How Clinicians Now Stage Filler Blood-Flow Complications

When filler blocks or damages a blood vessel, the skin changes in a fairly predictable sequence. A 2025 study of 120 patients from a Dutch referral centre used a five-stage system to describe those changes and mapped where on the face they occurred. For patients, the key lessons are that the earliest signs, like pale or blotchy skin, should be reported right away, and that early signs do not always progress to skin damage.

Why this was studied

Blocked blood flow, often called vascular occlusion, is an uncommon but serious complication of filler. Clinicians need a shared language to describe how severe an event is and how it is changing, so they can decide how aggressively to treat it and compare results across studies. Researchers also want to know whether some areas of the face are more likely to develop skin damage.

What the researchers did

The team reviewed photographs and records of 120 people referred to their clinic between 2019 and 2024 with blood-flow problems after facial filler. Most were women, with an average age of 40. Each case was mapped to the artery likely involved and to whether the affected area was in the central or outer part of the face.

They then classified each case using five stages:

1. Pale skin, where blood flow has been interrupted.
2. A blotchy, net-like red or purple pattern, reflecting disturbed flow in the area a vessel supplies.
3. Small pustules or blisters, an early sign of tissue injury.
4. Open sores or erosions, where the surface of the skin has broken down.
5. A dark scab, where tissue has died.

The first two stages are considered "non-necrotic," meaning the skin has not yet been damaged. Stages three to five involve tissue injury.

What they found

About 59% of the people in this group had reached a stage involving skin damage when they were seen, though none had the most severe stage. Most events involved the area supplied by the facial artery, which runs around the mouth, nose and chin.

The most notable finding was about location. Skin damage was more common when the problem was in the central face than in the outer face: about 63% versus 33%. In contrast, which main artery was involved did not make a significant difference. The authors suggest that the small connecting vessels in the central face may matter more than the main arterial branch, but this is a hypothesis to be tested.

They also note that early stages generally appear within the first two days, while skin breakdown tends to appear around day three or four. Not every case progressed: a small group with mild, stable early signs were watched carefully without intensive treatment, and none went on to skin damage.

How strong is this evidence?

This was a retrospective review from a single specialist centre. Because people were referred there, the group likely leans toward more serious cases, and milder events managed elsewhere are not included. Photographs were taken when people arrived, often after a delay and sometimes after treatment had begun, so early signs may have been missed. The study did not have information on how many injections were done in each area, so it cannot tell us the risk per treatment.

A staging system like this is mainly a tool for clinicians. It helps with communication and research, but it does not by itself tell anyone how likely a complication is.

It is also worth remembering that this group came from a referral centre that sees complications from many clinics, so the high share of skin damage reflects the cases sent there, not the typical outcome after filler.

What it means for you

Blood-flow complications are rare, and most filler treatments go smoothly. But knowing the early signs helps you act quickly if something does happen. Contact your clinic immediately, day or night, if you notice any of the following after filler:

• Pain that is severe, increasing or out of proportion to normal tenderness
• Skin that looks pale, white, dusky, bluish or blotchy in a lacy pattern
• Small pimples or blisters appearing a day or more after treatment
• Any change in vision, eye pain or droopy eyelid, which needs emergency care

Normal swelling and bruising look different: they are usually even, settle over a few days and are not accompanied by colour changes in a pattern. Our article on filler swelling and bruising describes what is expected.

Physician-led clinics keep emergency protocols and the dissolving enzyme hyaluronidase on hand so treatment can start promptly. Our article on vascular occlusion safety explains what a clinic should have ready.

Why a shared staging system helps

Before systems like this, different clinicians described the same skin changes in different words, which made it hard to compare cases or track whether treatment was working. A common scale lets a treating clinician, a specialist and a researcher all describe an event the same way. Over time, that should make it easier to learn which treatments work best at each stage.

For patients, the practical benefit is quicker, clearer communication. If you send a photo or describe changes to your clinic, terms like "pale", "lacy pattern" or "blisters" help the team judge urgency right away.

Frequently asked questions

Does this mean central-face filler is unsafe?

No. It means that if a blood-flow problem happens there, skin damage may be more likely, which is why careful technique and prompt reporting matter in those areas.

Will an early sign always turn into a wound?

Not always. In this study, some mild, stable early cases resolved with close monitoring. That decision should be made by a clinician who has examined you.

What is ultrasound used for?

The authors note that Doppler ultrasound can help map vessels before injecting and help locate the problem if a complication occurs.

If you have questions about filler safety, a consultation is a good chance to ask how complications are recognized and managed before deciding on treatment.

Source

Khoshnaw S, Schelke LW, Murray G, Velthuis PJ. Localization and staging of vascular adverse events after facial fillers: a detailed assessment. Aesthetic Surgery Journal Open Forum, 2025. Read the study