Skin
Anti Wrinkle Injections
AviClear
Chemical Peels
Extractions
Facial Thread Vein Removal
HIFU
HydraFacial™
Laser Rejuvenation Treatment
LED Phototherapy
Mesotherapy
Microneedling
Plasma Shower
Plasma Surgical/ Lesion Removal
Polynucleotides
Profhilo Structura
Skin Boosters
Sweat Reduction
Skin Rejuvenation
Skin Tightening
Thames Skin Signature Facials
Vampire Facial
Face
Anti Wrinkle Injections
Dermal Fillers
Dermal Filler Removal
Electrolysis
Face Contouring
Facial Thread Vein Removal
HIFU
Juläine
Laser Hair Removal
Laser Rejuvenation Treatment
Lip Fillers
Microneedling
Non-Surgical Blepharoplasty
Non Rhinoplasty
Plasma Surgical/ Lesion Removal
PRP Dermal Fillers
Radiofrequency
Temple Lift
Thames Brow Lift
Thames Face Lift
Thames Neck Lift
Thames Skin Signature Facials
Thames Smile
Vampire Facial
Hair
Electrolysis
Eyelash Enhancement
Xxtralash
Keravive by HydraFacial™
Laser Hair Removal
Microneedling
Vampire Facial
Professional
Body
Fat Dissolving Injections
Fat Reduction/ Muscle Sculpting
HIFU
Laser Hair Removal
Laser Rejuvenation Treatment
Minor Operations
Plasma Surgical/ Lesion Removal
Radiofrequency
Sclerotherapy
Sweat Reduction
Weight Management
Injectable Treatments Guide
Skin Concerns Guide
Brands
AviClear
Aqualyx
Calecim
Cryoglobe
Cutera Excel HR Laser
Cutera Excel V+ Laser
Cutera Secret Pro
Cutera TruSculpt Flex
Cutera TruSculpt iD
Dermalux
DermaPen – DMP8
Ellansé
Exosomes (EXO|E)
HIFU
HydraFacial
Hydrafacial PERK
InMode
Inmode Forma
Inmode Fractora
Juläine
Profhilo
Profhilo Structura
Plasma BT
Skinny pen injections
Skinade
The Skin Diary Skin Care Range
Teoxane Filler
Thermavein®
Vol U Lift
Totally Derma
Zo Festive Packs
Zo Peptide
ZO Skin Health
Skin
Acne
Acne Scarring
(Solar) Keratosis
Age Spots
Dark Circles
Dry Lips
Dry Skin
Eczema
Freckles
Hyperpigmentation
Keratosis Pilaris
Large Pores
Loose / Sagging Skin
Skin Tag
Melasma
Moles
Neck Wrinkles
Pigmentation
Psoriasis
Profhilo Structura
Rosacea / Facial Redness
Cysts
and Keloid Scarring
Sun Spots
Sweating
Warts & Verrucas
Wrinkles
Face
Crows Feet
Dark Circles
Double Chin
Eye bags
Facial Thread Veins
Facial Volume Loss
Forehead Lines
Frown Lines
Gummy Smile
Heavy Eye Lids
Jowls
Migraines
Marionette Lines
Misshapen Lips
Misshapen Nose
Nasolabial fold
Receding Chin
Sunken Cheeks
Short Eye Lashes
Smokers Lines
Teeth Grinding
Unwanted Hair Growth
Weak Jawline
Hair
Hair Loss
Ingrown Hair
Scalp Sweating
Unwanted Hair Growth
Body
Ageing Hands
Body Fat
Cellulite
Hand Sweating
Lack Of Energy
Muscle Definition
Muscle Tension
Stretch Marks
Sweat Reduction
Thread Veins on Legs
Unwanted Hair Growth
Shop All
ZO Skin Health
Exfoliating Cleanser
Gentle Cleanser
Hydrating Cleanser
Exfoliating Polish
Dual Action Scrub
Calming Toner
Complexion Renewal
Oil Control Pads
Instant Pore Refiner
Daily Power Defence
10% Vitamin C Serum
Enzymatic Peel
Skin Health Brightalive
Retinol Skin Brightener 1%
Firming Serum
Growth Factor Serum
Wrinkle + Texture Repair Retinol 0.5%
Radical Night Repair 1%
Acne Control
Clearing Mask
Rozatrol™
Hydrating Cream
Renewal Crème
Recovery Crème
Sunscreen + Primer SPF 30
Daily Sheer SPF50
Smart Tone SPF50
Broad Spectrum SPF 50
Body Emulsion
Zo Growth Factor Eye Serum 15ml
Intense Eye Cream
Eye Brightening Repair Creme – Hydrafirm
The Patient Journey
Consultations
Patient Reviews
Wedding Preparation
Careers
Meet the Team
Dr Anna Hemming
The THAMES Philosophy
London Treatments
Pricing Brochure
Gift Vouchers
Thames Events
Online Bookings
Correcting Dermal Filler Complications
Published 3rd June 2024
min read
Expert Reviewed By
Dr Anna Hemming recounts how she handled a rare & particularly challenging complication
At 1.42 pm, on a Thursday lunchtime, the notification of an email innocently arrived on my screen. As I was between patients I saw the first few words:
I didn’t want to bother you, but I I would check, is this normal?
