- I'm answering a really serious topic today
about an uncommon
but serious complication of dermal fillers.
This is asked from Rebecca Bold,
one of our followers on Facebook.
And she asks about blindness as a result
of dermal filler injections,
that is dermal fillers causing blindness.
And she asks how can this be prevented and what do we do?
So yes, it is true.
It is a very rare and serious complication
but it is possible to go blind
from having dermal fillers done.
This is something that's always in the back of my mind
as a practitioner and something I'm always thinking about
every time a do a dermal filler
about the possibility of this and how I can avoid it
and also explaining this risk to patient
is something which is, I guess, not always done
but probably should be even though it's quite rare.
Basically what happens, just to give a quick summary,
is that fillers can be injected into the arteries
which supply the eye, the retina,
and basically the filler gets pushed back
along this artery to the back of the eye,
to the artery to the back of the eye
which supplies the back of the eye, the retina,
and as a result you get death of those cells
and loss of vision, usually in one eye.
Now this is all pretty scary.
It is extraordinarily rare, however,
and different studies report different numbers.
I've heard around 40 to 50 in one study,
approximately half of those
being as a result of dermal filler
and half of those as a result of fat transferred to the face
so injecting your own fat into the face.
Other reports have said up to 100 people in the world.
But my general feeling
is that this is possibly under reported
and maybe if people have a partial deficit
it's not reported or maybe these things in other countries
have gone unreported.
Maybe in countries
where there is not such tight regulations.
But basically the prevalence is low.
If you compare it to the number of dermal filler treatments
that go on in the world.
So you're looking at millions and millions
and millions of treatments
and the risk of blindness as a result of dermal filler
is in comparison to the number
which have actually been done is extraordinarily low.
But nonetheless, it's such a serious complication.
You know you walk in for some fillers hoping to look better,
hoping to feel better, and to have a complication like this
is life changing for the patient
and for the practitioner as well.
I've been very fortunate,
in my career of 12 years of injecting,
I haven't ever had a case of blindness
and I hope to never have one.
But it's something that is, it would be disastrous,
absolutely disastrous for everyone involved.
And that's why I'd thought I'd talk about this today
with you to explain to you that there is a risk of it
but it doesn't mean you shouldn't have fillers done.
It just means that you need to understand
that who you're going to and the techniques they're using.
So you need to make sure that who you're going to
understands the things that need to be done
to prevent this sort of complication from happening.
So that's the first thing.
And also I guess if it a risk for you
that you can't tolerate then I guess that
hopefully this video will have stopped you
from undergoing a procedure
which you would have undergone had you not know the risk.
And I've actually had a, just to put this in context,
I've had a patient who was actually blind in one eye
and wanted some nose filler.
And I said to him, "Look, I'm not doing it for you
"because basically if on the off chance that you do go blind
"in the good eye that you have
"you will be completely blind."
So I actually refused to do his treatment for him.
So you have to put,
you know you have to have an understanding
of the context of this within each patient as well.
Let's go into exactly the mechanism of how this happens.
So if you look at the face anatomically
it's full of arteries and veins.
In fact, we can't even imagine how many there are.
There are thousands
literally running all different parts of the face
supplying everything from the skin down to the bone.
These arteries traverse through different depths
and of course they're all sort of interconnected in a way.
So there's a lot of anastomosis,
which means basically interconnections
between one artery and another.
And what happens in instances where you get blindness
from dermal fillers that your filler
has actually been injected into an artery
and it passes,
usually backwards against the flow of the artery,
against the flow of the blood
and backwards into the arteries which cause,
which supply the back of the eye,
which then causes death of those retinal cells.
So you basically kill off the back of your cell
because it doesn't have a blood supply
due to blockage of that blood supply with a filler.
So quite scary stuff.
Very, very scary stuff.
And because we don't see the anatomy of the face
from the inside, we only get to see the skin,
the surface anatomy, we're basically injecting
without any visual guidance.
So we can't see, we can't use ultrasound
or some sort of imaging technology
to visualize the arteries.
It's too complex, it's impossible to do that.
So basically we inject without any knowledge
of exactly where the arteries are.
But we do have an idea but we can't precisely pinpoint
the artery in a certain person.
And remember, everyone is different
so arteries may run, for example, along the nasolabial fold.
In one person it may run outside the nasolabial fold
and one person it might run inside the nasolabial fold.
