Staged Management of Vascular Occlusion With Ellansé (Polycaprolactone): A Modified Delphi Expert Consensus

Abstract Background Vascular occlusion (VO) is a rare but serious complication of dermal filler injection. Current management protocols are derived primarily from hyaluronic acid fillers and rely on enzymatic degradation with hyaluronidase. Ellansé (PCL-CMC) is a poly-ε-caprolactone (PCL)-based filler composed of PCL microspheres suspended in a carboxymethyl cellulose (CMC) gel carrier, neither of which is a substrate for hyaluronidase; a product-specific management approach is therefore required. Objectives To develop expert consensus recommendations for the recognition and management of VO associated with PCL-CMC. Methods A targeted literature review (PubMed, January 2009–August 2025), in vitro rheometry and flow testing, and a three-round modified Delphi consensus process involving seven international experts were used to develop a staged management algorithm. Results At 1:5 dilution, PCL-CMC viscosity decreased approximately 80-fold to near-aqueous levels; hyaluronidase solution conferred no additional benefit over saline alone. A full consensus or a consensus based on majority of the experts consensus (≥80%) was achieved on the majority of statements, including CMC-mediated obstruction as the primary mechanism, high-volume saline flushing with mechanical dispersion as first-line therapy, and retention of hyaluronidase in a supportive role. Conclusions This consensus-derived algorithm prioritizes reperfusion through dilution and mechanical dispersion rather than enzymatic degradation. Prospective clinical validation is required. Level of Evidence: 5 (Therapeutic) For image description, please refer to the figure legend and surrounding text.