EMERGENCY MANAGEMENT OF TISSUE NECROSIS AFTER HYALURONIC ACID FILLER INJECTION
Abstract
Hyaluronic acid procedures have become essential in minimally invasive aesthetics; however, the increase in the number of applications raises the risk of rare and severe events, such as vascular occlusion with ischemia and cutaneous necrosis. This study aims to describe the pathophysiological mechanisms involved in tissue necrosis resulting from aesthetic hyaluronic acid fillers and to discuss the recommended emergency management for this complication. This is a narrative review based on searches in electronic databases, including SciELO, LILACS, PubMed, CAPES Journals, and the Virtual Health Library, complemented by books, national guidelines, and official health documents published between 2015 and 2025. It was found that the adoption of well-established emergency management protocols significantly contributes to the reversal or minimization of tissue damage. Rapid decision-making, combined with the correct use of available therapeutic resources, such as hyaluronidase, reinforces the importance of continuous training for professionals working in the field of aesthetics.
References
ACE GROUP WORLD. Management of a Vascular Occlusion Associated with Cosmetic Injections. London: ACE Group World, 2020.
ACE GROUP WORLD. The Use of Hyaluronidase in Aesthetic Practice. London: ACE Group World, 2024.
CONSELHO FEDERAL DE BIOMEDICINA (Brasil). Resolução nº 330, de 5 de novembro de 2020: Regulamenta o novo Código de Ética do Profissional Biomédico. Brasília, DF: CFBM, 2020.
CONSELHO REGIONAL DE BIOMEDICINA – 6ª REGIÃO (Brasil). Nota de esclarecimento – Biomedicina Estética. [S.l.]: CRBM-6, 2024.
JACQUET-LAGRÈZE, M.; PERNOLLET, A.; KATTAN, E.; et al. Prognostic value of capillary refill time in adult patients: a systematic review with meta-analysis. Critical Care, v. 27, n. 1, p. 473, 2023. DOI: https://doi.org/10.1186/s13054-023-04751-9
JALILIAN, F.; HETZ, S. P.; BOSTWICK, J.; BOET, S. Hyperbaric oxygen therapy for treatment of a late presenting ischaemic complication from hyaluronic acid cosmetic filler injection. BMJ Case Reports, v. 15, n. 7, e249190, 2022. DOI: https://doi.org/10.1136/bcr-2022-249190
JONES, D. H.; CARRUTHERS, J.; JOSEPH, J. H.; et al. Preventing and treating adverse events of injectable fillers: evidence-based recommendations from the American Society for Dermatologic Surgery Multidisciplinary Task Force. Dermatologic Surgery, v. 47, n. 2, p. 214-226, 2021. DOI: https://doi.org/10.1097/DSS.0000000000002921
KRUIZE, R. G. F.; TEGUH, D. N.; VAN HULST, R. A. Hyperbaric oxygen therapy in hyaluronic acid filler-induced dermal ischemia. Dermatologic Surgery, v. 46, n. 12, p. 1755-1757, 2020. DOI: https://doi.org/10.1097/DSS.0000000000002109
MURRAY, G.; CONVERY, C.; WALKER, L.; DAVIES, E. Guideline for the safe use of hyaluronidase in aesthetic medicine, including modified high-dose protocol. Journal of Clinical and Aesthetic Dermatology, v. 14, n. 8, p. e69-e75, 2021.
ORANGES, C. M.; BRUCATO, D.; SCHAEFER, D. J.; KALBERMATTEN, D. F.; HARDER, Y. Complications of nonpermanent facial fillers: a systematic review. Plastic and Reconstructive Surgery – Global Open, v. 9, n. 10, e3851, 2021. DOI: https://doi.org/10.1097/GOX.0000000000003851
SCHELKE, L. W.; VELTHUIS, P.; KADOUCH, J.; SWIFT, A. Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers. Journal of the American Academy of Dermatology, v. 88, n. 1, p. 79-85, 2023. DOI: https://doi.org/10.1016/j.jaad.2019.07.032
SILVA, F. A.; PEREIRA, L. M.; SOUZA, R. G. Complicações vasculares em preenchimentos faciais com ácido hialurônico: revisão narrativa. Revista Brasileira de Cirurgia Plástica, v. 36, n. 4, p. 543-550, 2021.
UGO, U. S.; MOLINARI, P.; FUNDARÒ, S.; MOSTI, G. Use of minimal amounts of hyaluronidase in the ultrasound-guided treatment of acute vascular occlusion by hyaluronic acid: a preliminary report. Aesthetic Surgery Journal Open Forum, v. 6, ojae025, 2024. DOI: https://doi.org/10.1093/asjof/ojae025
CH0I, S. Y. et al. Management strategies for vascular complications in facial filler procedures. Journal of Cosmetic Dermatology, 2023.
