Case: Dr Subbio’s management of a filler-induced vascular occlusion
Drs Pearce and Subbio recently came together on Instagram to host a free live video discussing how to manage a dermal filler-induced vascular occlusion (VO) which included some great insight from two of the world’s leading aesthetic doctors, later hosted on the Aesthetic Mastery Show.
In this blog, we have condensed down some of their lengthy discussion and Dr Tim Pearce invites Dr Christian Subbio to walk us through a recent vascular occlusion case that he successfully resolved in the USA.
Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>
Vascular occlusion case study: Background
The vascular occlusion (VO) case described by Dr Subbio was referred to him by a skilled local aesthetic injector with many years of experience. The patient had been injected with dermal filler using a stationary bolus technique at the pre-jowl sulcus, which as Dr Subbio pointed out is facial artery territory.
Although he believes the product used was Juvéderm® Voluma, he explained that it does not really matter to him which product was used when faced with a vascular occlusion, noting that although some filler gels are more difficult to dissolve than others, as long as it is hyaluronic acid (HA), his plan of action will not change – inject hyaluronidase ( and repeat to dissolve the HA until the vascular occlusion is clear.
As is best practice when using a stationary bolus technique, the injector aspirated prior to injecting the filler. In this case, there was no flash back and the aspiration was negative; she proceeded to inject a 0.02ml or 0.03ml bolus on what was perceived to be the level of the bone. It was immediately painful for the patient, but neither thought much of it, likely due to the activation of the lidocaine within the product. The patient did not realise or report a problem until approximately six hours later noting some discolouration and increased pain (once the anaesthesia had ceased).
Vascular occlusion case study: The Park and Push Technique
The ‘Park and Push’ technique is routinely taught and expounded by aesthetic sector speakers but disparaged by Dr Subbio. The technique involves placing a needle into the face – parking the needle in a stationary position – and delivering a significant bolus of filler – pushing the product – with anything over 0.02ml or 0.03ml.
Dr Subbio explained that there are two ways this technique will likely result in a vascular occlusion. One way is if you have ‘parked’ your needle in the artery entering from the side, thus, when you ‘push’ the bolus of product, you will fill the artery causing a vascular occlusion. The other is if you are trying to move your needle but inadvertently the needle is within the lumen of an artery, thus as you push your product, the same outcome will transpire.
Although such instances are rare and unlucky, he concluded that he believes the real danger lies in placing the needle and then not moving whilst delivering a significant bolus of product; whether you aspirate or not, this is very likely to result in large vascular occlusions that fills the entire vascular tree.
Dr Subbio noted that there is significant debate when it comes to aspiration, because we know that aspiration is not reliable one hundred percent of the time, perhaps only half of the time.
However, he maintained that on the occasions it does warn the injector, it validates its use, stating,
“…injecting with a stationary bolus technique and not aspirating seems crazy, but if you are moving your needle tip, I don’t think you need to aspirate”.
Explaining further, he summarised that if there is movement and you pierce the vessel, you are only in there for a split second and there is limited possibility that you are going to fill the vessel with product to create a lager vascular occlusion, therefore, whenever possible (and that is the caveat), aesthetic injectors should be moving their needle, with small deposits, and not parking and pushing.
Vascular occlusion case study: Management
Seeing the patient six hours after the initial treatment, the original injector used all three vials of hyaluronidase (450 units of Hylenex®*) available to her, however, this proved not to be enough to resolve the occlusion. After attending the hospital emergency room, Dr Subbio was contacted and saw the patient approximately 10-12 hours post-treatment.
* Clinicians in the United States have Hylenex® with 150 units/vial of hyaluronidase. This differs in the UK where Hyalase®/Hyaluronidase is available with 1,500 units/vial.
Dr Subbio’s initial step was assessment and documentation. In the adrenaline of managing a VO, he noted that you might not feel like taking photographs or writing notes, but aside from the medico-legal aspects of protecting yourself as the treating clinician, documentation, images, and video are critical for reference as the VO management progresses. You must be able to compare how the patient was at time zero versus time x, y, or z so you can determine tissue status and any propagation of an embolus. Document sensation testing by asking the patient what they can feel as you palpate their face. Tissue without blood flow does not have sensation and these are the areas of concern.
In this case, he used video to record capillary refill time (CRT), working down the face to determine where good refill eventually became sluggish. He noted areas of livedo, which were not always a measure or indicator of poor blood flow beneath, and despite hyperaemia in the cheeks, blood flow was good. Dr Subbio highlighted the point that just because there are tissue changes, it does not mean there is going to be a necrosis.
