How Do You Know if You Were Injected into an Artery with Radiesse?

I heard you can die from this. How do you avoid injecting into an artery? My doctor injected me in the cheek and it turned white, started pulsating, turned bright red and she seemed to panic. Please let me know how to avoid this.

Doctor Answers 10

Filler injections into an artery

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The easiest way to say this is that you will absolutely know that something is wrong. The area will start to turn black (not like a bruise!), sometimes you can get whitish bumps (like goosebumps) across the area, and you will have intense pain. What happens is that an artery is blocked from the filler and the result is tissue death - and it hurts! Most of the time if you are going to have an arterial block with a filler, it happens around the lip area. You don't have this in your case. But it sounds like you had a panicky injector, which I realize stressed you out. To "avoid it", see very experienced injectors.

Risk of embolism from filler injection

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The type of embolism you're referring to is caused by injection of a foreign substance like filler into a blood vessel which causes a clot to form which can break off and then travel in the bloodstream causing damage. Since this involves the skin (and not an embolism of the lungs or heart), it is unlikely to result in death, but more likely to result in necrosis (due to lack of oxygen to the skin which can result in the tissue dying) and resultant scarring and nerve damage. This is particularly high risk around the eye area because an embolism could result in blindness. This is why nonphysicians and non-core trained specialists are advised to stay away from injecting in these higher risk regions. There are especially rich arcades of blood vessels in the infraorbital region and forehead, glabella and nasal region that are higher risk for embolism.This is something that is discussed amongst physicians at conferences and it is a known complication. Although unlikely to occur in experienced hands, it is a risk that needs to be disclosed and considered. I have done thousands of injections in over 15 years of practice and have never had this occur in a patient, but do know of numerous cases reported. There are many more cases of this occurring with inexperienced and nonphysician or nurse injectors. There is less risk when injecting superficially but greater risk when injecting deep. One of the techniques I use to try to decrease risk of embolism is to inject lidocaine with epinephrine prior to injection of the filler. The epinephrine causes vasoconstriction so that the blood vessels are less open therefore more difficult to inject directly into the vessel accidentally. Fillers like Juvederm and Restylane now contain lidocaine so many practitioners do not inject local anesthesia prior to the filler anymore, and doing the lidocaine with epinephrine prior to filler does have the disadvantage of causing more bruising and swelling and also less precision with correction, but it offers the safety advantage of constricting blood vessels therefore decreasing risk of injecting filler into the blood vessel resulting in embolism.

The vascular event you are describing is indicative of possible injection of filler into a blood vessel feeding the skin.  The reason you didn't have permanent damage is it wasn't a major artery.  Injecting into a major artery could result in full thickness necrosis of the skin.    When vascular occlusion of an artery occurs, there are definitive measures that need to be taken immediately to address that which could minimize and prevent any further damage.  An experienced practitioner would know how to address these potential complications.  Because complications can occur with these seemingly simple procedures, it's important to be in the care of an experienced board-certified dermatologist or plastic surgeon who knows how to treat these complications if they were to occur.  The last person you want doing your injection is someone who says they wouldn't know what to do if a vascular event happened.  Don't let someone blow you off by saying this is never going to happen, make sure the doctor you are seeing tells you they would know exactly what to do if this happened.

M. Christine Lee, MD
Walnut Creek Dermatologic Surgeon

Radiesse/Intra-arterial Injection

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Intra-arterial injection is a rare but possible complication associated with any filler - hyaluronic acid, Radiesse, fat, etc.  It has been associated with devastating consequences, including loss of tissue and blindness.  Fortunately, it is extremely rare.  The best treatment is, of course, prevention, but even that can not be guaranteed, and even in the best of hands.  In general, injecting small amounts at one "push", and injecting while withdrawing, diminishes the likelihood of this complication.  Early recognition and prompt intervention can ameliorate the problem with hyaluronic acid (Restylane, Perlane, Juvederm) since hyaluronidase (trade name Vitrase, Amphidase) can "dissolve" the injectate.  But it is difficult to reinject into the exact location and, regardless, there is nothing than can dissolve Radiesse.

