From Bruising to Blindness: A Practical Guide to Identifying and Managing Hyaluronic Acid Filler Complications

PURPOSE To provide a comprehensive, evidence-based review of the complications associated with hyaluronic acid (HA) dermal fillers and to offer practical guidance for their identification, prevention, and management. DESIGN Narrative review of the peer-reviewed literature, consensus guidelines, and postmarket surveillance data addressing the classification, pathophysiology, prevention, and treatment of HA filler complications. FINDINGS Hyaluronic acid fillers carry a favorable safety profile, with severe complications reported in fewer than 0.01% of injection sites. Complications are classified by onset. Early-onset events include ecchymosis, injection-site and hypersensitivity reactions, product displacement, and vascular occlusion. Late-onset events include biofilm-associated infection, delayed inflammatory nodules, granulomas, and hyperpigmentation. Vascular occlusion is the most feared complication and may progress to skin necrosis, vision loss, or stroke; prompt recognition and high-dose hyaluronidase, increasingly aided by ultrasound guidance, are central to management. Prevention rests on sound anatomic knowledge, appropriate product selection, and careful injection technique, while treatment is tailored to the specific complication. SUMMARY As filler use continues to expand, clinicians must be prepared to recognize, prevent, and manage the full spectrum of complications. This review consolidates current evidence into a practical framework intended to support safe practice and optimal patient outcomes.