Once at the area around the mouth and under the nose, the CRT was in the region of 3-4 seconds and very sluggish; there was significant livedo, duskiness, and pallor to the lips. This became the focus for flooding with hyaluronidase, rather than targeting the whole face which had differing levels of tissue change and CRT.
Both Dr Subbio and Dr Tim concurred that in cases of vascular occlusion, it is important to prioritise the areas to treat with the resources you have available, rather than wasting hyaluronidase on areas with minimal impact, especially if you could run out and find it difficult to source more over a weekend or late into an evening.
Dr Subbio treated this VO by reversing along the entire path of the vasculature, visualising the compromised vessel and the end organ – the capillary bed, and end arterioles. He maintains that perfusion is an end organ phenomenon, which means you could block an artery but if vessels higher up the face are patent and do not contain filler, they will be fine due to collateral flow because the face is extremely redundant when it comes to vasculature. Most of his efforts were focused around flooding the area most affected which was around the mouth and lower nose and at the source vessel to restore perfusion.
He initially used a bolus technique to place the hyaluronidase at various arterial branch points, allowing diffusion into the tissue and vessels, and then moved to a cannula technique which allowed for fanning and different depth placement of the enzyme.
Vascular occlusion case study: Reperfusion of the tissue
How do you know when you have got blood flow again? Dr Subbio admitted that even as a plastic surgeon, assessing perfusion can be confusing. If there is still pallor, and it is sluggish, you might not know if it is perfusing correctly after dissolving the area.
In this case study, Dr Subbio could see after his round of hyaluronidase that there was still some pallor, but unlike when he initially assessed the patient, when there was whiteness to the tissue, she now had tissue that had some pinkness to it, denoting a change, an improvement after the reversal, but was it enough, was he done? CRT was still a little sluggish, adding to the confusion.
Therefore, to assess perfusion, he has a simple tip. Get a needle and pierce the tissue to look for red, oxygenated blood. (Do not confused this with venous or deoxygenated blood which will appear darker in colour). Dr Tim agreed and pointed out this is a very useful test in darker skin patients where assessing perfusion can be more difficult.
In this case, a dot of red blood appeared in the patient’s lip, and Dr Subbio continued to needle prick test around the face. Although not a reason to celebrate complete correction of the VO, it showed that the patient had oxygenated blood getting to the tissue and the situation was not as dire as at the start. With continued hyperaemia (which was not at risk of necrosis), blood flow to all the tissue, a return of sensation, and only small areas of potential stasis which may or may not worsen, he deemed it safe to see the patient again 3-6 hours later. In this case, the following morning as it was late at night.
Before she left, Dr Subbio massaged the whole area, using nitroglycerin paste to aid in vessel dilation. The patient was also advised to massage the area regularly through the night to increase perfusion and relieve stagnation of the blood, alongside drinking water to maintain hydration.
After further assessment he referred her for hyperbaric oxygen treatment and noted that even though it was a massive vascular occlusion, the patient barely had any pustules. Had there been further concerns, Dr Subbio explained that he would have referred her for ultrasound assessment.
Vascular occlusions: Dr Subbio’s take home message
The lesson we can learn for the management of filler-induced vascular occlusions was succinctly summed up by Dr Subbio when he said,
“If there is some pallor, if there is some mottling, remember how dangerous these things can be…dissolve it. If there is ever any question about a vascular occlusion, treat it as a vascular occlusion because to get at these things a day, two days, or five days later is catastrophic.”
Is your worst nightmare causing a VO?
If you want to be a great injector then you need to get over your fear of complications. Register here for the next webinar to help you overcome your complications anxiety >>
Aesthetics Mastery Show
Managing Vascular Occlusions: Dr. Subbio’s Success Story in Saving a Patient from Necrosis
In this episode Dr Tim chats to Dr Subbio – a plastic surgeon with many years of experience, about how he saved a patient from a VO emergency. Plus, his tips for safe injecting and what you need in your emergency kit so that you can learn how best to manage and minimise vascular occlusions in your own practice. Watch the full Aesthetics Mastery Show here.
You might also like reading some of the comments from fellow injectors, including:
“As an injector of 25 years, i still appreciate, enjoy and learn from your videos. And this collaboration with Dr. Subbio was extremely useful and informative. I would recommend any new injector (or experienced one…) watch your videos. Thanks for your work in the field. Best.”
“Excellent points thank you . Especially asking the patient what they can feel.”
“So much information here, as always. Very interesting. Thank you for sharing this, very helpful with both conversations”
“Tim, Christian, many thanks to both of yours exceptional genuineness”
“Just brilliant please keep doing these!”
Read more and join in the debate on our YouTube channel..
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.
Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.