Vascular Occlusion Following Low-volume Chin Filler: Successful Management With High-dose Pulsed Hyaluronidase

Summary:

Vascular occlusion is an uncommon but serious complication of hyaluronic acid filler injections. If not recognized and managed early, it can lead to ischemia and even skin necrosis. Timely diagnosis and intervention are therefore crucial to minimize tissue damage and avoid long-term consequences. With the rising popularity of chin augmentation procedures, awareness of these rare complications is increasingly important for aesthetic practitioners. This report describes the case of a 54-year-old woman who presented with increasing pain, skin discoloration, and livedo reticularis approximately 24 hours after she had received hyaluronic acid filler injections in her chin. Clinical examination revealed delayed capillary refill time and mottled skin changes across the chin and neck. The high-dose pulsed hyaluronidase protocol was initiated 25 hours after injection. A total of 2850 IU of hyaluronidase was administered in a series of doses during a 15-hour period. Alongside enzyme therapy, the patient received oral aspirin, warm compresses, and gentle massage. Her symptoms improved quickly, and by day 21, she had fully recovered with no scarring or volume loss. This case highlights that even minimal filler volumes can trigger vascular occlusion. Preparedness to identify the vascular complications and apply the high-dose pulsed hyaluronidase protocol is essential to ensure full recovery and safeguard patient outcomes.

Hyaluronic acid fillers are routinely used in aesthetic medicine to restore volume and enhance facial contours. Among the common areas treated is the chin, a central component of facial harmony.¹ Although generally safe, filler injections carry the rare but serious risk of vascular occlusion, especially in anatomically complex zones such as the chin.² This area is served by a dense arterial network—including the submental, mental, and inferior labial arteries—all of which can be vulnerable to inadvertent injection or compression. In some cases, retrograde embolization may even lead to more severe ischemic events,³ affecting the tongue⁴ or the floor of the mouth. This case report, developed by CARE guidelines, details the diagnosis and treatment of a vascular event following chin filler injection and the successful application of the high-dose pulsed hyaluronidase (HDPH) protocol.

PATIENT INFORMATION

The patient was a 54-year-old woman who presented seeking chin enhancement to improve facial balance. She had undergone 2 similar procedures in the past without complications, the most recent being 2 months prior. Her general health was good, with no comorbidities, medication use, or known allergies.

CLINICAL FINDINGS

During the treatment, a total of 1 mL of hyaluronic acid filler was injected into the patient’s face, with 0.7 mL administered to the cheeks and 0.3 mL to the chin. Of the chin dose, 0.1 mL was placed at the chin apex and 0.2 mL was distributed across the lateral areas. A sharp needle was used for injection in the supraperiosteal plane. The injection at the midline was met with resistance and caused immediate discomfort, prompting the clinician to halt further injection at that point. The lateral injections were completed without any adverse response.

Approximately 6 hours after the injection, the patient began experiencing tightness in the chin area. By 24 hours, she developed worsening pain and mottled bluish discoloration (Fig. 1). On examination, livedo reticularis was evident over the chin and upper neck. Capillary refill time (CRT) exceeded 2 seconds, and the area was tender on palpation. There were no signs of ischemia in the oral cavity, tongue, or palate.

Fig. 1.

Twenty-four hours postinjection—bruising, mottled discoloration, and livedo reticularis on neck.

TIMELINE

The procedure was performed at time 0. Discomfort and tightness started at the 6-hour mark. By 24 hours, clinical signs of ischemia were fully evident. The patient presented to the clinic when ischemic signs became apparent, and HDPH was initiated immediately. The HDPH protocol was initiated at 25 hours with an injection of 600 IU of hyaluronidase (2 mL out of 1500 IU diluted in 5 mL of saline). This dose was followed by additional doses of 900 IU at 28 hours, 600 IU at 30 hours, and 750 IU at 40 hours, totaling 2850 IU (Fig. 2). Administration of hyaluronidase to the chin and neck area resulted in enhanced tissue perfusion, indicating the resolution of the vascular occlusion. CRT was less than 2 seconds. The patient also received aspirin, warm compresses, and massage. Pain resolved by day 3, discoloration improved significantly by day 14, and full recovery was achieved by day 21.

Fig. 2.

After administering a total of 2850 IU of hyaluronidase to the chin and neck area, improved perfusion was noted due to the relief of vascular occlusion. CRT was less than 2 seconds.

