Aesth Plast Surg
https://doi.org/10.1007/s00266-023-03722-3
ORIGINAL ARTICLES
Updated Filler Emergency Kit: Next-Generation Emergency
Solution
Nabil Fakih-Gomez1 • Carmen Alejandra Porcar Plana1 • Alba Verano-Garcia1
Cristina Muñoz-Gonzalez1 • Jonathan Kadouch2
Received: 28 April 2023 / Accepted: 17 October 2023
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2023
Abstract
Introduction: The rising popularity of facial filler injec-
tions has corresponded with an increase in reported com-
plications. While a filler emergency kit was previously
introduced, advancements in the field have highlighted
certain limitations, prompting the development of the
updated filler emergency kit (UFEK).
Methods: The authors conducted literature research up to
February 2023, focusing on PubMed and open web sear-
ches for articles referred to filler emergent complications:
vascular occlusion, blindness and anaphylaxis. Approxi-
mately 1200 articles were obtained from PubMed and other
sources, and 45 articles were reviewed.
Results: The developed UFEK protocol delineates specific
interventions meticulously tailored to address diverse
emergent scenarios linked to soft tissue fillers complica-
tions. This protocol emphasizes the urgent requirement for
timely and personalized interventions.
Conclusion: The UFEK offers a standardized, compre-
hensive and effective approach. This work contributes to
the responsible and informed progression of the field of
aesthetic medicine, providing more value and safety, both
for clinicians and patients.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
& Nabil Fakih-Gomez
info@drnabilfakih.com
1
Department of Facial Plastic and Cranio-Maxillo-Facial
Surgery, Fakih Hospital, Khaizaran, Lebanon
2
Practice for Aesthetic Dermatology, ReSculpt Clinic,
Amsterdam, The Netherlands
FAT INJECTION
•
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Fillers
Filler complications
Complication
protocol
Filler emergency kit
Introduction
Cosmetic procedures are a worldwide trend, with botuli-
num toxin and fillers being the most popular cosmetic
procedures. The most commonly used fillers are hyaluronic
acid (HA), followed by autologous fat [1]. Although these
procedures are generally considered safe, their increased
frequency (increasing by 42% from 2020 to 2021) [2] is
unfortunately accompanied by an increase in adverse
events [3]. In the literature, the frequencies of vascular
complications after fillers are unclear but estimated to be
between 1:2000 and 1:10000 (0.05–0.01%) [4].
Common complications include edema, erythema,
granulomas, noninflammatory and inflammatory nodules,
pigmentation changes, infections, abscesses, abnormal
scarring, and paresthesia [5]. While these reactions are
usually transient, there are other complications that are
considered emergencies due to their potential irreversibil-
ity, such as anaphylaxis and vascular occlusions [6–8].
These vascular complications have severe consequences,
potentially resulting in persistent skin necrosis, ophthal-
moplegia, permanent unilateral or bilateral vision loss, and
even stroke [7, 8].
The most important factor for avoiding serious com-
plications is prevention, which includes three fundamental
pillars for the injector: (1) deep anatomical and product
knowledge, (2) early detection, and (3) systematic action.
Despite the importance of systematic action in these
123

emergencies, there is little information in the literature [9].
Previously published FEK emergency kits have some
limitations [10], such as differentiation between acute and
late occlusion and different approaches depending on
whether it is an embolism or vasospasm. In this work, we
present an updated filler emergency kit (UFEK), which
represents a new approach to emergencies associated with
fillers, with the goal of providing more value and safety, for
both clinicians and patients.
Conventional classification suggests that complications
should be categorized as early (less than 14 days), late (14
days to 1 year), and delayed (more than 1 year) [11].
However, the authors propose to classify emergency filler
complications as early vascular occlusion (from immediate
onset during injection up to 6 h, when tissue is assumed to
still being viable) [12], late vascular occlusion (after 6 h,
when skin viability is compromised) [12], blindness and
anaphylaxis.
The importance of prevention, early detection, and
systematic action is emphasized in this work. Existing
emergency kit limitations are discussed, leading to the
development of an advanced approach to filler emergencies
with the UFEK.
Figure 1 Updated filler emergency kit (UFEK)
123
Aesth Plast Surg
Methods
Literature research was performed to gather information on
the treatment of complications after the injection of soft
tissue fillers up to February 2023 and was limited to pub-
lications in English. The search was focused on PubMed
and open Web searches. Approximately 1200 articles were
obtained by using the terms ‘‘filler complications’’, ‘‘in-
jectable filler complications’’ or ‘‘hyaluronic acid filler
complications.’’ We selected 45 papers based on the rele-
vant, complication protocol-related content of the articles
from PubMed and other sources.
The authors focused on reports of complications arising
from emergent/urgent situations following the use of HA
injectables for this review. This includes filler embolization
resulting in impending skin necrosis, blindness, and
anaphylaxis.
Results
The UFEK (Fig. 1) gathers the necessary material to
address four different emergent scenarios: acute and late
vascular occlusion, blindness, and anaphylaxis, as sum-
marized in Table 1.
Aesth Plast Surg

