MYTH - Ischemic events only happen to new injectors who don't know their anatomy - Goodman et al

Author: Mike Clague Aesthetic Nurse BSC   Date Posted:31 August 2018 

We have all seen it said on social media and in person.  "I am a safe injector because I am experienced and I know my anatomy".  This level of arrogance can lead to a catastrophic event.  It can happen to any injector at any time.  There have now been reports of blindness from many areas of the face. There are areas that are higher risk, such as the glabella and nose, but it can even happen while injecting a lip (something most people consider very safe).

DO new injectors have a higher risk of an ischemic event?  Assoc Prof Goodman et al ran a study to find out if experienced injectors who are trainers for Pharma companies have ischemic events. Let's take a look at the study.


Experience and Management of Intravascular Injection with Facial Fillers: Results of a Multinational Survey of Experienced Injectors

Greg J. Goodman1 • Stefania Roberts2 • Peter Callan3

Aesth Plastic Surg, published online10th June 2016


The authors wished to determine if ischemic events with dermal fillers happen to experienced cosmetic injectors. Intravascular injections leading to necrosis or blindness are the most devastating adverse events we can have as injectors. Early recognition of the signs and symptoms may lead to better outcomes.  The objective was to look at the occurrence, management and outcomes of intravascular events among experienced injectors.


An internet based survey was sent out to 127 injectors worldwide who are trainers for medical aesthetic pharmaceutical companies. A total of 27 questions were asked. 


50 fully completed surveys were returned. The majority of respondents were from Australia (28%), followed by Indonesia, South Korea and Taiwan. The remainder were from Europe, New Zealand and South America.   

71% of respondents had more then 11 years experience injecting fillers. All respondents were doctors (derms, plastic surgeons, cosmetic physicians).

62% of respondents had experienced an intravascular event with dermal filler in their career.

There is little correlation between experience and ischemic events with filler.


The findings of this survey are noteworthy because they show that the frequency of inadvertent intravascular injec- tion is high, even among very experienced injectors. Although 71 % of these respondents had 11 or more years of experience, 62 % had experienced inadvertent intravascular injection.



Don't use ischemic events as marketing collateral.  Don't say on your instagram "I am experienced so I don't have cases of blindness".  It could bite you back at some point.  

When a colleague has an ischemic event, be supportive.  Don't say "oh that's because they must have been doing something wrong".  It is not that simple.  Arteries are everywhere in the face, we are in and out of them all day.  Understand there are ways to try and avoid an ischemic event with filler BUT also know what to do if it does happen to you.  Know the signs, know how to use hyalase, have protocols in place, attend trainings and conferences.

To try and avoid an ischemic event with filler we teach-

  • Keep your needle tip moving at all times
  • Consider a large bore 22g cannula in areas that are risky
  • Do not treat noses or glabellas with dermal fillers, it just isn't safe
  • Inject slowly, gentle pressure on the plunger
  • Inject small amounts less than 0.1ml
  • Avoid semi-permanent and permanent fillers - if you can't take it out, don't put it in

Comments (1)

This a reassuring article

By: on 12 September 2018
I found this article reassuring because after injecting 1000 plus clients I had my first occlusion in a lip. It’s hard not to think that you have done something wrong but in actual fact I have used the same techniques since being trained. My experience was positive as I was exceptionally well supported by my supervising doctors and the occlusion resolved with hyalase. It’s also interesting to also note that where the occlusion was in the upper left lip I had only injected very small amounts with linear threads and superficially. I’ll be happy to hear your thoughts on my comment

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