With the rise in injectables everywhere, I am seeing weekly, new cases of influencers and others posting about their own experiences with vascular occlusions, sometimes from new injectors and other times from their regular treating clinicians. 

Each time I’ve posted on this topic on my Instagram feed to educate others, I invariably get patients in clinic pulling out of planned dermal filler treatments, to “think about it some more” or telling me in clinic that I need to stop frightening them. 

My goal and aim, with all that I do, is not to scaremonger but to educate. The medical aesthetic industry in Australia, while safer than that in places like the UK, is nonetheless, largely unregulated and heavily marketed to a largely unsuspecting public who sees them as akin to getting your hair, nails and makeup done. 

While there is no absolute guarantee against a poor outcome or a potentially serious complication, here are some ways to keep yourself safe when undergoing these treatments. 

The commonest point of confusion among laypeople post dermal filler treatment is “is this a bruise or a blockage?” 

Bruise vs Blockage ie Vascular Occlusion

A bruise is a traumatic injury, usually to unbroken skin, where underlying blood vessels are ruptured and blood leaks out into surrounding tissue. Over the next days to weeks, this blood is broken down by the body, and eventually cleared, returning skin to its normal colour and status. In injectable treatments, where a needle, is used to penetrate the skin barrier, bruising is almost a given, and among the commonest expected side effect, variable in size based on the degree of injury to skin and area injected. 

A vascular occlusion (VO), by contrast, occurs when blood is no longer able to flow within a blood vessel ie a blockage. This blockage may be partial, or complete, resulting in tissue downstream of the blockage being deprived of oxygen and other nutrients, resulting, if left untreated, in skin death eventually. In the case of dermal filler injections, this VO is due to unintended, and often unrecognised injection of some filler directly into a vessel. While enough blockage may occur immediately so as to warn the injector and patient, this may occur an hour or some hours later, which is why education and aftercare and followup in the first 24 hours or so is important. 

Given the serious nature of a VO, which is a life threatening emergency, how is a layperson to know the difference post injectable treament? 

While no two faces are the same, and no two people will have the same concerns, or outcomes, there are some important red flags to watch out for which should prompt you to reach out to your treating clinician for help if this happens within hours of your treatment. 

Two of the hallmarks of a VO that enable us to diagnose them are: 

• pain - often of sudden onset, severe and disproportionate pain, especially compared to the non VO side/ area, is a red flag.  
• skin discolouration - while it may initially resemble a bruise, with a VO, skin that is deprived of oxygen, rapidly begins to blanch (white spots or white areas within the bruise/ area), become bluish or mottled, and resemble a lacey pattern over skin. 

Any of these should prompt an affected person, especially within hours of treatment, to reach out to their clinician for help and advice, with photos of the affected area. 

Left alone, and we are reading of some injectors telling patients to sleep on it, or to watch and wait, or to even see them in the next day or two, these changes will progress to skin downstream of the blockage becoming starved of oxygen and discolouring further and eventually dying - the bluish discolouration may progress to blue-black; sterile pustules may form, as the skin begins to die, but we’d hope no one would ever get to that stage with proper aftercare and followup by their clinician. 

So can you guarantee avoiding a VO? 

The short answer, for anyone who chooses to have injectables, especially dermal filler, is no. 

While choosing a clinician on the basis of years of experience and their qualifications is important insurance against poor and especially catastrophic outcomes, every person has variable anatomy and medical procedures, unlike hair, nails and makeup are complex and delicate work; despite appropriate knowledge and experience, things can still go wrong which is why all medical procedures should be undertaken, ideally, with adequate informed consent and with full awareness of limitations and risks. 

How is a VO treated?

• A VO is a medical emergency and usually occurs within hours of treatment, so your clinician should have aftercare protocols in place already that safeguards you in the first 24 hours or so post treatment.
• This should be discussed with you at least briefly at the time of consent for the dermal filler your first time, and again as part of the aftercare.
• You should have a way to contact your clinician in the hours immediately following treatment if you have concerns or can’t differentiate between bruising and a possible VO and a way to send pictures across.
• They should be able to either reassure you on the basis of the pictures or be able to reopen clinic to assess you face to face if concerned at any hour of the day or night as time is of the essence here.
• If they confirm it is a VO, they should have the necessary drug on hand to dissolve the affected area once they determine where this is (likely to be).
• Post dissolution, you and your clinician should both see return of circulation to the affected skin before you’re allowed to go home. If this does not occur, more assessment may be needed, including from other clinicians they can access for help.
• Post dissolution, you’d normally be seen the next day for followup and then a week or two later if all is well, to assess the  skin to ensure it’s returning to normal. 

In most cases if caught early enough, VOs will resolve nicely with no longterm effect on skin integrity or quality. 

Take home message?

While I rely on our patients to know what to look out for, I do not expect them to suddenly turn into clinicians themselves and to know when to worry or not. So in my clinic, I rely on adequate aftercare and followup protocols to help keep patients safe. 

The key is to educate patients on what to watch out for without scaring them unnecessarily so that they worry that every bruise and bump might be disaster. This takes time, and a therapeutic relationship built on trust that cannot be rushed, and which is empowering for the patient.