Normally, I would leave my experienced team to deal with all emails, however, this was a patient I had treated with the previous day and, knowing the patient, something within the email didn’t seem right. Moments later, I was on the phone with her, asking if she was in pain (no), whether there was any blanching (yes), and various other questions. A photo immediately arrived of the kind we have all seen at complications training. This was not normal, and we needed to bring her in. Being 90 minutes away from the clinic, she arrived as soon as she could.
In the meantime, the clinic ran as normal, patients were seen, and, in the back of my mind, my complications file was being pulled out and the algorithm for occlusion (VO) ran through. By the time the patient arrived at the clinic, I had reviewed her notes (after images were normal, no mottling and no altered capillary refill time (CRT), reviewed the ACE guidelines for VO, and had all the emergency drugs at hand, just in case.
My patient is a 42-year-old with asymmetry. I had treated her 12 months previously with dermal filler with great success. Her 12-month review had recently passed and there was distinct volume loss to the temple, medial and lateral suborbicularis oculi fat (SOOF), as well as the tear trough. Her left side was always more depleted than the right and we had a plan to stabilise the deep fat pads, bringing deep alignment and then review, to address the tear trough depressions.
At the review, the tear trough filler was used to lift the under-eye, especially on the left. The immediate results were lovely, there was no pain or unusual after-effects, until seven hours after the filler, when the patient noticed some numbness (she thought initially it was the local anesthetic from the treatment).
In the evening, the area was slightly pinker, but it wasn’t until the next day and 24 hours after treatment that she emailed, as the area was still a bit pink.
HOW TO ASSESS POTENTIAL VO
Patients are often in pain, have reduced CRT in the area and surrounding skin, and display pallor initially and then mottling.
Immediate action is required if there is any suspicion of VO or spasm of the nerves causing hypoxia to the skin.
Rapid action is necessary to reverse the hypoxia before necrosis establishes, leading to tissue breakdown and wounds.
In this patient, the pallor stage was not visible in clinic, presentation occurred at 24 hours in the livedo reticularis phase.
Phases of a VO
1. Pallor – Occurs with immediate blockage of an arteriole as the blood flow is interrupted and blocks tissue perfusion. Lasts seconds – or persists longer.
2. Livedo reticularis – A mottled pattern appears on the skin from the build-up of deoxygenated blood from the venous network. Can occur rapidly, lasting hours.
3. Pustules – Typically at 72 hours due to the reduction in pH and sweat, along with metabolic changes due to hypoxia allowing staph. aureus bacterial overproduction.
4. Coagulation – Indicating necrotic change and can occur before pustule formation. Caused by worsening hypoxia, the skin darkens as cell lysis occurs and there is a leaking of blood into the . Skin tissue remains firm due to the coagulative necrotic process.
