Structured Training of Dermatology Residents in the Management of Soft-Tissue Filler-Induced Vascular Complications

September 2025 | Volume 24 | Issue 9 | 928 | Copyright © September 2025


Published online August 31, 2025

doi:10.36849/JDD.8039R2

Mohamad Bazzi MD MSa, Victoria Dekany BS MDb, Henry Zou BS MDc, Hany Deirawan MDd, Steven Daveluy MDd

aWayne State University School of Medicine, Detroit, MI
bCentral Michigan University College of Medicine, Mount Pleasant, MI
cMichigan State University College of Human Medicine, Lansing, MI
dWayne State University Department of Dermatology, Detroit, MI

Abstract
Background: Soft-tissue filler injection-related vascular complications (IRVC) can lead to tissue necrosis, vision loss, and stroke. Hyaluronidase-based injections are the mainstay of treatment, though other options include heat, massage, nitroglycerin, and anticoagulants. Given the narrow therapeutic window and limited early warning signs, we propose training residents to implement a standardized soft-tissue filler vascular complication (SFVC) management protocol.
Objective: This study aims to address gaps in procedural knowledge by providing residents with a lecture series followed by a hands-on cadaveric practice session.
Methods and Materials: An SFVC management protocol was developed based upon a literature review and expert opinion. Didactic instruction and practice sessions with cadavers were conducted with residents at an academic dermatology program. All resident trainees took a survey assessing their knowledge and satisfaction with the quality of training.
Results: Thirteen residents were included in this study. Overall, the aggregate confidence score for recognizing vascular events, acute management of filler complications, and performance of procedures after hands-on simulation on cadavers significantly increased between pre- and post-surveys (P<0.001).
Conclusion: Our intervention successfully demonstrated increased confidence among residents regarding the key components of SFVC, namely, in recognizing the signs and symptoms, managing an acute event, and finally, in performing advanced procedures for SFVC.

J Drugs Dermatol. 2025;24(9) doi:10.36849/JDD.8039R2

INTRODUCTION

Injection-related vascular complications (IRVC) result from inadvertent arterial occlusion by injectable filler materials used in minimally invasive facial aesthetic procedures.1 IRVC is rare but can lead to severe adverse effects, including skin and tissue necrosis, ophthalmoplegia, partial or complete vision loss, and stroke.1–3 Filler materials implicated in IRVC include hyaluronic acid (HA), calcium hydroxyapatite, human and bovine collagen, poly-L-lactic acid, and autologous fat; among these, HA is the most common filler used worldwide.2 Although rare, the exponential global surge in the popularity of filler injections has correlated with an increase in IRVC, and even more alarming, this number is believed to be underreported.1,2

The glabella, forehead, nasal dorsum, nasolabial folds, tear trough, midface, and temporal fossa are commonly implicated in IRVC.4,5 These facial injection sites are high-risk given the potential for accidental cannulation and occlusion of high-risk vessels, which include the ophthalmic artery, central retinal artery and branches, supratrochlear artery, dorsal and lateral nasal arteries, and temporal artery or vein.4,5 The leading hypothesis for IRVC pathogenesis is that the inadvertent cannulation of high-risk vessels causes retrograde flow and embolization of filler materials into the ocular, cerebral, or facial vasculature, which induces vision loss, stroke, or skin and tissue necrosis.1,3

IRVC-induced skin compromise is an urgent condition, while IRVC-induced vision loss or stroke is a medical emergency.1,3 To minimize the risk of IRVC, fillers should be injected slowly and in smaller aliquots.2 Treatment is aimed at recanalizing the occluded vessels and reperfusing the ischemic tissue.1 High-dose, pulsed hyaluronidase injections of the entire ischemic area are the primary treatment modality administered via retrobulbar, subcutaneous, intralesional, and sub-tendon routes.1,3,6 By degrading HA, hyaluronidase can induce ischemic