So you don't know where that main artery is going.
It could be either direction
or either side of the nasolabial fold.
So we can't be 100% specific as to the anatomy
for each person.
But there are sort of areas which are more risky than others
and for example the central part of the face
is very highly vascular.
And often that's why in Asian countries, for example,
where you get a lot of people who inject their noses
or around that area.
They often have a high incidence of blindness
in their countries because they inject so many noses
to make the nose taller and that's a very vascular area
which leads on to the eye.
So that is a risky area to inject, for example.
Because the more lateral we go,
the less likely we have blood vessels
that are associated with the eye area.
So the more centrally we are the more likely the risk.
So the key risky areas would be the forehead,
frown or glabella area, the nose, adjacent to the nose,
the nasolabial folds.
These are the key areas.
The facial artery runs up from the heart
up the side of the face, along the side of the nose,
through back to the back of the eye.
So you get a lot of vascular supply, arterial supply
through the central part of your face.
So certainly if you're looking at having any part
like those areas injected;
forehead, glabella or frown, nose, nasolabial folds;
then your risk is much higher.
The ironic thing about it is going back,
when we first started doing fillers,
I'm talking about 10, 12 years ago
and fillers were generally,
they were in the infancy back then
or certainly nowhere near as advanced as they are now,
the techniques anyway.
And pretty much patients used to come in and always say,
"Inject my nasolabial folds."
And they still do say that nowadays.
But we don't inject them as much
because generally we direct them to other areas
because filling the nasolabial folds
is not aesthetically an amazing place to fill.
But back then we used to say, we used to be good doctors
and listen to our patients and say,
"Okay, we'll fill your nasolabial folds for you."
Little did we know back then that the nasolabial folds
were actually one of the key areas
for vascular complications including blindness
'cause it's such a vascular area.
But we injected thousands and we were very lucky
to get away with no complications in this area
now in the history of doing this.
Actually what's happened in the past 10 years,
the knowledge and the awareness
of these sort of complications have increased and increased.
So it's interesting when we used to go back
just thinking of conferences you know,
cosmetic conferences, that I used to attend many years ago
there was never any talk about this
and now in more recent years
conferences often have a whole half day or whole section
that's associated with vascular complications.
Not just with blindness but with complications
of injecting filler into an artery.
And yes, there are just as a side point here,
there are other possible vascular complications
that you can get from injecting filler into an artery.
For example, you can block off an area of skin,
blood supply to an area of skin.
So that would cause death of the skin.
Which at worst could cause,
you're gonna need some sort of surgery
to put some new skin there,
put a skin graft there for example.
That would be also a very serious complication.
And I think the incidence of that
is actually a lot higher than incidence of blindness
as a result of dermal filler.
Now we'll go on to the next part
which is how do you treat blindness
as a result of dermal filler?
I'm talking more about the immediate management.
Now this might not be something necessarily
as relevant to you as a patient.
But it's interesting to know what the treatment is.
And as practitioners, we have very little experiences.
I have no experience in treating blindness
as a result of dermal filler because I've never had a case.
But as a whole because there's been so few cases,
we really don't have a lot of experiences with treating it
and the success of treating it, I believe,
has been very low.
So I'm not aware of many cases
which have actually been treated successfully
once the patient goes blind.
But I have spoken to a few of my colleagues
who are ophthalmologists
and one of the ophthalmologists I spoke to
said that the first thing you should probably try to do
is massage the eyeball to try and push that filler
out of the circulation.
So that could be a possible initial first step.
But really the key thing is
to try and get rid of that filler
in the artery in the back of the eye.
So what you'd really wanna do is use Hyalase
or hyaluronidase which is a filler dissolver.
So we commonly use this filler dissolver
for dissolving things like lumps or bumps or excess filler.
But this would be probably the number one thing you could do
to help avoid or help reverse blindness that has occurred.
And you actually need to get the dissolver
to the back of the eye.
So this is where it gets a bit scary.
So for the doctor involved, now interestingly
I think very few doctors
are actually trained in this technique.
I mean, I did some anesthetics back before I did cosmetics
and this technique's actually used
to get local anesthetic at the back of the eye
before you have a cataract surgery.
So it's the same technique
but instead of injecting local anesthetic
you actually inject dissolving agents.