Even if the area turned white it does not necessarily indicate a direct intra-arterial injection, but it is suggestive of vascular compromise.  That can mean pressure or other phenomena that indicate decreased blood flow.  That it turned red is probably good - but how is it now (I trust it's okay or you would have indicated as much)?

Hopefully, you're okay by know...I also hope that this has helped, and good luck,

Dr. E

Radiesse injection into an artery

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It sounds as if a trace of Radiesse  entered anarteriole (White color) and  was insignificant enough to be carried away with resultant vasodilatation (Red color).

Injecting with a blunt cannula, as opposed to a needle which has a sharp tip, could have avoided this incident.

Rarely, the angular artery, underlying  the  area between the cheek and upper lip, can be obstructed during the injection of a filler. This results in immediate blanching and severe pain, ending in sloughing of the skin.

Bottom line: You have nothing to worry about regarding the session that you describe. However:

I would select a more experienced operator in the future.

Eugene Mandrea M.D.

Eugene Mandrea, MD
Chicago Dermatologist
4.6 out of 5 stars 5 reviews

Not consistent with arterial injection

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The sequence of events (your observations) is not consistent with arterial injection. He/she may have inadvertently injected a branch of the facial artery (inferior or superior lingual arteries, angular artery). Since you don't have any untoward side effects and no necrosis of the skin (which is rare), then nothing bad seems to have happened. I understand that 'panic' does not inspire confidence in you - get someone else to do your next set of injections.

How do you know if you inject into an artery?

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It sounds like you are describing a vascular event.  Blanching, throbbing, change in color such as redness, or turning dark or dusky. Usually followed by increasing pain. If the occlusion is severe there can be tissue damage.  To avoid injecting into a vessel, It requires a thorough understanding of the anatomy. There are certain landmarks to avoid, in addition to injection techniques that minimize the risks. Injecting dermal filler should only be done by experienced, well trained medical professionals capable of administering emergency care if required. Complications can be serious but fortunately they are rare.

Sam Naficy, MD, FACS
Seattle Facial Plastic Surgeon
4.7 out of 5 stars 231 reviews

Skin Death and Blindness from Filler Injections

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  Skin death and blindness from filler injection is possible.  Blunt-tipped cannulae can reduce the risk over needle injection.

Blunt Tipped Micro-Cannulas

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Thank you for your question. From your description, it sounds like arterial injection was a possibility.  This is a known complication of all injectable fillers.  I would recommend you seek treatment from a surgeon experienced in using blunt tipped micro-cannulas for injection and the aspiration technique. These devices and maneuvers can help to reduce the risk of arterial injection and embolizaiton.

George Bitar, MD
Fairfax Plastic Surgeon
4.6 out of 5 stars 59 reviews

Cannulas and experience improve Radiesse safety

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In response to your question regarding how to avoid arterial injections with Radiesse I suggest a couple of things.  

First, it is important to see a physician with extensive experience injecting all types of filler.  Radiesse requires advanced skill because it cannot be reversed like the hyaluronic acid fillers (Restylane, Juvederm); therefore, if an artery is injected, there is no simple fix and skin necrosis and scarring may result.  An experienced physician will have a thorough knowledge of the facial anatomy and know the danger zones that require particular attention.  

Second, the use of blunt-tipped cannulas for injection as opposed to the needle that comes with Radiesse dramatically reduces the chance of entering an artery.  Ask your physician if they are familiar with the use of cannulas.

Michael Contreras, MD
Greenwood Village Dermatologic Surgeon

Radiesse in Artery

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Hi Mia.  Regardless of which product is being injected, it's possible to hit a blood vessel.  One of the techniques that help avoid this is to inject the product as the needle is being moved backward and outward toward the surface of the skin.  By injecting only as the needle is being pulled out, it dramatically reduces the chance of injecting into a blood vessel.

A good and experienced injector will be able to recognize immediately when this has happened and use massaging and warm packs to release the product from the vessel.

Harold J. Kaplan, MD
Los Angeles Facial Plastic Surgeon
4.4 out of 5 stars 7 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.