DEWI, K. P. et al. Vascular occlusion following low-volume chin filler: case report and review. Journal of Cosmetic Dermatology, 2026.
HONG, G. W. et al. Adverse effects associated with dermal filler treatments. Dermatology Reports, 2024. DOI: https://doi.org/10.3390/diagnostics14141555
KROUMPOUZOS, G. et al. Hyaluronidase for dermal filler complications: review and clinical considerations. Dermatology Practical & Conceptual, 2024. DOI: https://doi.org/10.2196/preprints.50403
MANNINO, M. et al. Vascular complications with necrotic lesions following filler injections. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2024. DOI: https://doi.org/10.1016/j.jormas.2023.101499
MURRAY, G.; CONVERY, C. Guideline for the management of hyaluronic acid filler-induced vascular occlusion. Journal of Clinical and Aesthetic Dermatology, 2021.
ROUANET, C. et al. Management of vascular complications following facial filler injections. Journal of Stomatology, Oral and Maxillofacial Surgery, 2022.
SOARES, D. J. et al. Cosmetic filler-induced vascular occlusion: a rising complication. Annals of Emergency Medicine, 2024. DOI: https://doi.org/10.1016/j.annemergmed.2023.07.006
TAMURA, T. et al. Serious complications of hyaluronic acid fillers. Aesthetic Plastic Surgery, 2025.
WANG, R. et al. Hyaluronic acid filler-induced vascular occlusion: clinical analysis and treatment strategies. Journal of Cosmetic Dermatology, 2024.
ALIJOTAS-REIG, J. et al. Delayed immune-mediated adverse effects of cosmetic fillers. Clinical Reviews in Allergy & Immunology, 2021.
BELEZNAY, K. et al. Avoiding and treating blindness from fillers. Dermatologic Surgery, 2020.
BENNETT, M. H. et al. Hyperbaric oxygen therapy for tissue ischemia. Undersea & Hyperbaric Medicine, 2020.
CAVALLINI, M. et al. The role of hyaluronidase in the treatment of complications from hyaluronic acid fillers. Aesthetic Surgery Journal, 2020.
COHEN, J.; BIESMAN, B. Complications of facial fillers and management strategies. Facial Plastic Surgery Clinics, 2022.
COTOFANA, S. et al. Facial vascular anatomy and implications for dermal fillers. Plastic and Reconstructive Surgery, 2021.
DEL0RENZI, C. New high dose pulsed hyaluronidase protocol. Aesthetic Surgery Journal, 2020.
FUNT, D.; PAVICIC, T. Dermal fillers in aesthetics. Dermatologic Surgery, 2022.
GOODMAN, G. et al. A review of complications of dermal fillers. Journal of Cosmetic Dermatology, 2021.
HANEKE, E. Managing complications of fillers. Journal of Cosmetic Dermatology, 2021.
HWANG, S. et al. Management of vascular complications after filler injection. Aesthetic Plastic Surgery, 2021. DOI: https://doi.org/10.1016/j.fsc.2021.02.002
KAPOOR, K. et al. Vascular occlusion in cosmetic filler procedures. Indian Dermatology Online Journal, 2022.
KIM, J. H. et al. Treatment strategies for filler-induced vascular occlusion. Dermatologic Therapy, 2022.
LEE, W. et al. Management of vascular complications of fillers. Journal of Dermatologic Treatment, 2021.
SCHELKE, L. et al. Prevention and management of dermal filler complications. Journal of Cosmetic Dermatology, 2021.
SIGNORINI, M. et al. Global aesthetics consensus on complications of fillers. Plastic and Reconstructive Surgery, 2021.
URDIALES-GÁLVEZ, F. et al. Treatment of soft tissue filler complications. Aesthetic Surgery Journal, 2021.
WOLLINA, U. Complications of aesthetic fillers. Dermatologic Therapy, 2021.
License
Copyright (c) 2026 RECIMA21 - Revista Científica Multidisciplinar - ISSN 2675-6218
This work is licensed under a Creative Commons Attribution 4.0 International License.
Os direitos autorais dos artigos/resenhas/TCCs publicados pertecem à revista RECIMA21, e seguem o padrão Creative Commons (CC BY 4.0), permitindo a cópia ou reprodução, desde que cite a fonte e respeite os direitos dos autores e contenham menção aos mesmos nos créditos. Toda e qualquer obra publicada na revista, seu conteúdo é de responsabilidade dos autores, cabendo a RECIMA21 apenas ser o veículo de divulgação, seguindo os padrões nacionais e internacionais de publicação.