Necrosis After Fillers – 5-Goal Safety Framework

What Is Necrosis and Why You Should Never See It

The Complete 5-Goal Framework for Injectors

Necrosis represents the worst possible outcome for any aesthetic patient. While it’s the complication that haunts every injector’s nightmares, there are five strategic goals you can implement that will dramatically reduce your risk of ever seeing this devastating complication in your clinic.

These aren’t just theoretical concepts, they represent a complete, systematic approach to safety that addresses every stage of the patient journey, from prevention through diagnosis, treatment, and recovery.

Understanding the Patient Journey Concept

Before diving into the five goals, we must accept a fundamental reality: we cannot lower the risk of vascular injury to zero. There will always be some probability of occurrence.

This acceptance isn’t defeatist, it’s realistic and allows us to build proper protective systems. This means we need a system that puts the patient in the best possible case scenario at every point along the whole patient journey.

The patient journey is crucial to understand because safety is never just about the injection technique or whether you did one safety step. It encompasses every decision and action from consultation through follow-up.

Strategic Goal #1: Make Sure Vascular Occlusions Stay Small

Since we can’t prevent every vascular occlusion, the first strategic goal is ensuring that if you’re going to have a vascular occlusion, it’s a small one.

The Core Principle

Inject in such a way that even if you’re in a vessel, you don’t spend so long in that vessel that you cause a massive vascular occlusion.

Practical Implementation Techniques

1. Use cannulas with constant directional changes. Using a cannula while moving in all sorts of directions, as many directions as possible, and sliding in and out reduces the severity of any potential occlusion.
2. Strategic product distribution. Think carefully about how much product you put in any particular area. You can do multiple small boluses on the periosteum instead of one big one, for example.
3. Keep the needle moving. Keeping the needle moving is a valid way of distributing the risk across multiple areas.

Understanding the Trade-Off

This technique lowers the risk of severity of vascular occlusion, which is different from the frequency of vascular occlusion. In fact, keeping the needle moving doesn’t decrease the frequency of vascular occlusion, it actually increases it.

But the hope is that the severity becomes so small that it’s almost insignificant if you block a vessel.

Important note: There’s a lot to unpack about this strategy, and it may not be as protective as intended depending on how practitioners are implementing it.

Strategic Goal #2: Lower the Frequency of Vascular Occlusion

Many practitioners get confused between severity and frequency, but it’s crucial to separate these concepts because many of our safety steps are actually pulling in opposite directions.

The moving needle technique increases frequency but decreases severity of vascular occlusion. Understanding these trade-offs is essential for making informed technique decisions.

Detection Through Enhanced Aspiration

If you are about to inject, is there anything you can do that would detect a high-risk needle placement?

Aspiration provides one answer. It’s not 100% protective, but you will detect probably around 50% of the time that you’re intravascular.

Maximizing Aspiration Effectiveness

You can increase detection rates further by:

1. Maintaining negative pressure in the syringe .Having negative pressure established before injection improves detection capability.
2. Making small movements while aspirating . Doing small movements in the area you’re about to inject scans a greater area for vessel position.

The “Old Medicine” Principle

Anyone who’s ever taken blood knows this old medicine principle: if you put your needle in to take blood and try to draw back and nothing comes out, move your needle.

As you scan a greater area for the position of your artery or vessel if you’re taking blood. It’s a simple way of slightly nudging the risk in your favor in terms of detecting intravascular placement.

It doesn’t matter if you’re in a tiny vessel that doesn’t aspirate because those are not the ones that cause large vascular occlusions. We want to detect intravascular placement in large, named vessels, and this technique helps accomplish that.

The 90-Degree Injection Principle

You can also lower the frequency of vascular occlusion by always injecting in a way that makes it hard to occlude vessels.

For example, if you’re injecting at 90 degrees to a vessel, even if you do go through that vessel, you’ll spend far less time in it than if you’re injecting parallel to the vessel and enter the vessel.

This represents another simple way of decreasing the frequency of vascular occlusion.

Strategic Injection Depth

Depth of injection is another way to decrease frequency, as long as you always inject in the plane where the vessels are least likely to be.

The safest injection planes:

• Upper dermis
• Periosteum (as long as you’re not near foramina)

When injecting in these planes, you will always be injecting where vessels are less likely to be. This provides another anatomical way of reducing risk.

The Reality Check

Even if you do all of these steps and all the others that you can add to it, there is still another issue: we are probably going to get a vascular occlusion one day anyway.

This brings us to the critical importance of the remaining three strategic goals.

Strategic Goal #3: Diagnose Quickly

We need to have systems and processes that enable us to diagnose a blocked vessel as soon as possible.

The Power of Immediate Capillary Refill Checking

One of the simplest things to do is to check capillary refill immediately after every injection.

Real-World Evidence

This systematic approach produces measurable results. At our previous clinic, SkinViva, there were 27 vascular occlusions on record, all of them were diagnosed and treated immediately. All clinicians were constantly being trained to check capillary refill before you discharge the patient.

Making It Effortless

When you get into the swing of this, it’s effortless because you’re always cleaning the skin anyway, as you push on it, you just observe blood flow.

Quick diagnosis is not quite enough alone. This leads us to the fourth strategic goal.

