Hyaluronic Acid Dermal Filler-Associated Vascular Occlusion-A Review of Prevention and Management Strategies

Significant complications are uncommon with aesthetic hyaluronic acid (HA) dermal fillers, but inadvertent injection of dermal filler into an artery can result in tissue damage, scarring, visual loss, and even stroke. Practitioners must therefore reduce this risk through proactive, preventative techniques. Early recognition of vascular occlusion (VO) is also crucial to minimize subsequent tissue injury.

To review and summarize evidence-based preventative measures and first aid management strategies for HA-associated peripheral cutaneous VO, explicitly excluding ocular and neurological complications.

A comprehensive literature search was conducted using the BestBETs methodology to review the preventative measures available for reducing the risks of HA-associated peripheral VO, with ocular and neurological side effects considered beyond this review's scope. We then examined the pathophysiology of VO and the evidence for its management to establish an HA dermal filler VO "first aid" protocol.

Our review underscored the importance of preventative strategies (practitioner skill and knowledge; cannula usage; microboluses of small filler volumes, low plunger pressure, and constant needle tip movement), along with the liberal usage of hyaluronidase, heat, and massage, and supports the addition of antiplatelet agents for acute management. Aspiration is controversial and cannot reliably exclude intravascular needle placement.

Prompt recognition and management of VO are critical to prevent skin necrosis, scarring, and long-term morbidity. Preventative practice, immediate treatment protocols, and further research are essential to enhance clinician confidence and improve patient safety in aesthetic HA filler procedures.