Table 1. The updated filler emergency kit (UFEK)

ACUTE VAE LATE VAE BLINDNESS ANAPHILAXIS

Hyaluronidase bole 1500 units
(minimum 4 boles)
0.9% NaCl 250 ml
Ultrasound scanner
Aspirin tablets 100 mg
Dexamethasone 8 mg IM
Prednisolone 20 mg
Hydrocorsone 100 mg IV
Ibuprofen 600 mg
Amoxicillin-clavulanate 875 mg/125 mg
Timolol drops
Brimonidine drops
Brinzolamide drops
Dilazem 30 mg
Pentoxifylline 400 mg
Mannitol 20% 250ML
Acetazolamide 250 mg
Clostripepdase An ointment
(collagenase)
Promethazine (25 mg/ml) 2 ml IV
Adrenaline 1 mg/ml 1:1000
Salbutamol 100 mcg/dose
Connectors
Angiocath 22-G x 25-mm
Syringes 1-cc, 3-cc, 5-cc
(2 of each)
Cannula 25-G x 38-mm
Cannula 25-G x 50-mm
Needles 33-G x 9-mm, 23G x 25 mm,
18-G x 38-mm (2 of each)
Sterile swab
Sterile gloves
Povidone-iodine prep pads
Lidocaine 2% 50 ml
Pulse oximeter

Included items in green, excluded items in red. VAE vascular adverse event

Discussion product used [13], timely identification of complications

Nonsurgical cosmetic procedures are a growing trend
worldwide. Fillers are becoming an increasingly common
practice in aesthetic medicine; therefore, their adverse
effects are also becoming more frequent. These compli-
cations can range from mild swelling and bruising to vas-
cular occlusion, anaphylaxis, or blindness.
Critical factors for filler complications lie in preventive
measures, which comprise three fundamental principles for
the injector: proficient understanding of anatomy and the
[14], and consistent strategy implementation [10].
Highlighting the need for a standardized approach to
manage an emergency resulting from filler injection, the
authors propose an updated kit to enable prompt and safe
responses to this stressful event.
Hyaluronic acid (HA) is the most commonly used filler
due to its advantage that it can be dissolved with hyalur-
onidase (HYAL) [15]. Therefore, in the case of a vascular
adverse event, the use of HA remains the first treatment to
consider [7]. Even in occlusion due to non-HA filler,

