An Expert-Informed, Four-Stage Algorithm for Early Recognition and Treatment of Cutaneous Vascular Occlusion After Hyaluronic Acid Filler

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ID: 331763
2026
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Ranked #115 of 125 articles by views in Aesthetic Surgery Journal Open Forum

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Abstract
Abstract Hyaluronic acid (HA) fillers are among the most widely used injectables for facial rejuvenation due to their reversibility with hyaluronidase and ease of use. However, despite their favorable safety profile, the risk of vascular occlusion remains. Early recognition and timely intervention for a vascular occlusion is essential to prevent ischemia, necrosis, and scarring. The authors have developed an up-to-date practical algorithm for the recognition and management of HA filler-associated vascular occlusion, incorporating current literature, pharmacologic principles, and real-world experience. Key elements from complication management protocols at high-volume centers were synthesized into a four-stage algorithm. The protocol was cross-checked against peer-reviewed publications from 2018–2026. Divergent recommendations were reconciled by prioritizing rapid, accessible, and low-risk interventions. The algorithm comprises: (1) recognition and mapping of ischemia using capillary refill testing; (2) immediate bedside measures including cessation of injection, aspirin, heat, and massage; (3) definitive enzymatic therapy with high-dose, pulsed hyaluronidase administered via a pillar grid across all affected tissue planes; and (4) adjunctive care such as vasodilators, corticosteroids, hyperbaric oxygen, and scar mitigation. The framework emphasizes repetition of hyaluronidase cycles within the first hours and next day to ensure complete filler degradation and tissue reperfusion. Vascular occlusion following HA fillers is a time-critical emergency. The presented four-stage algorithm suggests a standardized, stepwise approach that any injector can implement. By combining pathophysiologic insights with practical bedside actions and interventions, the algorithm aims to reduce delays and thereby may improve tissue salvage and enhance patient safety and care.
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Authors Saami Khalifian, Sheila Chang Barbarino, John P. Fezza, Tyler Fezza, Sachin M. Shridharani
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Journal Aesthetic Surgery Journal Open Forum
Year 2026
DOI
10.1093/asjof/ojag188
URL
https://doi.org/10.1093/asjof/ojag188
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