New Emergency Protocols for Filler Blood-Flow Blockages

A 2025 case series from a referral team in Iran and Spain describes a step-by-step protocol used on 25 people whose skin was starved of blood after hyaluronic acid filler. Most healed without scarring, and the two who scarred had arrived later with more advanced damage. For patients, the clearest message is about speed: whatever protocol is used, earlier recognition and treatment appear to matter most.

Why this was studied

A vascular occlusion happens when filler blocks or presses on a blood vessel, cutting off blood supply to an area of skin. It is uncommon, but if not treated it can lead to wounds and scarring. The standard first step is to dissolve hyaluronic acid filler with an enzyme called hyaluronidase, explained in our article on vascular occlusion safety.

What happens after that first step varies widely between clinics and published guidelines. Some patients arrive late, after the skin has already started breaking down, and need wound care as well as dissolving. This research team wanted to describe a structured approach that covers both the early and the later stages.

What the researchers did

The authors named their approach with an acronym, "THIS and FAT." In plain terms, it combines several steps depending on how advanced the damage is:

• botulinum toxin type A, given with the aim of reducing blood-vessel narrowing;
• high-dose hyaluronidase, in some cases guided by ultrasound directly into the affected artery;
• preparations made from the patient's own blood (platelet-rich fibrin), injected into or applied over the affected skin;
• aspirin and other medicines, including antibiotics;
• processed fat from the patient, and gentle removal of dead tissue for more advanced wounds.

They treated 27 patients and analyzed 25 (20 women and 5 men, average age about 32). Most had facial filler, most often in the nose, temples, chin, glabella or lips, while some had larger-volume body filler. On average, patients reached the team more than three days after their injection, which reflects that this was a referral centre seeing complications from elsewhere.

What they found

The paper reports that 92% of patients recovered completely without scarring. Two people developed scars, and both had the most advanced stages of tissue damage. Those with advanced damage had, on average, been referred later and had received larger volumes of filler.

The main side effect reported was temporary facial asymmetry from the botulinum toxin. The authors did not observe problems from the hyaluronidase.

How strong is this evidence?

This is a small case series without a comparison group. Every patient received the same bundle of treatments, so it is impossible to say which parts helped, which made no difference, and whether patients would have done equally well with standard care alone. Some skin damage after filler improves on its own once blood flow returns, which makes uncontrolled results harder to interpret.

Several parts of this protocol, including platelet-rich fibrin, fat grafting for wounds, and botulinum toxin for blood-vessel narrowing, are experimental in this setting. Their use here is research, not established standard care, and availability and Health Canada authorization of some approaches vary. The paper also discloses that two authors consult for a filler manufacturer. None of this makes the work unhelpful, but it means the findings are a starting point for further study rather than a new rule.

It is also worth knowing that this team saw patients who were referred to them, often days after the problem began. That is a very different situation from a clinic recognizing a problem in the treatment chair and acting within minutes. Results in one setting may not carry over to the other.

What it means for you

The most consistent message from this paper and others is that time and filler volume matter. The patients who did worst arrived later and had more product injected. That supports what most guidance already says: complications should be recognized early and treated promptly, ideally by the clinic that did the injection, with a clear plan for escalation.

Warning signs to report immediately, during or after filler, include:

• pain that is severe, increasing or out of proportion to the treatment;
• skin that turns white, grey, blue, purple or blotchy;
• coolness of the skin, or small blisters or pimple-like spots appearing over the next days;
• any change in vision, which is an emergency.

Physician-led clinics keep emergency supplies such as hyaluronidase on hand and rehearse what to do. If you have any concern after treatment, contact the clinic right away rather than waiting to see if it settles. If you cannot reach them and symptoms involve your eyes, go to the nearest emergency department.

Questions to ask at your consultation

• Do you keep hyaluronidase on site, and who would treat me if a complication happened after hours?
• How much filler do you plan to use, and could it be done in smaller stages?
• What signs should I watch for in the first few days?

At HealthPark, these points are covered before treatment, along with the option of choosing a smaller amount, a different approach or no filler at all.

Frequently asked questions

Does this mean clinics should use this new protocol?

Not on its own. A small study without a comparison group cannot show that it is better than established approaches. It adds ideas that larger, controlled studies will need to test.

Why would anyone inject more filler-related products into a blocked area?

The enzyme dissolves the filler; it does not add any. The other steps in this protocol aim to support blood flow and healing, though their benefit is still being studied.

Are body fillers riskier?

In this series, larger volumes were linked with more advanced damage. Large-volume body filler is not widely used in Canada, and its safety is still being studied.

If you are thinking about filler, a consultation is a good time to ask how complications are prevented and handled, so that you can make an informed choice.

Source

Nazari S, Fakih-Gomez N, Hadadian N, Bayat F, Bohlouli B, Muñoz-Gonzalez C, Pourani MR. A new protocol (THIS and FAT) for the treatment of filler-induced vascular occlusion: a case series. Frontiers in Medicine, 2025. Read the study