Case Report: Management of Polycaprolactone-Based Dermal Filler–Induced Vascular Occlusion

Abstract

A 42-year-old female presented to the clinic 3 days after receiving polycaprolactone (PCL)-based dermal filler injections in the hypodermal layer of nasolabial folds by the use of a needle. She had received 0.5 cc of PCL-based filler in each nasolabial fold under local anesthesia. She did not mention any pain during the injection. However, she noticed erythema and pain in the left nasolabial fold 1 day after the procedure, which she did not find significant and did not seek medical care for it; however, as the symptoms progressively worsened despite initial conservative management with over-the-counter analgesics she visited our clinic (Figure 1).

Her medical history was unremarkable, and she did not report any prior history of dermal filler injection in this area. The filler injection had been performed without immediate adverse events. Physical examination revealed erythema, tenderness, and moderate edema along the left nasolabial fold; there were also areas of dusky erythema and pustule formation indicating impending necrosis in the area. Her physical examination was otherwise unremarkable.

After 5 months of follow-up, the patient healed with minimal scarring and an excellent cosmetic outcome.

PCL-based fillers are generally considered safe for soft tissue augmentation due to their biocompatibility and longevity. However, as demonstrated in this case, vascular occlusion remains a significant risk associated with all dermal fillers, particularly in areas such as the nasolabial folds, where major arteries are present [1]. Vascular occlusion can occur due to direct injection into a vessel, or external compression of nearby vasculature by the filler material and inflammation. This can lead to ischemia and, if untreated, tissue necrosis and significant scarring [2].

Anatomical factors play a pivotal role in the occurrence of such complications. The facial artery, which arises from the external carotid artery, follows a tortuous course across the face, making it highly susceptible to inadvertent cannulation or compression. In the nasolabial fold, the facial artery and its branches, particularly the superior labial and angular arteries, lie close to typical filler injection planes within the dermis or hypodermis. The variable depth and tortuosity of the facial artery further complicate this risk. While in most individuals, it runs deeply in the lower two-thirds of the nasolabial fold before becoming more superficial in the upper one-third, in some patients, it may course superficially, lying within millimeters of the dermis even in the lower part, or it may be situated deeply at the alar base. This variability can lead to unpredictable outcomes, even when standard injection techniques are employed [3].

Furthermore, areas such as the glabella and the periorbital regions are considered “high-risk zones” due to the presence of critical anastomoses between the facial and ophthalmic arterial systems. Accidental intravascular injection in these regions can result in severe complications, including blindness or cerebrovascular events. These anatomical risks are further exacerbated by the use of sharp needles, rapid filler injections, or excessive injection pressure, particularly when using non-HA fillers [4].

The use of blunt cannulas, aspiration prior to injection, and slow, controlled filler deposition significantly mitigates vascular complications. Advanced imaging techniques, such as Doppler ultrasound, further enhance safety by enabling real-time visualization of vascular structures, particularly in high-risk areas or regions with common anatomical variations [5].

Several case reports and studies have described successful management strategies for vascular occlusion caused by non-HA fillers, including PCL. This case adds to the limited literature on PCL-induced vascular complications and highlights the importance of early recognition and intervention to prevent serious outcomes [6].

This case highlights the importance of early diagnosis and prompt treatment of vascular occlusion after PCL-based dermal filler injections. A combination of corticosteroids, hyaluronidase, and LMWH, along with supportive therapies like CO₂ laser and PRP, resulted in the successful resolution of symptoms and prevention of long-term damage and permanent scarring. This case underscores the need for practitioners to be aware of the potential risks and treatment protocols for vascular occlusion following non-HA filler injections.

M.A. and H.M. performed the research. S.Z. and H.L. wrote the paper. M.G. revised and supervised the manuscript.

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The authors declare no conflicts of interest.