Today I had a very serious case…..a patient who had an occlusion of a blood vessel from Juvederm in their face. They were sent to us by an emergency room physician who was sent the patient from a nurse injector in Denver when she realized the complication....one week after it occurred.

How does this happen?

Fillers such as Juvederm are injected with needle and syringes. These are the same needles that are used for example to place IVs. IV or intravenous catheters are used to deliver medicine or fluids into blood vessels. That is great for administering medicine but if a filler enters a blood vessel it can block the blood vessel and thus the blood supply to that area of the body. In the face, it can be supplying the skin. In the eyelids it can supply the blood going to the eyeball itself.

Any injector (Read again..any injector) regardless of training (MD, NP, PA) can inject inadvertently into a blood vessel. The blood vessels such as arteries are under the skin are essentially not visible. As a cosmetic injector of fillers such as Juvederm we inject it under the skin and draw back on the syringe to make sure it is not going in the blood vessel. That being said, pulling back on the syringe is helpful but does not guarantee that the syringe will not enter the blood vessel when the injector fully injects the filler under the skin.

What are the consequences of this?

Any areas where the blood vessel supplies the blood supply to the skin, will die. Similar to a stroke, vascular occlusion or blockage of the blood vessel from filler will result in the skin, muscle or eye dying. The patient may complain of sudden vision loss or pain and whitening of the skin in the area when this happens. Over time the skin necroses or dies completely resulting in scarring.

What is the treatment?

When this happens the injector must immediately inject hyaluronidase into the area to try to dissolve the filler. They can massage the area as well to promote the blocked vessel opening up. Hyaluronidase must be available. Like a stroke waiting days to open the blood vessel (like the patient we saw today) is not good and the tissue will most likely die with its oxygen being cut off. Sometimes vasodilators such as nitroglycerin paste can be used to dilate the blood vessel as well. As injectors my partner and myself have never had a vascular occlusion but like an airplane with a crash protocol we would be fools to not have the necessary equipment in case that did occur.

What is the one question should I ask my cosmetic injector?

“Do you have hyaluronidase?” If the answer is no. Run. Run away quickly. Yes,most likely you will be fine but if a complication occurs you will be left without the antidote. Though intravascular injection is very rare, it happens. Would you get into a car going to the mountains on I-70 without a spare tire? Would you get on a boat with no life preservers? Of course not even though the chance of a flat is low or boat getting a leak is low…but if you get one you are screwed...if you are unprepared.

As a physician we often see complications from injections from non-physician injectors who don’t have a medical director on site. It is something to consider when getting an injection of cosmetic filler or botox. Do you research and get your treatment from someone who is trained properly and can help you if there is a problem. This patient most likely will suffer irreversible scarring. The practioner did not have the juvederm antidote in her clinic. Her medical director was not nearby and had no idea what was done. The patient was referred way too late for this occlusion to have a chance of reopening.