February 25, 2021

Vascular necrosis is arguably the most severe potential complication from dermal fillers. It is something that even the most accomplished practitioner fears and worries about, never mind those newer to aesthetics. 

Let’s start seeing worrying about something as a positive. There are many practitioners who do not have the medical background to fully understand the risks associated with dermal fillers, let alone how to minimise the risk and what to do should the worst happen. If you are a qualified medical practitioner who is working out how to carry out treatments as safely and responsibly as possible, then we’re here with advice and support to help.

What causes necrosis?

Tissue necrosis is caused by insufficient oxygen supply to skin cells. Over a relatively short period of time, this causes cell dysfunction and then cell death.

When an area of skin cells die abnormally, this is very dangerous. It leads to disfiguration, scarring and potential infection.

As filler treatments are predominantly carried out on the face, this adds further stress to the situation. Nobody wants to leave their patient with life-changing scarring.

Responsible clinicians must recognise the risks, understand the issues and know how to avoid vascular necrosis. Even the best practitioner must realise that it is not possible to eliminate the risk completely; therefore it is also vital to interpret warning signs, be able to quickly and accurately diagnose a problem and know how to treat it effectively.

Key principles of avoiding dermal filler necrosis

Impending vascular necrosisInject with careful consideration of the 3-dimensional anatomy. Most people can easily read a diagram and learn to know where the key arteries are on the face. To inject safely you need to understand the 3-dimensional position of the arteries, and which layer of the face they will most likely reside.

General anatomical principles for artery avoidance are:

  1. Arteries usually are not at the depth of the bone except where arteries enter the face at the foramen, or the notch in the mandible.
  2. Arteries are not usually superficial, at the level of the dermis, but beneath in the hypodermis or lower.

13-point-plan – reduce the risk of vascular necrosis

  1. Try to pass arteries at 90 degrees instead of in parallel, which makes cannulation into a vessel less likely.
  2. Aspirate habitually. The more you aspirate the easier it gets- like wearing a seatbelt, do it all the time and it’s there when you need it.
  3. Be stable when you aspirate to make it count when you inject in the same place.
  4. Aspirate for 3-10 seconds, particularly in high-risk areas.
  5. In high-risk areas aspirate along linear threads to increase safety.
  6. In most places, use a cannula if the result would be the same as with a needle.
  7. Be gentle with cannulas, they only increase the pressure required to penetrate a vessel, they do not make penetration impossible.
  8. Remember in tight spaces (like noses) it is easier to penetrate an artery with a cannula.
  9. Always check capillary refill times after every procedure, partly so your eye becomes attuned to what is normal, to reassure yourself and your patient, or in the worst case make sure diagnosis occurs as early as possible.
  10. Always explain to your patient the risks and what the signs and symptoms of an occlusion are so that they seek help properly. The worst cases are invariably the ones diagnosed the latest.
  11. Give your patients an advice leaflet detailing the potential risks and complications and what to do in case of any concern
  12. Always be prepared, carrying emergency reversal kit at all times if you’re injecting.
  13. Keep an emergency reversal protocol handy- You may only have to do this once in 10 years.

Vascular Necrosis – Summary

Firstly, remember that most occlusions you have hours before scarring is likely. You should still act swiftly and decisively. If a client contacts you with post-treatment concerns that may indicate tissue necrosis, it needs to be treated as an emergency with full seriousness, even if that means going out of your way to arrange an appointment and/or liaising with them ‘out of hours’.

Prevention is always preferable than treatment, so focus your daily efforts on excellent practice that is fully mindful of the risks involved. This is really something you integrate into all of your processes. Embrace continuous learning to become more knowledgeable and increase your confidence. You can do this through peer networking, keeping up to date with the latest research and techniques and continuous self-development through training courses. For example, Dr Tim Pearce has developed a very popular Dermal Filler Complications Mastery Course, which encompasses detailed tuition on how to manage and avoid dermal filler complications. It includes an illustrated and animated video guide to every dermal filler complication; diagnosis, pathogenesis, treatment guide and preventative techniques; as well as a comprehensive handbook and other downloadable resources.

It takes years to develop the concepts and the mental model of what’s going on under the skin. Make full use of the resources available to you.

Useful Links

Further reading about dermal filler complications and anatomy

You may find the following articles useful:

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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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