So you can actually get,
you'd have to get a need, an injector,
right behind the eyeball.
So you'd have to go just in the orbit there
and go right behind the eyeball
and inject the dissolver right behind there
so with the hope that the dissolver would pass through
to the arteries that are blocked by the filler
and then resolve the impending death
of the retinal cells there.
So that would be the treatment,
the ultimate treatment for someone who goes blind.
It sounds absolutely crazy
and you could imagine the scenario
of someone having fillers done and then going blind
and then the doctor having to inject a needle
right to the back of the eye.
It's a bit like Pulp Fiction,
that scene where they have to give the adrenaline
straight to the heart.
I mean it would be absolutely terrifying, I think,
for both parties.
The treatment really is not something any of us will get to
or have to be involved with.
But probably more important for us
to know about is prevention.
So how do you prevent, as a doctor,
how do I prevent causing blindness with dermal fillers.
You've gotta think about it.
As painful as it is to think about, the consequences,
you have to sort of think about it in advance.
It has to be in the back of your mind at all times
when you're injecting dermal fillers.
Now I do explain, when I do inject risky areas,
I do explain the risk to my patients of blindness,
but it's sometimes a touchy area to touch upon
and you do have to put it into perspective for your patients
but I guess first thing would be
to make sure your patients understand the risk.
And that gives them an opportunity
to back out of that treatment
or to try something else, try other treatments or whatever.
So that's the first part.
Now the second part of the prevention
is the technique really.
So the technique that I use or your doctor uses
for injecting the dermal fillers.
Now because the face is filled with arteries
I wouldn't be surprised
if we're actually injecting into arteries
a small amount of filler now and then.
I wouldn't be surprised if that was the case
but I think the amount we inject
could possibly be too small to make any problems
or maybe it just gets in there and nothing happens.
So I think the first thing is is to inject slowly.
So you don't wanna be too quick on your injections.
That for me that means putting less pressure on the plunger
on the back of the plunger when I'm injecting.
So when I'm injecting I inject slowly,
don't put too much pressure on the back of the plunger,
and watch the patient, watch for any signs of pain
which can be associated
with injecting near an artery or vein.
So sometimes when you inject in your artery or vein
they get a bit of a twinge.
So if they have pain you would stop.
And injecting really slowly and watching the patient,
watching the skin, watching what happens as I inject.
And I think that's really important.
The next thing is to use cannulas in appropriate areas.
So where, especially in high-risk areas,
for example the glabella or the frown area,
if I have to inject that area then I use a cannula.
Which is basically a rounded tip needle.
So it's not sharp at the end, it's rounded
so if it hits against an artery it will hopefully
push past it.
As opposed to a needle which if you hit an artery
you may insert the needle into the artery.
So that would give you an intravascular injection.
So using a cannula would potentially avoid the artery.
Using a cannula can certainly help
with avoidance of arteries by slipping around them
but it doesn't mean that you will not inject,
it doesn't give you certainty
of not injecting into the artery.
So injecting into the direction of the artery
is probably the wrong thing to do.
So if you know an artery is running this way,
don't inject in that direction, you know?
So inject perpendicular to it not parallel to the artery.
'Cause you know it's gonna go,
we know the general direction of arteries.
So we can inject perpendicular to them rather than parallel.
So for the frown, we know the frown is a big artery
going up this way, we inject this way
to avoid cannulating basically,
or injecting into, like when you have a cannula in your hand
before you have an anesthetic or an operation.
You wanna avoid slipping the cannula or needle
into the artery.
So go perpendicular to it.
Now I think the most important thing is though
is for your practitioner to understand the anatomy
and the various risks associated with each area.
So if your doctor or nurse or injector
understands the anatomy of what they're doing
then it's probably going to be less likely
that you'll have a problem.
Because they know where the important structures run
as a general rule and they try to avoid those areas.
Okay, so I hope that was not too frightening a talk for you.
It was meant to be educational and not to scare you.
But I hope that I've informed you better
about the possible risks and as a result
maybe you can choose more wisely
whether you want to have fillers done or not
or you can pick an appropriate practitioner
with appropriate experience.
Or even ask them the right questions.
If you have an existing practitioner already,
ask them the questions about what they know.
Maybe I've helped you in some way.
So thank you for your time, it's been a fairly long video.
But thank you for your time and listening to me.
I hope that this helps you in some way in the future.