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What Are Complications of Fillers?

Can filler really cause blindness? Can I go blind from anti-wrinkle injections?

You may have heard in the media lately of a recent tragic event involving a patient losing the vision in one eye following treatment with dermal fillers. The details have not been made public, and I have no familiarity with the specific details of the case or what has occurred, but I do know that this case has shocked the cosmetic community and our hearts are with the unfortunate patient.

Blindness following injection with dermal fillers is far and away the most feared complication that cosmetic injectors have to think about, and one that we all must talk about with our clients before treatments. Even though the risk is so tiny, the consequences are so catastrophic that injectors should be morally and legally obliged to mention it to every client prior to their filler injection.

The reason that blindness is a risk following dermal filler injections has to do with the anatomy of the arteries that provide the blood supply to the eye. Most of the blood to the eye actually comes from an artery called the “ophthalmic artery”, which runs from deep inside the skull and then forwards to the back of the eyeball.

In many arteries however, there can be “cross-channels” from other arteries which communicate with each other. Sometimes there are arteries from the area between the eyes above the nose, a region also known as the glabella, which can communicate with the ophthalmic artery and the eyeball. Sometimes this also happens from arteries in the temples.

These anatomical variations are so variable amongst people that we never can be sure when and where we will find them. We just have to assume that they are there, in order to avoid the “worst case scenario”. The reason that this feared complication has never before been seen in Australia has a lot to do with the high standards followed in the Cosmetic Injecting Community and the general commitment to ongoing education and patient safety. The “No-Go” injecting “Danger-Zones” are generally avoided, or if injected they are done with extreme caution and only by the most experienced injectors with the safest techniques.

Whilst this is the first case of blindness in Australia, there have been multiple incidents worldwide, especially in some parts of Asia where injections to the glabella (or the bridge of the nose) are common. When you look at the statistics, with the number of people treated with dermal fillers each year numbering in the thousands, and fillers having been around for so many years, the number of cases of blindness is extremely low.

What is slightly more common, and not spoken about as much, is tissue ischemia and necrosis from injections into an artery. Ischaemia means “lack of blood to a tissue”, and necrosis means “tissue death”. It’s essentially the same thing as happens with filler being injected into an artery that travels to the eye, except the artery (and the filler) in this case travels to and lodges in other tissue, usually skin.

It’s another rare and feared complication, but thankfully in experienced hands the risks are very low, as the “No-Go” injecting “Danger-Zones” are well known. One more possible complication is injecting so much filler into a “tight” area (such as the nose, where the skin is bound down much more tightly to the underlying tissue). Too much filler may actually compress the veins and arteries in these areas, and ischaemia and necrosis may occur.

How would I notice if I had these problems? How would they be treated?
If you had filler inadvertently injected into an artery which travelled to your eye, the visual changes would be noticeable very quickly, within minutes usually. Your injector would then have to immediately flush the area with an enzyme which breaks down filler.

This could potentially mean an injection between the eyeball and the eyelid, to get to the back of the eye where the filler may be lodged. You would then be urgently sent to the nearest large hospital with an eye specialist (Opthalmologist) for treatment. A hyperbaric chamber (if available) can sometimes be used to increase the amount of oxygen in the blood and hopefully save the precious eye tissue. An important question to ask your injector is, “do you have filler dissolving enzymes in your clinic”?

Ischaemia and necrosis to other tissue can be more difficult to notice and diagnose, because it can come on slowly, typically four to six days after the injection. The skin may become “dusky”, painful and the capillary refill may be slower (capillary refill is where you compress some skin to squeeze out the blood, and then wait to see how long until it goes from white back to normal). Again, the answer is large amounts of filler dissolving enzymes injected in the area to dissolve the filler.

How can these complications be avoided?
These devastating complications can be avoided by risk management. There is a risk to every medical procedure (and it’s sometimes easy to forget that cosmetic injections are in actual fact a medical procedure). Clinicians perform a mental calculation and weigh up the risk versus the benefit of every procedure and fillers and anti-wrinkle injections are no different. Avoiding the “No-Go” injecting “Danger-Zones” is the best way to minimise risk.

The use of a blunt tipped cannula as opposed to a needle may be preferred in some areas to minimise the chance of puncturing and injecting into an artery. In theory at least, a blunt tipped canula should push aside a blood vessel rather than puncture it. Cannulas aren’t appropriate for every injection though, so after puncturing the skin and finding the exact place that we want to inject it’s a good idea to “pull back” or “withdraw” the plunger of the syringe.

If the needle tip is sitting in a vein or artery we will see a backflush of blood, which we won’t see if the needle is sitting in other tissue. Injector experience is of such huge importance, and sometimes we as injectors need to have the confidence and the courage to say “no” and refuse to inject in a situation or area which we find unsafe. After all, we get cosmetic injections for beauty, so why would we risk serious injury?

Can I go blind from anti-wrinkle injections?
This is highly unlikely for a number of reasons, but mostly because of the very different effects of filler and anti-wrinkle injections. Filler works by doing exactly that: filling. It is a big molecule, designed to take up space and expand. Anti-wrinkle injections work by paralysing and weakening specific muscles in the face that cause wrinkles when they contract. They are very small molecules and are highly unlikely to block an artery, even if they were injected into one.

After all has been said and done, these serious complications are very rare. Otherwise we would not be injecting fillers into anyone! No clinician wants to cause a serious complication. Far and away the most common side effect of dermal filler injections is swelling and bruising to the area, which usually settles down after a few days and is easily managed. But it is important to be aware of the risks involved, and to be able to discuss them with your injector for your own piece of mind and safety.