Hyaluronidase & Vascular Occlusion Update 2019

In April 2014 I wrote a blog post called ‘Holy Shit, It’s Filler Blindness!’. I felt at the time that the post was needed as there was a lot of fear in the industry about the newly infamous filler-related ischamia of the skin or retina, potentially resulting in the need for a skin graft or even worse, sudden, irreversible blindness.

My post was based upon the ‘Expert Consensus…’ (see below) and we went on to use their proposed protocol, with some adaptation as the basis of our hyaluronidase/hyalase assessment station on our training courses. The blog post still gets more hits than anything else on our websites, but, ‘expert advice’ has changed regarding the management of dermal filler-related skin ischaemia and blindness since then, and also, we now have a peer-reviewed and evidence-based document. Here’s a quick update (skin ischaemia > blindness).

Quick Links

Consent Form for hyaluronidase

February 2014

Aesthetics Complications Expert (ACE) Group.
The Use of Hyaluronidase in Aesthetic Practice
Summary: Use 1.5-30 units hyalase for skin ischaemia, depending on the size of the effected area.

March 2014

Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Inglefield, Collins, Duckett, Goldie, Huss, Paun, Williams (March, 2014). Part funded through an unrestricted educational grant from Merz Aesthetics UK). Not available online.
Summary: Use 30 units of hyalase for all incidences of skin ischaemia.

Facecoach: Dissolving Hyaluronic Fillers (4 years ago)
March 2017

Aesthetic Surgery Journal, Volume 37, Issue 7, 1 July 2017, Pages 814–825
Summary: Use 500-1,500 units hyalase for skin ischaemia, depending on the area of skin affected. Larger area → use more hyalase. They claim that there’s no point in using hot towels or GTN patch or paste and that they have always had a 100% resolution in everyone treated up to 48 hours after the ischaemic event. For blindness, they recommend knowing where your nearest hyperbaric chamber is and identifying your closest ophthalmologist is (so they can give a retrobulbar injection of hyalase in the case of blindness within 2 hours. This treatment option seems to be a fairly new suggestion but gives us hope. It looks to me like the same injection ophthalmologic surgeons use when prepping for cataract surgery, except they use a local anaesthetic instead of hyalase.

Hyaluronidase diffuses through blood-vessel walls if in high enough concentration, so inject liberally, all over and around the effected area. The author of this article says that the affected area should be ‘flooded’. The subtle beauty of this method is that knowledge of the facial vasculature is not essential as injections are simply given throughout the affected area, and the affected area should be easily identified visually as pale, or later, as red, mottled, grey or blistered.


The Use of Hyaluronidase in Aesthetic Practice (V2.4). Martyn King, Cormac Convery, Emma Davies.

Method: How Will I Administer Hyaluronidase from Now On?

Remember that prevention is better than cure. Aspirate before each injection with hyaluronic acid gel, inject slowly and stop immediately if the patient experiences unexpectedly high levels of pain.

  1. Add 1ml 0.9% Normal Saline (preferably Bacteriostatic) to a 1500 unit vial of hyaluronidase.
  2. Take this solution (all of it) and add to 1.5ml 0.9% Normal Saline. The result is 1500 units in 2.5ml saline; 600 units/ml.
  3. Perform a patch test to check for allergic response to hyaluronidase. Give 0.1ml of your solution intradermally on the inside of an arm. Wait 20-30 mins; if a red, itchy weal appears, this is a sign that the patient is allergic to hyaluronidase.
  4. If not allergic, give multiple small injections of the solution (0.06ml = 3 graduations of a 1ml insulin syringe = 6 graduations of a 0.5 or 0.3ml insulin syringe) throughout the area affected by the vascular occlusions OR in and around the lump. In both cases, firm massage of the area injected, should then be performed.
  5. Total dose depends on size of affected area (see diagram below). With this dilution, 500 units is 0.83ml, 1000 units is 1.67ml and 1500 units is 2.5ml.
  6. If complete resolution occurs, stop and review the following day. If not, repeat hourly until full resolution (normal skin colour).

Flourish (Electronic Cosmetic Records System) has a hyalase form, which everyone can access for free with a free trial. To enable the form, follow these 3 steps once you have an account set up. Setup a free 10 consultation trial if you don’t already have one. Then you can copy and paste our hyalase consent form if you’d rather use another system. Also checkout Dermal Revolution if you haven’t already 😉

Thanks for reading (see the Questions & Answers section below the Flourish info)

Dr Michael Aicken

[email protected]


Flourish instructions for enabling the hyaluronidase consent form

Click on the settings ‘cog’ on the top right of the screen, once logged into Flourish.

Click on a practitioner.

‘Edit User’ and tick / untick whatever forms you use in your clinic. Here we’ve discussed hyalase obviously, so tick that.

Questions & Discussion, based upon the article above and emails I’ve had about it

Q: I have spoken with quite a few practitioners who make the hyalase syringes up ready to go. Wondered your thoughts on this?

A: Do you mean that they make up hyalase before they have a case of vascular occlusion, so that it’s ready? If that’s the case, then I don’t recommend it. There’s an infection risk but more importantly, there are no guarantees that the hyalase will work if the storage recommendations are not followed.

Q: Can you also confirm with me our medical kit? Currently I have GTN patches, EpiPen and hyalase. Do we no longer need the gtn patches?

A: Good question! As always, with rare complications like vascular occlusion, it’s good to side with a group of experts. I’d recommend either the Expert Consensus or the ACE guidelines (both referenced above). The paper referenced in my article, states that GTN plays only a minor role, if any, in the management of vascular occlusion. But currently that’s just one paper, and the 2 group guidelines still recommend it, so, although it may be removed from the advice in future, and it’s a hassle to get if you’re a non-prescriber, it’s probably worth keeping in your emergency kit for now.

Q: If we were ever to need to use a hot compress what would you suggest to use? Just want to keep my medical kit updated and ensure is correct.

A: A hot towel/paper.

Q: Should Piriton be in my emergency kit?

A: Piriton isn’t an emergency drug as it doesn’t treat any emergencies – it’s for allergies. In anaphylaxis, where airway and / or organ perfusion are compromised, an epipen or equivalent is needed immediately (one every 5-10 mins until an ambulance arrives). Piriton may be administered in hospital later, but it’s the adrenaline/epinephrine injection that can save a life. Piriton can be bought over the counter by the customer if they feel they have an allergy but be aware that it’s unlikely to help with swelling of the lips following dermal filler treatment as it only works to suppress allergic, histamine-mediated swelling.