What is the role of hyperbaric oxygen therapy (HBOT) in the treatment of filler occlusion/complications?

Updated: Nov 16, 2020
  • Author: Emi Latham, MD, FACEP, FAAEM, UHM; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Compromised tissue after the injection of cosmetic fillers is an immediate and potentially devastating complication. Fillers can be of different materials such as hyaluronic acid, calcium hydroxyl apatite, and poly-L-lactic acid. Most commonly, filler compromise results from injection of the filler into the artery, thereby causing occlusion via thrombus or embolization. Occlusion may occur in an anterograde or retrograde fashion, or both directions. Another possibility is compression of a vessel by injection of too much product into the area surrounding the vessel, thereby pressing on the vessel to cause occlusion. Filler ischemia is an immediate complication that can be recognized by acute blanching of the tissue, and maybe in just the injected site, or it may involve the watershed area. The tissue can continue on to become dusky with delayed capillary refill. If the occlusion continues, necrosis of the skin can occur. This is usually accompanied by pain; as the compromised tissue becomes more necrotic, this becomes more painful. Many products are formulated with lidocaine and this does help with pain, but it does not alleviate the pain associated with tissue necrosis.

HBOT in filler complications is used to continue to oxygenate compromised tissue until the body can either resolve the occlusion (with native hyaluronidase) or begin new angiogenesis at the site. There is enough oxygen dissolved in the plasma to sustain the life of the tissue by diffusion alone. HBOT should be used in conjunction with other supportive treatments, such as hyaluronidase, saline, steroids, and aspirin.

The treatment schedule is typically on a standard wound treatment table (USNTT9) until the tissue demonstrates persistently improved symptoms of coloration, capillary refill, and if the patient has demonstrated a plateau in improvement. The use of HBOT to treat acute occlusion due to fillers is not a UHMS-approved indication and also may not be covered indication by insurance.

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