May 4, 2023

Dr Tim Dr Subbio 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.

You can read the blog about Dr Subbio’s management of a filler-induced vascular occlusion case, and also check out Dr Subbio’s emergency kits for managing filler-induced vascular occlusions.

In this blog, we have taken another part of their discussion where Dr Tim Pearce and Dr Christian Subbio talk about facial vasculature redundancy and the role of choke vessels in compromised blood flow through filler-induced vascular occlusion.

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 >>

What are choke vessels?

In the previous blog where we revealed Dr Subbio’s management of a filler-induced vascular occlusion case, he explained how he treated the vascular occlusion (VO) by reversing along the entire path of the vasculature, visualising the compromised vessel and the end organ – the capillary bed, and end arterioles.

Dr Subbio 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 to restore perfusion.

Dr Tim was keen to learn more about the idea of redundancy in the vasculature, explaining that aesthetic clinicians often have a mental model of the vasculature as akin to a tree; yet it does not behave like a tree. If you cut anywhere along the branch of a tree, the branch that is severed will die, but if you cut a vessel, there are connections in between – choke vessels – that allow the tissue to survive; hence, perhaps we should reimagine the mental model to a series of loops.

Dr Tim and Dr Subbio

How do choke vessels work?

He asked Dr Subbio to explain more about the strength of the connecting choke vessels and their impact on capillary refill and the formation of necrotic tissue.

Dr Subbio used an illustration to show a vessel and how it perforates the tissue, supplying blood in an arborizing pattern – this is an angiosome or perforasome – a territory (tissue area) that is supplied by that vessel. If you were to cut the vessel, and there was nothing else available to supply the blood, that tissue would die. However, there is always an adjacent vessel or perforasome right next door which is connected to the former vessel via tiny connections called choke vessels. These act as a back-up if there is ever a compromise to blood supply. In this instance, if you block the blood supply in the first vessel with filler, and there is no oxygenation to the tissue, the choke vessels will dilate and allow blood flow between the adjacent perforasome and the compromised perforasome. The dilation of the choke vessels does take a little time to establish but there is the connection to restore tissue perforation and prevent tissue necrosis. Redundant vessels will link from all sides to ensure there is blood flow to the tissue via this collateral circulation. This is particularly pronounced in the face due to considerable redundancy in the vasculature, asserts Dr Subbio.

He used the example of injecting dermal filler from the jawline which results in blocking the major vessels around the mouth and side of the nose as filler keeps ascending through the vasculature (as a vascular occlusion) – including blocking the facial artery, labial arteries, and lateral nasal artery, for example. He believes that the tissue around the nose would still be safe from necrosis due to the microvasculature and the presence of choke vessels that will allow localised redundancy to back up the blood supply to the tissue from the opposite side. That is, unless the blocking filler makes its way all the way up to the capillary bed and/or the sites of secondary flow – meaning the end organ is blocked. In this case, no amount of vasculature redundancy can aid blood flow to the tissue, and it will become deoxygenated and necrotic. Being able to gauge the perfusion in the tissue will help establish the extent of blocking – if there is capillary refill (even slow and sluggish) then the capillaries themselves are not compromised – but if the vascular compromise is considerable, flooding the area with hyaluronidase is the best solution.

Dr Subbio did point out that the debate is still very much open on all of this, and he continues to discuss it with many of his surgical peers. For example, if there is no filler in the capillaries, but the capillary refill is not good, and the tissue starts to necrose, it could be one of those rare instances where there simply is not enough redundancy in the facial vasculature to maintain the blood supply. We still have a lot to debate, the subject is nuanced, abstract, and confusing and subject to much conjecture. Of course, that is the fun part, according to Dr Tim and he enjoys such discussions with medical colleagues like Dr Subbio.

For further reading on choke vessels, have a look at this interesting paper from 2020 – Importance of choke vessels in injectable fillers – which explores the key messages that choke vessels are dormant vessels which open up in special vascular compromise situations, and help to alter the circulation; and, this altered circulation may help in ameliorating the severity of damage caused by vascular occlusion after fillers.

Read more blogs on the management of vascular occlusions.

Dr Tim always loves to hear from his followers, so why not drop him a comment on social media, you can find Dr Tim Pearce on Instagram. You can also follow Dr Subbio on Instagram.

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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.


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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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