Case Study: Dealing with a Suspected Vascular Occlusion
So, I want to share a story to give you an idea what to look for in the event of a vascular occlusion and what you can expect from getting the filler dissolved. Late one evening after I was already at home, a lady calls me, frantic that her lip that recently received filler wouldn’t stop swelling. To be clear, I've never met this patient and I had not done her lips. Her regular injector was closed, and she was frantically calling random clinics until she found me. I was closed too but as my work number was linked to my cell, I answered. My immediate thought was she was experiencing a vascular occlusion. This is where dermal filler is accidentally injected into a blood vessel and blood flow is blocked off from a region of your face, in this case her lips. This can cause a lot of pain, swelling, and if not treated quickly, can lead to areas of tissue dying from ischemia (lack of oxygen) which may lead to long-term scarring. This is the biggest risk with dermal fillers but fortunately, it’s quite rare. Based on studies, the frequency is approximately 1 in 5000. 1
Without seeing her in person, this was my best guess and treating it as an emergency, I asked her to meet me at the clinic in half an hour whereI kept a supply of hyaluronidase, the enzyme that we use to dissolve the filler. The benefit of blood flow to the lips is that the arteries and veins encircle the upper and lower lips which provide blood flow in two directions.This can delay the onset of ischemia more so than areas of the face where blood only flows in one direction. So, this was the condition of her lips when she arrived at my clinic that evening:
She had gotten filler 2 days ago and had felt a lump in her upper lip that she was massaging out when her lip suddenly and very quickly started swelling about 2 hours earlier and was only getting bigger. This is unusual for a vascular occlusion as normally, you’d know pretty much right away that something is wrong. The fact that this happened after 2 days is odd, but I couldn’t rule anything out just yet. The first thing I checked was the blood flow to her lips by applying firm pressure for 5 seconds when releasing and seeing if the color goes from white to pink in less than 2 seconds. If the skin stays pale and white, that’s a bad sign. It means blood isn’t returning to the area fast enough and the tissue there is going to die. Strangely, her capillary refill appeared to be good. Her upper lip, even the swollen area, returned to a nice, healthy pink color under 2 seconds after releasing pressure. I rested a little easier at this point knowing that her condition wasn’t critical and we weren’t at risk of having parts of her face die on us.
Nevertheless, the rapid swelling was a bit concerning and I hypothesized one of 2 things may have happened.
1. By massaging the filler, she may have shifted some of the filler that temporarily blocked off blood flow via compression of blood vessels in the area, causing blood to back up and result in swelling.
2. By massaging the filler, she may have aggravated the area and triggered an acute inflammation response.
Despite not being a medical emergency, there was still the issue of the swelling and some noticeable migration of some previous filler. This was visible superior to the vermillion border of her upper lip and there was still a noticeable lump of filler inside her upper right lip where the swelling was located that she wanted to get rid of and redo later.
We went ahead with dissolving the filler in the upper left lip with hyaluronidase. For those of you who have not had this done, it’s not the most pleasant feeling. Before we dive deeper, I just want to note that this is an enzyme that we already produce in our bodies. Our bodies constantly breakdown and create hyaluronic acid so, like the filler, this is just a more concentrated version of what our bodies already produce and is fully biocompatible. There is a slight risk if you’re allergic to bees as bee venom has hyaluronidase in it as well, so a person who is allergic to bees theoretically may react similarly when hit with a large concentration of this stuff. That is also why we keep an Epi-Pen handy just in case.
Anyway, this enzyme stings like hell when injected so I always mix it with a bit of lidocaine for patient comfort. You can also expect some bruising to the area and a fair amount of swelling. This is the after effect of the hyaluronidase:
Yeah, it sucks. It’s always better to do add more filler later than having to take it away. For those who are considering lip fillers for the first time, I’d recommend just half a syringe to start then work your way up as your lip volume adapts to the changes. Otherwise, you might end up here and it’s not fun. Amazingly this is her lip after 2 weeks when our patient came back to have her lips touched up. All the filler is now gone, and so is the swelling:
And the final result!
This story had a happy ending but vascular occlusions, potential or not, are no joke. To recap, the symptoms of a vascular occlusion to watch out for are:
1. Swelling to the injection area
2. Bruising(in addition to the swelling)
3. Increasing pain after the treatment is done (the area should feel tender, but pain should not get worse)
4. Blanching of the surrounding area after pressing on it indicating slow capillary refill
If any of this happens, call your injector right away or any injector that you can get a hold of. I think I can speak for a lot of injectors in saying that this is one of our greatest fears. I even keep a supply of hyaluronidase at home in case I need to rush over to a patient’s home in the middle of the night. Just remember that there is always a risk with dermal filler, but with the right knowledge, we can prevent and mitigate any problems before it gets serious.
Written by Phil Wong
July 2, 2023
References:
- Alam M, Kakar R, Dover JS, Harikumar V, Kang BY, Wan HT, Poon E, Jones DH. Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection. JAMA Dermatol. 2021 Feb 1;157(2):174-180. doi: 10.1001/jamadermatol.2020.5102. PMID: 33377939; PMCID: PMC7774041.
