Cosmetic fillers: A popular choice for millions of Americans, but not without risks - including the rare possibility of blindness

In the battlefield of cosmetic enhancements, fillers tend to be viewed as low-risk and low-impact. But new reports show that they’re not risk-free and can even be deadly. In rare cases, dermal fillers put people at risk of vascular occlusion.^[]

Vascular occlusion can occur if filler is injected into a blood vessel and left untreated, leading to necrosis and the death of skin tissue. Depending on placement of the filler, it can result in complications like blindness.

Although vascular occlusion is “extremely rare,” it can have extreme health consequences, says Constance M. Chen, MD, a board-certified plastic surgeon based in New York. She encourages doctors to have thorough conversations with patients before procedures and to intervene quickly if a procedure appears to have gone wrong.

“Warning signs that a patient is in trouble after fillers include visual loss; red, painful or tender nodules; area of filler injection turns black,” says Chen. “Regardless, you should follow up after treatment so any issues can be caught and treated early.”

What should the proper filler injection technique look like?

There are a couple of different techniques commonly used to inject fillers, including tunneling, point, stretching, dual plane, and bolus techniques, says Chen. The bolus technique tends to be the riskiest technique, as it involves jabbing filler into the skin as the needle is inserted, “which is less precise” than the other methods. It can be “difficult to know exactly where the needle and filler will land,” adds Chen.

The other techniques require more care and detail, Chen explains.

Tunneling technique: Insert the injection needle at a 30- to 45-degree angle and follow the direction of the wrinkle you are looking to correct. Wait until you are withdrawing the needle to inject the filler.

Point technique: Inject several small droplets of filler—“numerous microinjections”—into deep layers of the skin and in close proximity to one another.

Stretching technique: If the patient has a lot of loose skin, stretch out the skin around the wrinkle before injecting it with filler. 

Dual plane technique: This is used to create a more natural look by injecting filler into different levels (planes) of the skin.

Have we been downplaying filler risks?

Some types of fillers can be dissolved: one of the reasons fillers are seen as a low-risk cosmetic procedure. This is the case with hyaluronic acid fillers, which can be dissolved with an agent called hyaluronidase. Other types of fillers, like silicone fillers, cannot be dissolved. Silicone fillers need to be surgically removed and, for that reason, tend to be riskier than hyaluronic fillers, says Chen.

People who run into complications with their fillers may want or need to have them removed or dissolved to fix the problem. However, this isn’t a foolproof solution, Chen says.

Mitigating risks before injections

Cosmetologists and patients should discuss the goals, risks, and benefits of fillers before a procedure to ensure that the patient remains safe and healthy. This should first involve screening the patient for underlying health conditions and not performing procedures on people who are at risk.

People who are allergic to injection ingredients (e.g., someone who is allergic to hyaluronic acid or silicone) would not be good candidates for fillers, says Chen. They may likewise not be appropriate options for people with bleeding disorders or seizures, she adds.

Preoperative conversations should also go over what medications the patient is taking and any other variables that could impact how the body responds to the filler, she says. Doctors should also go over the patient’s goals and expectations from the procedure.