Dr Tim’s lessons from vascular occlusion cases seen in 2021

During 2021, Dr Tim Pearce noticed a worrying trend appearing in relation to the worsening severity of cases of vascular occlusions from dermal filler injections that were referred to him for advice and assistance.

When he first started studying complications in aesthetic practice himself, it was dominated by cases of vascular occlusion in the lips, which we now know to be one of the easiest to diagnose, manage, and treat, as they are usually isolated to the lip.

However, in the last twelve months he has noted more vascular occlusions reported within his network that are presenting in unusual places, with more significant compromise, over a larger area, and all in are much more difficult to diagnose and treat.

In this blog, Dr Tim Pearce shares his observations on this growing trend and the lessons we can all learn from the cases of vascular occlusion (VO) that he reviewed last year, specifically looking at ways to reduce the risk of these cases being unresolved and becoming necrotic.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.

Is the number and severity of vascular occlusions getting worse?

Upon reviewing all the VO cases he consulted upon in 2021, Dr Tim wondered if vascular occlusions were getting worse and more atypical than in previous years. He does admit that the VOs that end up at his ‘door’ are usually the more challenging cases because, thankfully, more and more aesthetic practitioners are now trained and able to independently manage and resolve the simple cases of occlusion and compromise. This may skew the data somewhat, but there could still be a shift in the risk across the entire aesthetic sector.

Are full face filler treatments risking vascular occlusion?

A more holistic, but ultimately business-centred approach to aesthetics has ultimately led to greater volume delivery across the midline and in multiple facial areas at the same time, with the formation of package deals for higher volume, full-face filler treatments. Dr Tim believes that this approach to treatment will naturally only lead to the occurrence of many more complex vascular occlusions.

Similarly, higher volumes placed per injection point cause more complex vascular occlusions, they affect deeper structures in the facial tissue, and this is particularly true for cases of VO seen in the chin and jawline, where an originally localised occlusion goes on to disrupt certain areas of blood supply to the neck.

When multiple areas of the face are injected within one treatment session, it can make it more difficult to accurately locate the primary point of a blockage, adding to the struggle to diagnose and treat with the same level of certainty as you would when you have only treated one smaller area. Dr Tim recalls one of the strangest VO cases he reviewed last year which presented with blood flow disruption across the whole face, from the forehead to the oral commissures on both sides. As the treatment involved injections in multiple areas, it took some considerable time to establish the best place to target the reversal with hyaluronidase.

Is non-surgical rhinoplasty the main cause of vascular occlusion?

Dr Tim also believes that aesthetic injectors are more routinely treating areas of the face that are regarded as riskier, and they are doing so more aggressively. He notes that the treatment of noses for non-surgical rhinoplasty featured more often in the complex VO cases he saw in 2021, a treatment which was deemed quite rare, especially amongst mainstream aesthetic practitioners a few years ago, but which has now become the norm.

He believes that the simplistic view of this procedure portrayed on social media adds to the relaxed attitude about the skills needed to perform treatment on the nose, with aggressive, high-volume approaches for dramatic results for Instagram-able before and after images sometimes taking priority over safety. The limited space within the tissue of the nose and the proximity of significant vessels, which have connections to those in the ophthalmic region, makes the nose a more dangerous area and risks complications including pressure in the tissue with persistent redness from compression of vessels, damage to the internal structures and cartilage of the nose, vascular occlusion, and necrosis.

For more on safely treating noses, have a read of our previous blogs on spotting septum necrosis, a severe complication from non-surgical rhinoplasty, and red nose tip could be pressure necrosis.

Do you need to refer a vascular occlusion to an expert every time?

Finally, Dr Tim has observed a trend which seems to perpetuate the perception that patients need to be moved or referred to ‘experts’ if they have a vascular occlusion. This is of course appropriate at times, but he worries that this is an unreliable expectation for every (small) case of a VO as there are no practitioners on call 24 hours a day, and the more clinicians involved in the referral of a case, the more chaotic it can become for all concerned, especially if this involves significant travel and delay for the patient to achieve a solution.

