clinical symptoms and warning signs to know how to treat and manage the complication. Vascular compromise has several stages like pain, Livedo reticularis, blue/gray appearance, and skin breakdown and blister formation that the patient will gradually show them. We will breakdown every stage’s symptoms and signs in detail.
If you are injecting a small amount of filler (<0.1ml) it will carry downstream of the blood flow and would not block the main arteries. Still, blockage of the small arterioles or capillaries is possible but usually, it is not symptomatic due to collateral circulation. But when we are injecting a large amount of filler with a higher pressure than blood pressure, the bolus will be pushed to the proximal part of the artery, against the blood flow. After removing the needle, the injected particle can go anywhere such as branches of the ophthalmic artery, and make blindness and embolization. So you should be aware of your injection pressure and the injection should always be slow. Prevention is the key to manage vascular complications.
If you have a problem, stop the injection and tell the patient what happened. Then start vigorous massage and warm compress and using Hyaluronidase (high dose) with plain lidocaine. Do not forget to use lidocaine, because the patient will be in a lot of pain due to injection, ischemia, and vigorous massage. You should do the treatment every 60 minutes and the patient must not go home until you see no ischemia sign.