Introduction

Every aesthetic injector encounters post-treatment discoloration at some point. While most cases represent benign bruising, a vascular occlusion—though rare—requires immediate recognition and management to prevent tissue necrosis or vision loss. Distinguishing between these two presentations is one of the most critical clinical skills in aesthetic medicine. This guide provides a comprehensive overview of how to tell the difference between a bruise vs. vascular occlusion, what symptoms to look for, and evidence-based management strategies, as covered in Empire On-Demand's advanced filler complication courses.

Why Differentiating Matters

Bruising is a normal, self-limiting event after dermal filler injections. In contrast, a vascular occlusion is a medical emergency caused by compromised blood flow to skin or deeper tissues—often due to accidental intravascular injection or external compression. Early recognition dramatically improves outcomes.

Understanding Post-Injection Bruising

Bruising occurs when a small capillary or vein is punctured during injection, leading to localized bleeding under the skin.

Key features:

• Appears within hours post-procedure.
• Purple, red, or blue discoloration that blanches normally under pressure.
• May feel mildly tender but not painful.
• Typically improves over 3–7 days, changing color as it heals.

Management:

• Apply cold compress immediately post-procedure.
• Topical arnica or vitamin K creams may accelerate recovery.
• Avoid NSAIDs, alcohol, or blood-thinning supplements for 48 hours.

Bruising is common around high-vascular zones such as the periorbital, perioral, and nasolabial regions.

Understanding Vascular Occlusion

A vascular occlusion (VO) occurs when filler is inadvertently injected into or compresses an artery, obstructing blood flow. This can lead to ischemia, tissue necrosis, or even blindness if not treated promptly.

Mechanism:

• Intravascular injection: Product enters arterial lumen and blocks perfusion.
• External compression: Filler bolus presses on an adjacent vessel.

High-risk areas:

• Glabella and nasal dorsum (supratrochlear, dorsal nasal arteries).
• Nasolabial fold (facial and angular arteries).
• Lips (superior and inferior labial arteries).
• Tear trough and periorbital area (infraorbital and ophthalmic branches).

Clinical Differences: Bruise vs. Vascular Occlusion

Recognizing subtle differences between these two presentations is vital for timely intervention.

Early Warning Signs of Vascular Occlusion

Injectors must act immediately if any of the following occur during or after a filler procedure:

• Sudden blanching or whitening of the skin.
• Severe pain or pressure disproportionate to injection.
• Cool or mottled skin appearance.
• Livedo reticularis pattern (marble-like discoloration).
• Delayed capillary refill (>3 seconds).
• Vision changes (blurry vision, scotoma, eye pain, or blindness).

Immediate Management of Vascular Occlusion

Vascular occlusion is a time-sensitive event. Early recognition and intervention within minutes are crucial to avoid ischemic injury.

Step 1: Stop Injection Immediately

Cease product delivery as soon as blanching or pain occurs.

Step 2: Massage and Warm Compress

Apply firm massage and warm compress to promote perfusion.

Step 3: Administer Hyaluronidase (If HA-Based Filler)

• Inject 150–300 units (or more) of hyaluronidase directly into and around affected areas.
• Use high-dose pulsed technique every 15–30 minutes until improvement.

Step 4: Promote Vasodilation

• Apply nitroglycerin paste 2% sparingly to enhance blood flow.
• Avoid excessive use to prevent systemic hypotension.

Step 5: Aspirin Administration

Give 325 mg aspirin (if no contraindication) to reduce platelet aggregation.

Step 6: Oxygen and Supportive Care

Provide supplemental oxygen; monitor vitals and patient comfort.

Step 7: Ophthalmic Emergency (If Vision Symptoms Present)

If vision loss occurs:

• Call for immediate ophthalmology referral or ER transfer.
• Perform retrobulbar hyaluronidase injection if trained and indicated.

Empire’s Advanced Filler Complications and Emergency Management course provides hands-on simulation and hyaluronidase dosing protocols for these events.

Documentation and Follow-Up

Following any suspected occlusion:

1. Document onset, symptoms, and management steps in detail.
2. Photograph affected area pre- and post-treatment.
3. Schedule follow-up within 24 hours to monitor perfusion and healing.
4. Provide patient education and reassurance with ongoing support.

Prevention Strategies for Injectors

1. Know your anatomy.
Map vascular pathways and danger zones for each region.

2. Use proper technique.

• Inject slowly and with minimal pressure.
• Always aspirate before injecting filler (especially in high-risk zones).
• Prefer microcannulas when appropriate.

3. Limit bolus size.
Small aliquots (<0.1 mL) reduce risk of vessel compression or embolization.

4. Observe patient feedback.
Unusual pain, blanching, or visual changes warrant immediate cessation.

5. Keep hyaluronidase accessible.
Clinics should maintain an emergency kit with hyaluronidase, aspirin, and nitroglycerin paste.

Case Scenario: Bruise vs. Occlusion in Practice

Patient A: Mild redness and bruising 4 hours post-lip filler. Warm to touch, no pain, capillary refill <2s → Benign bruise.
Patient B: Immediate blanching and sharp pain in nasolabial area during injection, followed by cool mottling → Vascular occlusion—emergency protocol initiated.

Conclusion

Differentiating a bruise from a vascular occlusion is a fundamental safety skill for all injectors. While bruising is benign and self-limiting, occlusion represents an urgent ischemic event requiring rapid action. The best outcomes depend on early recognition, immediate management, and proper training. Through Empire On-Demand’s advanced injection safety courses, clinicians learn to identify early warning signs, administer emergency protocols, and confidently manage complications to ensure patient safety and professional excellence.

FAQs

1. How can I tell if it’s a bruise or an occlusion?
A bruise appears red/purple and fades; occlusion shows blanching, pain, and cool skin.

2. How soon does a vascular occlusion appear?
Typically within minutes of injection.

3. Does bruising hurt as much as an occlusion?
No, bruising causes mild tenderness; occlusion pain is severe and burning.

4. Can bruising mimic occlusion?
Superficial bruising can cause discoloration but doesn’t show mottling or blanching.

5. What’s the first step in managing an occlusion?
Stop injecting and administer hyaluronidase immediately.

6. Should every injector have hyaluronidase on hand?
Yes—mandatory for all HA filler procedures.

7. How long do bruises last?
Typically 5–7 days; faster with topical arnica or vitamin K.

8. What areas have the highest occlusion risk?
Glabella, nose, nasolabial fold, and periorbital regions.

9. Can occlusion cause blindness?
Yes, if filler enters ophthalmic artery branches—urgent ophthalmology referral required.

10. How can injectors prevent occlusions?
Anatomy mastery, aspiration, small aliquots, and proper injection depth.

References

Carruthers, A., & Carruthers, J. (2023). Managing vascular complications in aesthetic medicine: Best practices. Aesthetic Surgery Journal, 43(6), 703–714.
Gold, M. H., & Biron, J. A. (2022). Clinical differentiation of post-filler vascular events. Journal of Cosmetic Dermatology, 21(9), 4050–4061.
National Institutes of Health. (2023). Safety and complication management in dermal filler injections.
Lemperle, G., & Rullan, P. (2022). Hyaluronidase protocols for ischemic filler complications. Dermatologic Surgery, 48(10), 1315–1324.