Vascular Occlusion After Filler: Diagnosis and Hyaluronidase Protocols

Background: Intra-arterial injection of hyaluronic acid filler is a rare but potentially devastating complication that can result in skin necrosis, blindness, or stroke. Consensus on early recognition and hyaluronidase dosing has evolved rapidly. Objective: To present an updated diagnostic algorithm and pulsed high-dose hyaluronidase protocol derived from an international expert panel and 214 documented vascular events. Methods: Multidisciplinary panel review of 214 cases of suspected vascular occlusion (2018–2024) treated with early hyaluronidase. Time-to-recognition, cumulative hyaluronidase dose, capillary refill trajectory, and 30-day outcomes were analyzed. Results: Median time to intervention was 42 minutes among patients with full recovery versus 6.5 hours among those with residual scarring (p<0.001). A pulsed protocol of 500–1500 units of hyaluronidase every 60 minutes until capillary refill normalized was associated with 94% complete resolution when initiated within 90 minutes. Escalation criteria included persistent livedo, pain out of proportion, and delayed capillary refill beyond three cycles. Sublingual nitroglycerin and warm compresses provided no measurable benefit over hyaluronidase alone. Conclusions: Early recognition and aggressive pulsed high-dose hyaluronidase remain the cornerstone of vascular occlusion management. Every injector should have a written protocol, adequate hyaluronidase on-site, and immediate escalation pathways for ophthalmic or cerebral involvement.