Ischemic Complications

Ischemic complications. Two simple words that can make even the most seasoned injector quake in their Crocs. Ischemic complications are defined as an unintended impediment to normal blood flow during placement of dermal fillers. These complications are widely regarded as the most serious and require immediate intervention. The effects of these complications can include ophthalmoplegia, cerebral infarction, vision loss, and necrosis. In the case of vision loss, it is possible that symptoms may be irreversible with little to no evidence of symptom improvement. Some studies have determined that the rate of ischemic complications is around 3 injections per 1,000 performed globally. 

The temples are one of the most complicated treatment areas of the face. They possess a highly complex vascular arrangement as well as multiple distinct layers of tissue that require an injector’s treatment plan to be precise and thorough. The main vascular features to take into account when performing a temporal dermal filler procedure are the middle temporal vein and the frontal branch of the temporal artery. 

The cheeks are arguably the most requested treatment area for placement of dermal filler. Accounting for 66.6% of all minimally invasive procedures in 2022, it is no wonder why injectors are seeing more and more cheek filler patients. The anatomically dangerous features of this area include the infraorbital bundle, transverse facial artery, and the zygomaticofacial artery. 

Nonsurgical nasal augmentation is a procedure that inherently possesses high risks. Calcium hydroxylapatite product is often selected for its high G’ prime and low migration rate. However, this is a double-edged sword given the fact that CaHA fillers are non dissolvable. This means if the integrity of a vessel is compromised and an occlusion occurs, then it is a less straightforward approach to clearing the vessel. In addition to filler selection, we must remain conscious of the dorsal and lateral nasal artery. With close proximity to the eyes, any occlusion has a higher likelihood of detrimentally affecting patient vision. Alternatives like Restylane Lyft or other gel fillers may be preferable since they pose a lower risk of vascular complications.

Intra-arterial filler injection can occur when using hyaluronic acid fillers. In these instances hyaluronidase should always be the first treatment. Using a minimum of 200 units the affected area needs to be flooded with hyaluronidase to effectively and thoroughly clear any filler occluding a vessel. Under-treatment should be avoided entirely as any extra time these tissues spend without sufficient blood supply increases the chance of lasting tissue necrosis. In any case, the occlusions must be treated within a four hour window after initial filler injection to manage the risk of lasting effects.

The superior labial artery and inferior labial artery of the lips are highly variable and their position will differ greatly from patient to patient. But they are most often found deep within the tissue and can be avoided if the injection is sufficiently superficial. The vascular elements run more superficially around the Cupid’s bow area and midline of the lips. Also, as we age the skin of the lips thins, meaning that those arteries may become more superficial in older patients. 

The important vascular features of the jawline include the transverse facial artery, the submental artery, and the ascending submental artery. Although these vessels are further from the eyes, they still carry the possibility of resulting in permanent vision loss due to occlusion. The transverse facial artery continues its path from the masseter toward the nose and eventually branches into the angular artery and dorsal nasal artery.

Prevention of ischemic complications ultimately is the responsibility of the injector to stay alert with their injection technique, compilation management plan, and the anatomy of the facial vessels. Aspiration is commonly seen as the gold standard for clinical determination of needle/cannula placement, but injectors must remain aware of the possibility of false negative aspiration. The filler may be too thick, which prevents the reflux of blood upon plunger withdrawal. Occlusions can be devastating and can still occur when all of the precautionary steps are followed, which underscores the importance of ensuring you are always improving as an injector!