Case Study: Dealing with a Suspected Vascular Occlusion

It was 9 PM when my phone rang. A woman I'd never met was frantic—her lip wouldn't stop swelling after getting filler two days earlier. Her regular injector was closed, and she'd been calling clinics until she found me. I was home, but my work number forwards to my cell.

My first thought: vascular occlusion.

This is what happened next, and what you need to know if you ever find yourself in a similar situation.

What Is a Vascular Occlusion?

A vascular occlusion occurs when dermal filler is accidentally injected into a blood vessel, blocking blood flow to a region of your face. It causes intense pain, rapid swelling, and if not treated quickly, tissue death from lack of oxygen—potentially leading to permanent scarring.

This is the most serious complication with dermal fillers. Fortunately, it's rare, occurring in approximately 1 in 5,000 cases.¹

Without seeing her in person, I couldn't confirm my suspicion, but I wasn't taking chances. I asked her to meet me at the clinic in thirty minutes. I keep hyaluronidase on hand—the enzyme that dissolves hyaluronic acid filler—for exactly these emergencies.

Assessing the Emergency

Here's what her lips looked like when she arrived:

She'd gotten filler two days ago and felt a lump in her upper lip. While massaging it, her lip suddenly swelled within two hours and kept getting bigger. This timeline was unusual—vascular occlusions typically show symptoms immediately, not two days later. Still, I couldn't rule anything out.

The Capillary Refill Test

The first thing I checked was blood flow. I applied firm pressure to her lip for five seconds, then released. If the skin returns to a healthy pink color within two seconds, blood flow is adequate. If it stays pale and white, that's critical—it means tissue is dying.

Her capillary refill was good. Even the swollen area turned pink within two seconds. I relaxed slightly. This wasn't a medical emergency, and we weren't at risk of tissue necrosis.

But the rapid swelling was still concerning.

Two Possible Explanations

I hypothesized two scenarios:

1. Compression from massage: By massaging the filler, she may have temporarily compressed blood vessels, causing blood to back up and triggering swelling.
2. Inflammatory response: The massage may have irritated the tissue, causing acute inflammation.

Despite the good capillary refill, there was visible filler migration above the vermillion border (the line between the lip and skin) and a noticeable lump in her upper right lip.

We decided to dissolve the filler with hyaluronidase.

What Dissolving Filler Feels Like

If you've never had filler dissolved, here's what to expect: it's not pleasant.

Hyaluronidase is an enzyme our bodies naturally produce to break down hyaluronic acid. We're just using a concentrated version, so it's fully biocompatible. There's a slight risk for people with bee allergies since bee venom contains hyaluronidase, which is why I keep an EpiPen available.

The injection stings intensely, so I always mix it with lidocaine. You'll also experience bruising and significant swelling immediately after.

Here's what her lip looked like right after the hyaluronidase injection:

Not fun. This is why I always tell first-time filler patients to start with half a syringe and work up gradually. It's much easier to add more filler later than to deal with this.

The Recovery Process

Two weeks later, she returned for a touch-up. The filler was gone, and so was the swelling:

And here's the final result after we added half a syringe of Restylane Kysse:

Warning Signs of Vascular Occlusion

This case had a happy ending, but vascular occlusions—suspected or confirmed—require immediate attention. Watch for these symptoms:

1. Rapid swelling at the injection site
2. Bruising (beyond normal post-injection bruising)
3. Increasing pain after treatment ends (tenderness is normal, but pain shouldn't escalate)
4. Blanching when you press on the area—if the skin stays white and doesn't return to pink quickly, blood flow is compromised

What to Do If This Happens to You

If you experience any of these symptoms, call your injector immediately. If they're unavailable, call any injector you can reach. Most of us will respond to these emergencies, even after hours.

I keep hyaluronidase at home in case I need to rush to a patient in the middle of the night. This is one of our greatest fears as injectors, and we take it seriously.

The Bottom Line

Dermal fillers carry risks, but with proper knowledge and quick action, we can prevent serious complications. If something feels wrong after your filler treatment, don't wait—contact a medical professional immediately.

And if you're considering lip filler for the first time? Start conservatively. You can always add more.

Written by Phil Wong

Reference:

1. Alam M, Kakar R, Dover JS, Harikumar V, Kang BY, Wan HT, Poon E, Jones DH. Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection. JAMA Dermatol. 2021 Feb 1;157(2):174-180. doi: 10.1001/jamadermatol.2020.5102. PMID: 33377939; PMCID: PMC7774041.