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we observe restore of blood flow within minutes (Figure 1). It is important to realize that the occluded arteries are found at the borders or sometimes even outside the clinically affected area [8]. There is some discussion about this approach. Many scholars do not accept that large facial arteries can be occluded. Should that be the case, anastomoses and collateral vessels will take over the blood supply in their opinion. They feel that the clinical picture is provoked by smaller elements of the filler substance coming loose, traveling to end-arterioles of the skin and eventually blocking oxygen transfer in capillaries. Alternative to our approach they flood the clinically affected area superficially and deep with large doses of hyaluronidase (usually 1500-3000 units) [9]. In our clinic, however, we follow the hypothesis of Ian Taylor’s group, that after contact with the filler vasoconstriction of the artery occurs. Concurrently choke anastomoses will prevent arterial blood to flow from bordering vasosomes into the affected skin. Indeed HA filler has proved to be an irritant for the endothelium and may induce vasoconstriction [10]. Also it seems improbable that part of the filler substance will come loose, since the filler itself is designed to be very cohesive. Recently we published 42 cases of Vascular Adverse Events (VAE) in the face referred to us in 22 months [8]. The locations and arteries implicated are given in table 1. In another study we calculated the incidence of these vascular adverse events to be 1:6600 [11].Thus, a regular cosmetic doctor performing 1500-2000 treatment/year, will meet a VAE every 3-4 years. Restore of blood flow within two days is generally thought to be sufficient to prevent tissue from becoming necrotic. Figure 1: A case of obstruction of superior labial and columellar artery. Above 1 day after hyaluronic filler injection. Below 1 day after hyaluronidase injection in the filler pockets under ultrasound guidance. Arteryinvolved N. of Cases Submental 7 Inferiorlabial 7 Facial + Superior Labial 1 Superior Labial + Columellar 6 Superior Labial 3 Columellar 2 Angular 5 Dorsalnasal 3 Transverse Facial 1 Infraorbital 1 Frontal Branch External Carotid 3 Zygomatico-Orbital 1 Supratrochlear 2 Supraorbital 2 Total 44 Table 1: occluded arteries by fillers in 44 consecutive cases 2018-2020 [11]. Citation: Velthuis PJ, Schelke LW (2021) Fillers and Vessels: The Story of Arterial Obstruction after Cosmetic Treatment. J Angiol Vasc Surg 6: 069. • Page 3 of 3 • J Angiol Vasc Surg ISSN: 2572-7397, Open Access Journal DOI: 10.24966/AVS-7397/100069 Volume 6 • Issue 2 • 100069 It is questionable whether fillers can block arterial blood flow by compression. The general opinion is that this may only happen in the tight skin on the tip of the nose. However we have recently seen a case of temporary hair loss after filler injections that we believe resulted from filler placement between fascial sheets in the temple (van der Elzen et al. submitted). Some doctors hold the opinion that obstruction of venous vessels can cause a delayed blockage of the vascular system. This may account for cases sometimes seen where the symptoms do not appear ‘on the needle’, but several hours later. We fail to see the mechanism of this. Vision loss is a very grave and feared complication in facial filler treatments. This is caused by fillers injected in arteries that anastomose with branches of the ophthalmic arteries [12]. In particular the nose and glabella regions are implicated. In those cases the filler supposedly travels in the direction opposing the blood flow. The extrusion force of the filling substance must be high enough to counteract the pressure of the blood flow in the ophthalmic artery. Another hypothesis may of course be the Taylor notion of provoked vasoconstriction [13]. Occlusion of the CRA leads to intense pain in the eye and immediate loss of vision. There is debate about how much time there is before vision loss is irreversible. Since retinal tissue must be regarded as an extension of the brain with its susceptibility for anoxia, it is generally believed there is very limited time for action, perhaps 30-90 minutes. Only in case of CRA occlusion by hyaluronic acid filler there is a potential way to dissolve the filler. For other filler types there is no antidote.
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