DIAGNOSTIC ASSESSMENT

The diagnosis of vascular occlusion was made clinically, based on the patient’s history, acute onset of pain, symptom progression, and the presence of livedo and delayed capillary refill. No imaging was performed.

THERAPEUTIC INTERVENTION

Treatment was initiated 25 hours after filler injection using the HDPH protocol when the patient reported to the clinic the following day. Injections were delivered at the subcutaneous and supraperiosteal levels in the affected area. The total dose administered was 2850 IU during a 15-hour period. Supportive measures included oral aspirin (75 mg daily), warm compresses, and gentle massage. The patient’s condition began improving within 12 hours of starting treatment.

FOLLOW-UP AND OUTCOME

By day 3, the pain and delayed capillary refill had resolved. Day 6 postinjection showed progressive resolution of ischemic changes (Fig. 3). Residual purplish erythema and ecchymosis remain visible over the mentum, with faint yellowish-brown discoloration extending inferiorly along the anterior neck. The discoloration faded progressively and had resolved entirely by day 14. The patient achieved complete recovery by day 21 (Fig. 4). There was no visible residual scarring or loss of volume. At her 3-month follow-up, she remained complication-free.

Fig. 3.

Day 6 posthyaluronidase injection, showing significant reduction of ecchymosis and soft tissue edema.

Fig. 4.

Clinical appearance on day 21 posthyaluronidase injection, showing complete recovery of skin tone and tissue architecture, with no residual signs of vascular compromise.

DISCUSSION

This case offers valuable clinical insights into the risks and management of vascular occlusion, even when small amounts of filler are used. A total of only 0.3 mL of filler was injected into the chin, reinforcing the idea that even minimal filler volumes can cause significant ischemic events, especially in high-risk zones such as the midline chin. The presence of pain, discoloration, and delayed CRT should raise immediate clinical suspicion, regardless of filler volume.

The key to successful management lies in recognizing problems early and taking immediate action. Injectors must be prepared to treat such complications promptly, even in resource-limited settings where diagnostic imaging such as ultrasound is not available. In this case, diagnosis and intervention were guided entirely by clinical findings.

This case reinforced several essential principles in the prevention and management of vascular occlusion following dermal filler injection. First and foremost, it is essential to understand that the chin is a vascular danger zone. The use of sharp needles increases the risk of inadvertent vascular penetration. To mitigate this risk, it is advisable to use blunt-tipped cannulas (25G or larger) in high-risk areas, as they have been shown to reduce the likelihood of intravascular injection significantly.

Prevention strategies must also include technique modifications, such as slow injection speed, minimal bolus size (ideally <0.1 mL per deposit), and a deep supraperiosteal injection plane to avoid injury to superficial vessels.⁵ Aspiration before injection is a standard precaution, though its reliability remains debated due to variability in technique and vessel collapse. Despite its limitations, it may offer an additional safety check in combination with other strategies.⁶

Anatomical knowledge plays a foundational role in safe injection practice.⁷ The mental artery, which exits the mental foramen and supplies the chin and lower lip, lies in close proximity to common injection sites. It forms anastomoses with the inferior labial artery, which in turn connects to the submental artery, running along the lower border of the mandible. These arterial networks can facilitate retrograde filler migration, thereby increasing the risk of ischemic complications beyond the immediate area, including the floor of the mouth and tongue, through connections with the lingual arteries. Point-of-care ultrasound is being increasingly explored for confirming vascular occlusion and guiding hyaluronidase injections.⁸

In this case, prompt diagnosis and the use of the HDPH protocol were instrumental in achieving a positive outcome. The HDPH protocol applied in this case was first described by DeLorenzi⁹ and has since been validated in subsequent reviews and case reports. The HDPH protocol involves administering high doses of hyaluronidase in pulses to dissolve the filler and restore perfusion.¹⁰ Clinical improvement often begins within hours, as seen in this patient.

This case underscores that even very small volumes of filler, such as 0.3 mL in the chin, could precipitate vascular occlusion in high-risk anatomical zones. Clinicians must monitor patients carefully following filler injection and maintain a low threshold for intervention when early signs of vascular compromise are observed. Successful reversal using the HDPH protocol demonstrates that protocol-based intervention, even if started late, can restore perfusion and prevent long-term sequelae.

PATIENT PERSPECTIVE

The patient was understandably anxious when symptoms began but felt reassured by the swift response and was pleased with the resolution of her symptoms.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Written informed consent was obtained from the patient for the publication of this case report and the use of clinical images.