Strategic Goal #4: Diagnose Comprehensively

Quick diagnosis must be accompanied by comprehensive diagnosis. There’s an issue seen many times in clinical networks: clinicians will get the diagnosis correct, but they will underdiagnose how severe it is.

A Real-World Example of Underdiagnosis

Someone injects a small area of the lip, they get a vascular occlusion which they identify through pallor in the lip, and they initiate a reversal process and send the patient home. Then it turns out 24 hours later that the patient has vascular compromise affecting their chin and their lower neck.

This was all down to underdiagnosis.

Why Underdiagnosis Happens

This is something you will see play out even in small vascular occlusions, they initially seem smaller than they actually are. At least in observed cases, there’s an initial diagnosis, and over the course of a couple of hours you realize the area is a little bit bigger than what you first thought.

So it’s very important to spend time diagnosing comprehensively.

Hidden Tissue Injury

The most obvious example of underdiagnosis is when you actually have deeper tissue injury that you can’t see.

Examples of hidden injury:

• A chin injection that affects the tongue
• A lip injection that affects the nose
• A nose injection that affects the septum

These are all examples where the injury is actually worse than you first think, so it’s really important to spend some time getting a comprehensive diagnosis.

Strategic Goal #5: Reverse Comprehensively

The final strategic goal addresses treatment intensity and duration.

The Product Selection Foundation

If you’ve used a non-reversible product, which you would have done if you had thought hard about how to reduce severity, then you will have the chance to reverse the process.

The Undertreatment Problem

Some clinicians undertreat at this point. While this opinion is hard to prove scientifically, it’s believed to be better to overtreat than undertreat vascular occlusions.

Evidence from clinical networks shows vascular occlusions where practitioners followed a relatively low-dose protocol, for example, a 1500-unit vial, discharge the patient, see them back in 24 hours, and those patients still got necrotic injuries.

The Comprehensive Reversal Protocol

The recommendation is to keep your patient with you until you have capillary refill restored, so long as you have the type of product that you can do this with, then release.

Complete protocol:

1. You should see blood flow back into the lips
2. Keep going in all the areas that are affected
3. Use repeated high-dose hyaluronidase injections
4. Apply massage and warm compress
5. Continue until blood flow is normal

Timeline Expectations

Cases have been reported where this process has gone on for 8 to 12 hours with one vascular occlusion.

However, if you’ve injected small amounts and done everything you can do to reduce the severity, this is unlikely. The vascular occlusions typically seen take around 90 minutes to 2 hours before blood flow starts to return, though there will be some exceptions.

It depends a lot on how you’ve injected.

How the Five Goals Work Together

These strategic goals create a comprehensive safety system:

Goals 1-2 (Prevention):

• Reduce severity if occlusions occur
• Reduce frequency of occurrence
• Create multiple preventive layers

Goals 3-4 (Detection):

• Diagnose quickly through systematic checking
• Diagnose comprehensively to understand full extent
• Prevent underestimation of injury

Goal 5 (Treatment):

• Reverse comprehensively with adequate intensity
• Maintain treatment until restoration
• Avoid premature discharge

Practical Implementation: Your Action Plan

Immediate Changes:

Prevention (Goals 1-2):

• Review injection techniques for severity reduction
• Practice enhanced aspiration with movement
• Assess injection angles relative to vessels
• Verify you’re working in safest tissue planes

Detection (Goals 3-4):

• Implement mandatory capillary refill checks after every injection
• Train all staff on comprehensive assessment
• Create protocols for evaluating full extent of compromise
• Establish systems for detecting hidden tissue injury

Treatment (Goal 5):

• Stock adequate hyaluronidase supplies
• Develop comprehensive reversal protocols
• Plan for extended treatment sessions when needed
• Establish clear discharge criteria based on capillary refill restoration

Learning from Real Cases

To understand how this process actually unfolds in real clinical situations, studying documented cases provides invaluable insight. These cases capture important details about complication progression and management that are rarely published in academic literature.

Real-world case studies reveal the nuances of:

• How quickly compromise can extend beyond initial injection sites
• The timeline of vascular occlusion development and resolution
• Effective vs. ineffective treatment protocols
• The importance of extended observation and treatment

Conclusion: A Complete Framework for Zero Necrosis

Necrosis is the worst outcome for any patient, but by following these five strategic goals, you can work toward never having a necrotic injury in your clinic.

The framework is comprehensive:

1. Make occlusions small (severity reduction)
2. Reduce occlusion frequency (prevention)
3. Diagnose quickly (immediate detection)
4. Diagnose comprehensively (full assessment)
5. Reverse comprehensively (adequate treatment)

Each goal serves a specific function, and together they create a complete safety system that addresses the entire patient journey, from injection technique through diagnosis and treatment, ensuring patients remain in the best possible scenario at every point.

Clinics that implement these systematic approaches see vascular occlusions but not necrotic injuries. The difference lies not in avoiding all complications, but in having robust systems for managing them effectively when they occur.

By accepting that risk cannot be zero but building comprehensive systems to manage it, you can practice confidently, grow your skills, and protect every patient throughout their journey.

Ready to master the most common complications so that you can 10x your injecting skills and confidence? 

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Aesthetics Mastery Show

How to reduce injury risk an injector – 5 simple steps you can do

Dr Tim says:

“I believe you can get through your whole injection career without ever causing a necrotic injury by following these 5 steps.”

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