6 ways to reduce the risk of vascular occlusions becoming necrotic

1. Attitudes towards support in emergency situations
   If you are a non-medical aesthetic practitioner or a non-prescriber and find yourself in an emergency, you must have a prescriber in place who has agreed to support you in the case of a vascular occlusion. They will be prescribing the hyaluronidase (Hyalase®) and will be responsible for how it is used, helping you by medically manage the complication, taking your client on board as their patient. This cannot be done remotely. They can also seek further medical advice from other medical aesthetic and complications experts and seek onward refer, if needed, more easily. They should not simply charge you for a prescription and leave you to get on with it.
2. VO rescue is an algorithm and not a step-by-step process
   Many aesthetic practitioners regard the route out of a vascular occlusion as a simple series of steps or protocols to follow, when in fact, it is more complex than that, especially when the VO is more severe, and not simply a localised case in the lip, for example. This could lead to an unreliable and inadequate outcome, which may get worse in a percentage of cases as the many variables requiring management in more complex cases may not have been addressed appropriately with a step-by-step approach. An algorithmic approach includes an ‘if’, then ‘that’ approach which is a more dynamic route to rescue and resolution of the VO, guided by what you see if front of you, rather than simply following a one-size-fits-all dosing requirement and instruction sheet. The restoration of capillary refill is the end goal, and this may need more treatment than generic advice dictates.
3. Perform regular and repeated assessments of your patient
   Do not be tempted to immediately leap into a reversal protocol when approaching a rescue situation, instead repeat regular and thorough assessments, rather than relying solely on your initial assessment. Once you have identified a vascular occlusion, start to think anatomically, and consider the areas that may be affected, and repeatedly assess these during the rescue. To achieve this, you must know your anatomy, thinking in terms of the 3D structures that could be affected both deeply and laterally away from the point of injection, and not simply at the skin’s surface. Consider evaluating internal facial areas that you can access – inside the nostrils, the gums in the mouth, the tongue, etc. – looking for abnormal blood supply.
4. Perform a full-face CRT test
   In the case of more complex vascular occlusion, extend your capillary refill tests (CRT) to include a full-face test by using both your hands to comfortably and firmly compress both sides of the patient’s face, and then observe the blood flow upon release. You should note an area of isolated blood flow that is slower than other areas and thus is compromised. This is your target area for rescue.
5. Do not rely on ultrasound devices
   Ultrasounds can be useful in cases of vascular occlusion, but Dr Tim admits that they are not a panacea. It is not always easy to locate the area being blocked using an ultrasound device, and this can lead to delays, when the use of CRT is a quicker, simpler, and often more obvious solution to identifying where targeted rescue is required.
6. Massage the area
   Massage in the case of vascular occlusion is an important component to rescue. Dr Tim notes that this tip became clear to him when he performed the experiment comparing the use of hyaluronidase (Hyalase®) versus saline for the dissolution of hyaluronic acid-based filler products. During this experiment, where he dyed the filler with food colouring to aid visibility, he observed that the breakdown of the product was not as swift as we may expect. It was, however, helped by agitation with the needle in the petri dish to increase the surface area of product that could be targeted by the enzymatic action, the same is therefore likely to be true if massage is applied to the tissue post-delivery of the hyaluronidase.

Saline vs Hyaluronidase Comparison

See the results from this experiment comparing saline versus hyaluronidase to dissolve hyaluronic acid filler.

Are you still anxious about delivering cosmetic injectables safely?

If you want to learn more about mastering medical aesthetic treatments and complications or conquering the anxiety of where to place your needle, then register for the next Dr Tim webinar.

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Filler Complications eLearning Courses

If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• Botulinum Toxin Complications Mastery
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In addition, browse our FREE downloadable resources on complications.

Dr Tim Pearce eLearning

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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