In the last decade or more, fillers have become increasingly popular for noninvasive rejuvenation of the face, with a subsequent increasing number of adverse effects reported with rise in their use in the scientific literature. 

The most serious complications of fillers include vascular complications (VO) and blindness. But how common is the most catastrophic side effect of all, blindness in one or both eyes, and who is most at risk? 

With increased education and posts on social media of the side effects of medical aesthetics, especially fillers, comes necessary and healthy apprehension among patients, who should rightly be apprehensive. Medical aesthetics, often presented by marketing as “just beauty” is anything but, and carries rare but serious risk as well as significant limitations, so it is absolutely important patients are aware of these. 

To better educate patients, it is imperative that your clinician keeps up to date with the latest data and protocols, so in this blog post, I went over 3 main articles looking to answer 3 main questions: 

1. How common is blindness from fillers? 
2. Are there areas of the face most at risk and if so, what are they? 
3. If someone chooses to have filler, what are some green flags when choosing a provider? 

The 3 articles I used are listed below. A summary of their findings follows: 

• between 1905 and 2015 98 cases of blindness were reported globally
• the bulk of these were within 2010 - 2015
• in 2014 alone, more than 5.5 million filler treatments were reported globally
• between 2015 and 2019, a further 48 cases of blindness/ vision loss were reported due to fillers 
• virtually every anatomic location where filler is Injected on the face is at risk for blindness

• the commonest sites are:
  • • • glabella
    • nose
    • nasolabial fold
    • forehead

• note all these structures are midline ie located in the middle of the face, almost in a straight line, where circulation is most vulnerable to blockage. 
• of the fillers that caused vision loss:
  • fat transfer was most common culprit at 47.9% (and not dissolvable) 
  • HA fillers accounted for 23.5%
  • collagen, for 8.2%
  • PLLA, a biostimulatory filler, for 3.1%
  • Cahydroxyapatite, another biostimulatory filler, for 2.0%

• the last article referenced here is a case study of filler into the glabella(frown area), the highest risk area of all to inject due to its close location to two major arteries, the supratrochlear and supraorbital arteries. 

The conclusions reached by the articles: 

• rising demand for fillers won’t be going anywhere anytime soon
• moving to full face rejuvenation also means that larger volumes of filler (or fat) are needed to achieve desired results (even if you are open to face/neck lift, the only solution to volume replacement is with fat or filler)
• concern that non expert injectors are injecting fillers without adequate understanding of facial anatomy, increasing risk of complications
  • while the outcome can be devastating, in experienced hands the risk is still very very low.
  • conversely, when vision loss does occur, outcomes are almost unequivocally poor with no clear protocol or evidence base for their management. 

• the highest risk areas for vision loss again:
  • glabella (frown lines) 
  • nose
  • nasolabial folds (smile lines) 
  • forehead

So what are some mitigating factors you can use to stay safe if you decide to undergo full face rejuvenation with fillers? 

• check your clinician’s qualifications
• check their protocols in the event of any complications - anaphylaxis, vascular occlusion, followup and vision loss
• check they have backup plans in place in the event of a disaster 

If the idea scares you too much, it is perfectly reasonable not to have any fillers at all as long as you understand  that volume replacement is not possible without fat or fillers. After all, none of these treatments is medically necessary and you should never feel pressured to proceed if you are undecided, nor should you ever pressure your clinician into a treatment they do not feel is best for you. 

At Skin Essentials, Dr Joshi does not inject the glabella at all, and will only undertake highest risk areas such as forehead, nose and nasolabial folds in patients she has known for some time, and when it will make a significant difference to their outcome AND they understand the risks. These are not areas to undertake at a first consultation nor without a standing relationship. We take your safety, and our own, very very seriously. 

Did you know of these high risk areas? 

Sources: 

1. Dermatol Surg 2015 Oct;41(10):1097-117. doi: 10.1097/DSS.0000000000000486.

Avoiding and Treating Blindness From Fillers: A Review of the World . Literature

2. Aesthet Surg J 2019 May 16;39(6):662-674. doi: 10.1093/asj/sjz053. (Update on Avoiding and Treating

Blindness From Fillers: A Recent Review of the World Literature)

3. https://doi.org/10.1016/j.ajoc.2022.101407

Ophthalmic artery occlusion after glabellar hyaluronic acid filler injection