123

HYAL can be advantageous due to its edema-reducing
effects, decreasing occluding vessel pressure [16].
The estimated dose of HYAL varies depending on the
thickness and number of areas involved; based on the old
treatment protocol, proper HYAL dose is approximately
300–600 units of HYAL, whereas if we base it on the new
modality of ‘‘high-dose pulsed HYAL’’, it is approximately
500 units, every hour, for each localized affected area as
described by deLorenzi [17]. Reevaluation and reinjection
are performed until perfusion returns to normal. Ultrasound
(US)-guided HYAL injection has been shown to be more
effective [18, 19].
Two variations to this posology are the nose, where 900
units are used, and in the case of blindness, where retrob-
ulbar HYAL injection should be considered. However, there
is no consensus about retrobulbar HYAL injection in cases
of blindness, with some articles in favor [20–23] and some
articles against it [24–26]. Proper retrobulbar HYAL injec-
tion dosage is estimated to be approximately 800 units [26],
although more units have been applied in some cases [27].
Regarding antiplatelet and anticoagulant treatment, it is
important to consider terminal artery embolization and
vascular tree vasospasm as the causative agents of arterial
occlusion [28]. The skin does not contain terminal arteries;
instead, the flow is controlled by compensation mechanisms
of small vessels that are closed or have low flow in the basal
state and increase their flow according to the needs of the
supplied territory [29]. These vessels are called choke ves-
sels [28] and provide double protection against arterial filler
occlusion: (1) some choke vessels of the ischemic area will
dilate, compensating for the blood supply, and (2) vasos-
pasm occurs in vessels acting as a barrier and preventing the
embolus from arriving at a terminal artery [18]. What trig-
gers vasospasm in choke vessels is unknown [30], but HA
has been shown to be a strong inflammatory response
inductor within blood vessels [31]. This new concept of
choke vessel spasm is the major determinant of the location
and extent of tissue necrosis following inadvertent hya-
luronic acid intraarterial injection [29].
As the choke vessel mechanism causes ischemia within
the vascular territory but also blocks HA embolus, pre-
venting irritation spread to other territories, the use of
vasodilators such as nitroglycerin, phosphodiesterase inhi-
bitors or prostaglandin analogs is not included in early
occlusion treatment [29]. However, an antiplatelet agent
such as acetylsalicylic acid (AAS) is included in the kit, as
blood fluidization improves perfusion in the affected
territory.
In late occlusions, vasodilators should be considered
after HYAL treatment and positive pinprick test results or
HA embolus dilution confirmed by ultrasound [32, 33]. In
the UFEK, calcium channel blockers, such as diltiazem, are
considered vasodilators. Phosphodiesterase inhibitors are
123
Aesth Plast Surg
not included because of secondary effects but may be
considered [34]. Pentoxifylline is also included because of
its beneficial effect on improving ischemic symptoms [35].
In late vascular occlusion, application of clostridium A
collagenase ointment once daily has been demonstrated to
enhance wound healing by selectively removing necrotic
tissue without affecting healthy skin [36].
Occlusion of the ophthalmic artery occurs because of
HA embolism via retrograde from the supratrochlear,
supraorbital, and dorsal nasal artery [37]. In this case,
vasodilators could be useful since they could move the
embolus to a more distal branch, causing less ischemic
damage [38], although this is not proven. To improve
ocular perfusion and dislodge the embolus, it is important
to decrease intraocular pressure [8, 39]. With this purpose,
triple topical hypotensive therapy (timolol, brimonidine,
and brinzolamide), oral acetazolamide, and intravenous
mannitol are included.
Vascular occlusion can compromise blood flow and
nutrient supply to the affected area, which weakens the
immune system and increases invasive infection [40].
Polymicrobial (staphylococci, streptococci, enterococci,
E. coli, and other gram-negative bacteria) infections are
common, with Staphylococcus aureus being the most fre-
quently implicated pathogen in vascular occlusion-related
infections [40]. Based on its broad spectrum coverage,
amoxicillin-clavulanate would be indicated for empiric
treatment, and in cases of suspected methicillin-resistant S.
aureus (MRSA), vancomycin should be considered [41]. In
early vascular occlusion, which is considered to be diag-
nosed and resolved at the moment of intervention, no
ambulatory antibiotic is needed.
Decreasing the inflammatory component with systemic
corticosteroids is recommended in emergent cases
[16, 42, 43]. Intramuscular (IM) administration is supposed
to result in fast and complete absorption with high absolute
