Filler necrosis

Filler necrosis is tissue damage that can develop when the blood supply to part of the skin is severely reduced following a dermal filler treatment. It is usually associated with a vascular occlusion, where filler enters a blood vessel or restricts blood flow around it.

This complication is rare, but it requires urgent medical assessment. Warning signs can include unusually severe or increasing pain, pale or mottled skin and an area that feels colder than the surrounding skin.

Contact your treating practitioner or clinic immediately if you notice these symptoms. Do not wait to see whether they improve on their own.

Important: sudden loss of vision, severe eye pain, weakness, confusion or difficulty speaking requires emergency medical help. Go to A&E or call 999.

Read more about filler treatment.

How does filler necrosis develop?

The problem begins with a vascular occlusion. This means that blood flow through a vessel has been reduced or blocked. Filler may have entered the vessel directly, or pressure from the injected material may be affecting it from outside.

Without an adequate blood supply, the skin receives less oxygen. If circulation is not restored promptly, the affected tissue can become damaged.

Vascular complications can occur in any treated facial area. Particular care is required in areas with complex blood vessels, including:

• the nose and nasal bridge;

• the area between the eyebrows;

• the nasolabial folds;

• the lips and surrounding area;

• the forehead and temples.

Knowledge of facial anatomy, careful injection techniques and a clear emergency protocol can reduce risk, but cannot remove it completely.

Read more about what fillers are.

Symptoms of filler necrosis

Symptoms may appear during treatment, shortly afterwards or develop over the following hours. The appearance can vary between people and across different skin tones.

Early warning signs

Possible early signs include:

• sudden whitening or unusual paleness of the skin;

• severe, burning or increasing pain;

• skin that feels noticeably cold;

• slow colour return after pressure is applied;

• symptoms extending beyond the injection point.

Pain may occasionally be absent or delayed, particularly when a local anaesthetic has been used. Skin colour and temperature changes should therefore not be ignored.

Changes that may develop

As circulation remains restricted, the skin may become dusky, blue, purple or mottled. A lace-like or marbled pattern can develop across the affected area.

On brown or black skin, early colour changes may be less obvious. Increasing pain, altered sensation, coolness and differences compared with the surrounding skin can also be important warning signs.

Signs of tissue damage

Without prompt treatment, the skin may become darker, numb or damaged. Blisters, broken skin or wounds are later signs and require medical care.

Do not wait for these advanced symptoms before contacting the clinic.

Read more about filler complications.

Normal swelling or a possible vascular occlusion?

Some swelling, tenderness, redness and bruising are common after dermal fillers. These effects should normally remain manageable and gradually settle.

More likely to be a normal reaction

• mild or moderate swelling;

• a localised bruise;

• slight tenderness around the injection point;

• skin that remains its usual temperature;

• symptoms that gradually improve.

Possible warning signs

• white, grey, unusually pale or dusky skin;

• blue, purple or mottled discolouration;

• severe or increasing pain;

• skin that feels cold;

• numbness or altered sensation;

• symptoms that spread or worsen rather than settle.

It can be difficult to distinguish an early vascular complication from an ordinary post-treatment reaction. Contact the treating practitioner immediately when symptoms appear unusual, painful or progressive.

Read more about filler side effects.

What should you avoid doing?

Do not wait for the symptoms to disappear by themselves.

Avoid massaging, pressing or repeatedly touching the area unless the treating clinician specifically instructs you to do so. Do not apply heat, ice, creams or home remedies without medical advice.

Do not attempt to obtain or administer hyaluronidase yourself. Assessment and treatment must be performed by an appropriately trained healthcare professional.

Photographs may help the practitioner understand how the skin is changing, but taking photographs should not delay contacting the clinic.

How quickly should you act?

Prompt assessment is important whenever a vascular occlusion is suspected. Treatment is intended to restore circulation before significant tissue damage develops.

Contact the clinic immediately rather than waiting until the following day. The practitioner should explain where and how you will be assessed.

Use NHS 111 when you need urgent advice and cannot reach the clinic. Sudden loss of vision, severe eye pain or symptoms such as facial weakness, arm weakness or speech difficulty require immediate emergency help through A&E or 999.

How is filler necrosis treated?

Treatment depends on the filler material, the affected area, the examination findings and how long the symptoms have been present.

The clinician may assess the colour, temperature and circulation of the skin and monitor whether the affected area is changing.

When a hyaluronic acid filler is involved, hyaluronidase may be administered to break down the filler. More than one assessment or treatment may be needed. Hyaluronidase does not dissolve every type of filler.

Additional care may be used to support circulation and manage damaged skin. Complex cases, eye symptoms or neurological symptoms may require urgent referral to hospital specialists.

Treatment decisions must be made by the clinician assessing the person. Online information cannot determine the appropriate treatment or dosage.

Read more about dissolving fillers.

Can the skin recover?

Recovery depends on the extent and duration of the reduced blood supply, the vessels involved and how quickly treatment begins.

When the problem is recognised and managed early, the affected skin may recover without permanent damage. A prolonged interruption to circulation can lead to wounds, pigment changes or scarring.

Follow-up may be required even after the blood supply appears to have improved. The clinician can monitor healing and arrange wound care or specialist referral where necessary.

The possibility of vascular occlusion is one reason to choose a practitioner who understands facial anatomy and has a documented plan for recognising and managing filler complications.

Frequently asked questions about filler necrosis