Cosmetic Filler–Induced Vascular Occlusion: A Rising Threat Presenting to Emergency Departments
Received 6 February 2023, Revised 1 May 2023, Revised 4 July 2023, Accepted 10 July 2023, Available online 11 August 2023, Version of Record 15 December 2023.
Danny J. Soares MD a b, Stephanie D. Hynes NP-C b, Christina H. Yi MD b, Sabrina Shah-Desai MS, FRCS c, Steven C. Irving MD d
University of Central Florida, College of Medicine, Orlando, FL
American Foundation for Aesthetic Medicine, Fruitland Park, FL
Ophthalmology/Oculoplastic Surgery, Private Practice, London, United Kingdom
Department of Emergency Medicine, AdventHealth Hospital, Orlando, FL
Vascular emergencies from cosmetic filler–induced vascular occlusion represent an iatrogenic etiology that poses a threat to patients, with sequelae that range from disfiguring skin necrosis to blindness and stroke. As cosmetic fillers continue to grow in popularity, the importance of early identification, triaging, and management of these rare but potentially disabling injuries has motivated efforts to educate the public and professional audiences. In this practice review article, we outline components of acute care pertaining to these injuries based on evolving practice guidelines and best evidence recommendations.
Introduction
Dermal fillers have changed the landscape of plastic surgery, emerging as one of the most popular cosmetic treatments of the 21st century.1 Designed for ease of injection, this class of soft implants is formulated with a variety of biocompatible/resorbable gels approved for dermal and subcutaneous placement.2 Given their versatility and affordability, these products have evolved beyond “wrinklefilling” and are now routinely employed in facial sculpting.3,4 With the rise in demand, the incidence of filler-induced vascular occlusion has also grown, with complications ranging from facial skin necrosis to blindness and stroke. This notable uptick in adverse outcomes has prompted the US Food & Drug Administration (FDA) to relabel filler products and call for improved training in the early identification and treatment of these injuries.5, 6, 7, 8 Given the potential for patients with filler-induced vascular occlusion to present to emergency departments (EDs), ED professionals should be equipped with current knowledge on this time-sensitive condition. In this article, we offer guidelines based on current evidence and consensus guidelines, recognizing the need for cautious interpretation and implementation due to the still-limited quality of supporting evidence.
Epidemiology
Filler-induced vascular occlusion injuries are rare occurrences, estimated at 0.01 to 0.05% per treatment based on retrospective studies.9, 10, 11 However, given the rapid rise in popularity of dermal fillers, with more than 4 million treatments performed in the United States alone in 2022, filler-induced vascular occlusion injuries have seen a corresponding increase in incidence.1,12,13 These figures are likely to grow given the increasing number of nonspecialized practitioners performing
Pathophysiology
Filler-induced vascular occlusion represents an impending tissue infarction caused by the accidental injection of dermal filler into an artery, resulting in blockage, distal embolization, thrombosis, and possible spasm of the affected arterial network.18 This effect creates an injury akin to embolia cutis medicamentosa (also known as Nicolau syndrome), leading to tissue ischemia and irreversible damage.19 Because the face is supplied by the internal and external carotid arterial systems, which
Filler Agents
Since the introduction of Restylane (Galderma Laboratories) into the US market in 2003, numerous fillers have gained FDA approval for cosmetic use. Hyaluronic acid gels, comprising approximately 80% of all products used in the United States, currently dominate the filler market due to their versatility and rapid reversibility via existing hyaluronidase solutions. Consequently, hyaluronic acid fillers also account for approximately 80% of all filler-induced vascular occlusion injuries.6 The
Illustrative Case Presentation 1
A healthy 47-year-old woman presented to the ED with acute-onset facial pain and skin discoloration located over the central part of the forehead.23 Two days prior, she had received hyaluronic acid filler injections into the glabella for correction of frown lines by a cosmetic practitioner. During treatment, she experienced immediate pain over the forehead radiating to the left eye, with blanching of the central forehead skin (Figure 1A). Over the ensuing 48 hours, her pain worsened
Illustrative Case Presentation 2
A 59-year-old woman presented to the ED with acute vision loss after hyaluronic acid filler treatment of frown lines 3 hours prior to arrival. Upon injection, she recalled experiencing sudden dizziness, nausea, and right frontal headache, followed by complete vision loss in the right eye. She received immediate hyaluronidase injections into the glabella and central forehead by her cosmetic provider, with little improvement. At the ED, evaluation revealed livedoid discoloration of the right
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