bioavailability [44], so it is indicated for emergent com-
plications. Intravenous (IV) hydrocortisone will be added
in anaphylaxis [45]. For ambulatory treatment in late
occlusion, we included prednisolone tablets [9].
Anaphylaxis is a life-threatening type I hypersensitivity
reaction [45]. The first step in anaphylaxis cases is to
administer IM adrenaline. Apart from the IV corticos-
teroids mentioned, antihistamines and salbutamol should
be considered [45].
We present a revised application kit protocol, specifying
each scenario: acute vascular occlusion, late vascular
occlusion, blindness, and anaphylaxis:
Acute Vascular Occlusion
Stop the injection immediately once signs of vascular
occlusion appear, which include pain, pallor, or blanching
Aesth Plast Surg
of the skin. Dilute 1500 U HYAL in 5 ml of NaCl,
obtaining 30 U HYAL per 0.1 ml. Inject 500 U HYAL
ultrasound guided subcutaneously per area of vascular
occlusion. Reevaluation and HYAL reinjection were per-
formed each hour until perfusion returned to normal.
Embolus dilution is confirmed by the pinprick test or
ultrasound. Administer aspirin 300 mg sublingual and 100
mg every 24 h. Administer IM dexamethasone. Give
ibuprofen 600 mg every 8 h. Monitor the patient for
24–48 h to ensure that the occlusion was resolved.
Late Vascular Occlusion
Dilute 1500 U HYAL in 5 ml of NaCl, obtaining 30 U
HYAL per 0.1 ml. Inject 500 U HYAL US guided sub-
cutaneously per area of vascular occlusion. Administer
aspirin 300 mg sublingual and 100 mg every 24 h.
Administer IM dexamethasone. Prednisolone 20 mg daily,
ibuprofen 600 mg, and amoxicillin-clavulanate 875 mg/
125 mg every 12 h are given. Reevaluation and HYAL
reinjection are to be done each hour until perfusion returns
to normal. Embolus dilution is confirmed by the pinprick
test or ultrasound. Once embolus dilution is confirmed,
diltiazem 30 mg and pentoxifylline 400 mg can be used.
Collagenase ointment should be applied daily. Hyperbaric
oxygen chamber therapy at 2–3 atm (1:30 h/7–10 days) is
recommended. Patient care wound and revision should be
daily.
Blindness
Once visual acuity is affected, there are 90 min to act with
the minimum sequelae. Ocular hypo tensors are given:
mannitol IV 250 ml in 1 h, acetazolamide orally, and
timolol, brimonidine, and brinzolamide drops are applied.
Ocular massage may decrease intraocular pressure. If the
doctor is experienced in retrobulbar injection, retrobulbar
800 U HYAL injection can be performed slowly in the
lower temporal third of the orbit, although there is no
evidence of its effectiveness. Administer aspirin 300 mg
sublingual every 24 h, IM dexamethasone, ibuprofen
600 mg every 8 h are given. Vasodilators can be consid-
ered, although there is no evidence of their effectiveness.
Refer to ophthalmologist for more specialized maneuvers
to decompress the anterior chamber.
Anaphylaxis
The objective is to stabilize the patient and refer them to
the emergency department. IM adrenaline 1 mg/ml
(1:1000), IM dexamethasone and IV hydrocortisone were
administered. Administer inhaled salbutamol and promet-
hazine (25 mg/ml) 2 ml by IV.
Conclusion
The increasing popularity of cosmetic procedures, partic-
ularly fillers, has led to a corresponding increase in adverse
events, including severe complications such as anaphylaxis
and vascular occlusions. Prevention, early detection, and
systematic action are critical factors in managing these
emergencies. It is imperative to develop individualized
protocols for each situation, providing enhanced value and
safety to both clinicians and patients. Limitations of
existing emergency kits have led to the development of
UFEK, which provides a standardized approach to
managing emergencies associated with fillers. The UFEK
represents a valuable tool for clinicians and patients in the
management of emergencies associated with fillers. With
this work, it is hoped that the field of aesthetic medicine
will be able to continue to evolve in a positive and
responsible manner.
Acknowledgements N.F.G., C.A.P.P., C.M.G., and J.K. were
involved in the hypothesis/clinical observation. N.F.G., C.A.P.P.,
A.V.G., C.M.G., and J.K contributed to the study design/methodol-
ogy. N.F.G., C.A.P.P., A.V.G., and C.M.G. contributed to the
research/data assessment. N.F.G., C.A.P.P., A.V.G., and C.M.G.
analyzed the data. N.F.G., C.A.P.P., A.V.G., C.M.G., and J.K. wrote
the paper.
Funding None of the authors received any funding or financial
support for the content of this article.
Declarations
Conflict of interest The authors N.F. and J.K. are both consultants
for Merz Aesthetics (Frankfurt, Germany).
Human or Animal Rights This article does not contain any studies
with human participants or animals performed by any of the authors.
Informed Consent For this type of study, formal consent is not
needed.
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