January 18, 2024

necrosis diagram

In the aesthetic sector, you will hear practitioners talking a lot about vascular occlusion, but understanding what causes different types of vascular compromise and how necrosis occurs is a vital awareness lesson for all practising aesthetic clinicians. You might be surprised to learn that there are many theories.

In this blog, Dr Tim Pearce demonstrates how necrosis can develop following a vascular compromise, and why you should be aware of how to spot the signs of impending necrosis so you can avoid it in your practice.

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What are the causes of vascular compromise-induced necrosis?

Dr Tim Pearce Anatomy MannequinMany aesthetic clinicians are led to believe that if you inject a dermal filler into an artery, you will instantly block it, stopping blood flow and causing a necrotic injury through vascular occlusion. However, there is a problem with this oversimplification, points out Dr Tim. During an interview with surgeon, Dr Subbio, he explained that in surgery they routinely remove whole sections of arteries or tie them off, never untying them, yet this does not cause a necrotic injury. Therefore, it must be something other than filler staying in the main vessel that causes these necrotic injuries.

Dr Tim notes that in many cases of necrosis – where you get tissue breakdown – there is only a delayed capillary refill and not a complete capillary refill. These two positions create a confusing situation, so what is causing the issue? It is quite a grey area – i.e. where significant compromise in blood flow through partial blockage of the main vessel and blockage of some of the smaller vessels, but not a complete blockage, can still lead to necrosis. But that is probably not the only cause or mechanism of action, yet many of these ‘workings out’ are theoretical because it is very difficult to prove in real cases what is disrupting blood flow.

The best option is to review some case study examples to reveal indicators for potential necrosis causes.

Causes of necrosis – pressure on the capillaries

We know from general medicine that pressure sores occur when you put mechanical pressure on the outside of a group of capillaries or vessels. This is commonplace on pressure points around the body, particularly if you leave a patient in bed without moving them for a long enough period, their skin will necrose.

Dr Tim believes the same thing happens in certain areas of the face, particularly in the midline – the chin, nose, and glabella. All these areas have a particular propensity to necrose differently.

When looking at a patient, this manifests as an area of necrosis that tends to be round and is associated with high-pressure tissues. For example, in the chin, the dermis can feel quite thick, with a circular lesion around the surface of the chin, underneath a pressure point. This is sometimes caused by high volume, high pressure, and high G Prime dermal filler products.

Similarly, in the glabella, Dr Tim has seen several cases with patients having treatment for lines in the glabella who get a distinct black line which does not track the supratrochlear artery but is instead along the area injected with a superficial necrosis. This also fits with a pressure causation from dermal filler on the capillaries, rather than arterial compromise, where you would expect to observe more of the area being affected.

The best example, however, is probably the tip of the nose. It has no major arteries and is essentially a capillary bed. Following the so-called Tinkerbell nose tip lift procedure, many patients either have a red nose that persists for several weeks, sometimes with pain, or there is a small subsection of patients where it results in some mild tissue breakdown with pustule formation and peeling of the skin. This tends to be a less severe necrotic injury, but it can become quite severe if the pressure is high enough and left for long enough that none of the dermis gets any blood supply. This scenario is therefore unlikely to be caused by intravascular injection and is more likely the result of high G Prime dermal filler products pushing on capillaries. Get more insight on non-surgical rhinoplasty complication: red nose tip could be pressure necrosis.

Causes of necrosis – filler compression from outside an artery

Again, drawing on general medical knowledge, we know that occasionally compression of a vessel causes vasoconstriction. Therefore, in aesthetic practice, one of the things that may be happening is when vessels are traumatised, either by filler surrounding them on the outside, or some product that is partially inside, it may trigger an inflammatory process and cause vasoconstriction or spasm that potentially leads to necrosis. Essentially, the vessel is tightening up either due to mechanical pressure from the filler gel or a combination of mechanical pressure and vasoconstriction.

Vasoconstriction can cause significant vascular compromise, in terms of what we see clinically, and potentially this could result in some sort of necrosis, particularly if there is no natural body reaction to vasodilate.

Causes of necrosis – venous occlusion

Most of our face is a network meaning that if you block a particular vein, there are many other ways that blood can drain from the area. However, if you imagine the drainage is significantly impaired, there would not be enough of an exit route to allow new blood to come in; this could result in some form of necrotic injury, caused by decreased outflow.

The easiest place to understand this, for illustration, is in the eye, which is a more closed system, explains Dr Tim, but it is quite difficult to hit those veins. However, he did come across a very interesting case many years ago from Dr Patrick Treacy where a patient was injected in the nose with Juvéderm Volbella and this was linked with a venous sinus thrombosis that occurred a few days later causing blindness. Venous sinus thrombosis is a known cause of blindness in medicine, but could it be triggered by a low molecular weight dermal filler that causes blood clotting? This is potentially another way that aesthetic patients may suffer from a type of vascular occlusion.

In other parts of the face, there are cases where patients get a ‘bogginess’, a swelling, or a ruddiness due to a decrease in oxygen blood flow, but true necrosis is less likely with venous occlusion because there are multiple ways out. However, in the eyes or if the compromise is large enough, that is a different story.

In summary, Dr Tim believes it is very difficult to cause necrosis in this instance, but there may be certain extremely rare situations where venous occlusion could also cause a necrotic injury.

Anatomy review of the eye area and the potential for blindness

It is important to consider the anatomy to understand how a venous occlusion could potentially affect the drainage of the eye and cause blindness. Looking from the front of the skull, some veins run within the orbit which connect quite closely to the location of the nose.

If you injected enough dermal filler into some of these veins, an occlusion or blood clot in the area of the basilar plexus could potentially cause a decrease in venous drainage from both eyes. This would be a worst-case scenario where an inability for blood to leave the eye means fresh blood cannot enter the eye and the vessels which supply the retina will not be able to replenish the blood flow to the eye, leading to blindness. This could be caused by a low-viscosity dermal filler product, or a high-viscosity product injected in the nose, passing into the basilar plexus causing inflammation, clotting and potentially even an infection which results in decreased venous drainage.

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Aesthetics Mastery Show

PERMANENT brow ptosis from a cannula?! Temple filler safety tips & cannula advice

Dr Tim says:

“Having a thorough understanding of how necrosis happens increases your awareness as an injector. So, in this episode I use industry leading 3D anatomy to demonstrate how necrosis develops so that you can spot the signs to avoid it in your practice. Having a thorough understanding of how necrosis happens increases your awareness as an injector.”

Watch the full Aesthetics Mastery Show here.

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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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