Know the Risks

What you need to know about the dangers of a vascular occlusion following dermal fillers and how you can keep yourself safe

Dermal fillers can be extremely safe and effective treatments in the right hands.

They can help to lift and smooth lines, replace volume loss and enhance and beautify certain areas of the face and body. However, the injectable gel can also cause side effects. We’re sure you’ve seen the most dangerous dermal filler side effect commonly covered in the media – a vascular occlusion (VO). Although the majority of dermal filler treatments performed by a skilled and highly trained medical practitioner do not have complications, it’s important to be aware of this risk before having the treatment. To get the lowdown on the risks of VOs following dermal filler treatments and to find out what you can do to help prevent this happening to you, we spoke to Dr Martyn King, chair of the Aesthetic Complications Expert (ACE) Group World, an association that aims to diagnose, manage and prevent complications in aesthetic medicine.

Dr Martyn King,

aesthetic practitioner, Cosmedic Skin Clinic, Tamworth

IG: @cosmedic_clinic

What is a vascular occlusion?

Vascular occlusion refers to the blockage of a blood vessel, which stops blood from being able to travel. There are two types of VO: partial – when some blood is able to pass through the vessel – or complete – where the vessel is completely clogged resulting in the absence of blood flow. If the blood supply to the skin and surrounding tissue is impaired in any way, the result is a lack of oxygen and other essential nutrients to the area. This may severely impact the health of your cells and may lead to death of the tissue (necrosis), ulceration, infection and permanent scarring. This is why a VO can cause a very distressing appearance for patients as well as pain and other signs and symptoms. In the rarest occurrence, a VO may even pass into the blood vessels supplying the eye resulting in vision disturbance and even blindness!

How is a vascular occlusion caused?

A foreign substance such as an injectable dermal filler may block a blood vessel by being injected directly into it. Dermal filler can also cause a VO if it is injected very close to the wall of the blood vessel, compressing or ‘kinking’ it (check out the image). Although VOs might occur precisely where the dermal filler is injected, they can also happen at a different location as the filler can travel along the blood vessel where it will eventually reach a narrower point and get stuck – this is known as embolisation.

How common are vascular occlusions?

Thankfully, VOs are a rare complication of dermal filler treatments, with an incidence of 1 to 10 cases per 100,000 treatments (0.001% to 0.01% risk). However, due to the increasing number of treatments being performed in the UK, the ACE Group World help to manage two to three cases of VO each week. Most of these are reported to have been caused by non-medical professionals. Indeed, out of

How a blood vessel can become blocked due to dermal fillers

Normal blood flow

Partial blocked vessel due to dermal filler

Complete blocked vessel due to direct dermal filler placement

Complete blocked vessel - dermal filler compression

616 complaints regarding dermal fillers to an independent accreditation body, 83% of the treatments reported were carried out by beauticians, hairdressers and lay people (someone who is not qualified in a given profession).

What are the symptoms of a vascular occlusion?

An experienced and competent medical practitioner will normally spot the signs and symptoms of a VO immediately. If a VO is not successfully treated, the skin can become discoloured, bumpy, ulcerated, sloughy and black.

The common symptoms of a VO are: • Blanching: The skin may become white in appearance in a reticulated (net-like) fashion following the course of the skin supplied by the blood vessel. In darker skin types, blanching is more difficult to spot but there will still be a change in colour in a characteristic pattern. Additional signs and symptoms of a VO may need to be relied on more for skin of colour. • Pain: It is normal to experience some pain or discomfort, but severe pain should alert the practitioner to a potential complication. • Purple skin colour: Often the skin will appear dusky or purple in colour and may be cool to the touch. This shouldn’t be confused with bruising, which is a common and harmless side effect. • Capillary refill: The capillary refill time (the amount of time it takes the skin colour to return to normal after applying pressure for three seconds) is often delayed.

How do practitioners avoid vascular occlusion?

There is a lot that practitioners do to avoid the terrible threat of VO. A highly skilled, reputable and registered medical practitioner who has extensive training and experience will have a lower risk of causing a VO as they will have a thorough understanding of the anatomy and blood supply and know where the ‘danger areas’ are. They will also implement strategies and techniques to lower your chances. You should know that there are certain factors that make you higher risk of a VO, such as if you have had surgery in the area before, as surgery may change the location of your vessels. Your practitioner should perform an in-depth consultation to ensure you are not at higher risk. Certain injectable products also have a greater inherent risk. Your practitioner should be choosing reputable dermal fillers that have passed rigorous safety tests with multiple case studies of successful results.

Think you have a vascular occlusion? Here’s what to do…

If you are experiencing significant pain or changes in the colour or appearance of your skin following a soft tissue filler treatment, you should seek immediate advice from your treating practitioner. Remember it could likely be a bruise, but if you are unsure, it’s always a good idea to check. A respected medical practitioner should provide you with aftercare advice, or a leaflet following your treatment which should have an emergency contact number on it. Do call this if you suspect you have had a complication, such as a VO. You may initially have a phone or video call, but this is not a substitute for a face-to-face review, and you should request this if they do not offer this to you. If you can’t get hold of your treating practitioner, or you don’t feel they are taking your concerns seriously, don’t be afraid to get a second opinion from another aesthetic practitioner near you. A VO is time-critical, and the earlier it is diagnosed and treated, the better the outcome.

How is a vascular occlusion treated?

The most important aspect of treating a VO is to first correctly diagnose this complication. If your practitioner is unsure of the diagnosis, they may contact another practitioner to seek advice. If the practitioner notices any skin changes, sometimes by stopping the treatment, massaging and applying heat, a VO may be avoided. But they may need to proceed to remove the dermal filler to unblock the vessel by injecting an enzyme called hyaluronidase. This can dissolve the most common type of dermal filler in the UK – hyaluronic acid. Depending on the severity of the complication, your practitioner may also advocate the use of heat, massage, aspirin, oxygen therapy, antibiotics, and wound management techniques. Of course, if there is any vision disturbance, this requires emergency admission to an eye hospital.

Should the chance of a VO stop you getting treatment?

As with any medical procedure, it’s important you are educated so you can weigh up the pros and cons of any treatment and understand the risks. If you are considering treatment, you should ask how your practitioner reduces the risk and how they would manage this complication if it were to happen. You should only seek treatment from a medically qualified practitioner who is regulated with their professional body such as the General Medical Council, Nursing and Midwifery Council and the General Dental Council. They should also work in a suitable clinical environment, such as a medical aesthetic clinic, where there are drugs and equipment in place to deal with a VO, should it occur. Although rare, the risk of a VO is something that is significant and should be discussed during your consultation. If your practitioner doesn’t mention this, or just breezes over it, then this should raise alarm bells! The majority of dermal filler treatments provide satisfactory results without any issues, but sometimes things can go wrong. Always research your practitioner and be absolutely confident they have the training and ability to avoid and manage any complication so you can be sure that you are in safe hands.