5. Tissue destruction – Skin breaks down due to a build-up of denatured structural proteins (collagen, fibrin, elastin) neutrophils, bacteria, and haemoglobin. Devitalised tissue is initially moist creamy/yellow or green (slough) and then becomes black (dark) and dry. This occurs days after the occlusion.
HOW TO TREAT A VO?
• Stop treatment (if they are with you) and inform them about what is happening
• Check and video CRT on both affected and unaffected skin for comparison
• If CRT is delayed, it indicates vascular compromise
• Massage the area firmly, applying heat to encourage vasodilation
• Assess
• Get help
• Hyaluronidase (do not skin test, ensure medications are at hand just in case)
• Disinfect the skin
• Reconstitute 1500 hyaluronidase in 1ml NaCl 0.9% or 1-2% lidocaine
• 1500IU by needle or throughout the affected artery and wider area of ischemia. More than one vial may be needed
• Apply heat and massage area vigorously (helps mechanical breakdown of HA)
• Assess CRT and if >3 seconds repeat hyaluronidase hourly
• Review patient daily
• Clinical resolution may be required over the following days to avoid deterioration
• Make detailed notes and take images and videos
• Advise insurers so they are aware of the situation.
Medications that may help Aspirin or Clopidogrel 300mg stat and 75mg per day.
The following may also help reverse compromise:
• Nitroglycerin paste
• Hyperbaric oxygen
• Steroids only if clinical indication
• Wound management
• Antivirals if tissue has started to break down
• Antibiotics.
PROGRESS OF THIS PATIENT’S VASCULAR EVENT
On arrival in clinic the day after dermal filler treatment, we talked through the situation openly. She was not in pain; her CRT was sluggish in the area treated and the surrounding vascular pathway. Livedo reticularis was present with non-blanching erythema and even greying of the tissue in the distal vascular pathway.
My gut feeling was the vessel had experienced a spasm, affecting the distal branches delivering oxyhaemoglobin to the skin.
With open discussion we planned her treatment. Immediate aspirin, hyaluronidase and antibiotics were started due to the delayed presentation, to try to decrease pustule formation and necrosis.
Day two
As I was attending a conference 10 minutes away from her the following day, we planned to review at the conference, where I arranged a room and place where we could treat her again. 1500IU of hyaluronidase was administered, exosomes were started topically and after with colleagues a short course of prednisolone commenced.
Day three
We arranged hyperbaric chamber sessions starting the following day along with review and a further 1500IU as the area was still firm. Tiny white pustules started to appear in the apical triangle to the side of the nose. The erythema was shrinking and the numbness was improving.
Day four
The area was injected one last time with 1500IU hyaluronidase and a further hyperbaric chamber session attended. Bruising from hyaluronidase flooding can be seen in the filler treatment area.
Day five
A small area in the apical triangle has potential for necrotic breakdown.
Day seven
The patient has a further hyperbaric chamber session. The bruising, inflammation and vascular compromise settled and the apical triangle crusting was mildly better.
Day 10
Further hyperbaric chamber session
Day 12
Day 16
Day 45
Day 12, 16 and 45 saw huge improvements in the look and feel of skin, with reduced numbness. The patient was left with a small amount of erythema. The apical triangle remained intact and didn’t .
IN TOTAL
• 9 appointments
• 4 x 1500 IU hyaluronidase
• Aspirin 300mg stat, 75mg OD
• Flucloxacillin 500mg QDS 7/7
• Prednisolone 40mg OD 5D
• 5 hyperbaric chamber sessions
We have our next review planned and aim to help resolve the erythema in completion with laser genesis or excel V+ treatment.
The patient is hugely relieved that we were able to get on top of the vascular event as soon as we were aware of it. She is happy with our treatment.
This article was originally featured in . June 2024.
Monday – 09:30-16:30
Tuesday – 09:00-17:30
Wednesday – 09:00-19:30
Thursday – 09:30-17.30
Friday – 09:00-17:30
Saturday – 09:00-16:30 by appointment
Thames Skin Clinic
Baylis Mews,
Twickenham TW1 3HQ
Copyright © 2026 Thames Skin Clinic. All rights reserved.
Make an enquiry
Please consent to providing your above data to us in accordance with our .