Patterns of Filler-Induced Facial Skin Ischemia: A Systematic Review of 243 Cases and Introduction of the FOEM Scoring System and Grading Scale

The incidence of facial skin necrosis has increased considerably because of the growth in the popularity of dermal fillers. This study describes the patterns and severity of facial skin ischemia, along with associated neuro-ophthalmologic injuries, in the published literature through the introduction of the facial artery, ophthalmic artery, distal external carotid artery, internal maxillary artery (FOEM) facial angiosome scoring system and grading scale. A systematic review of all photographic cases of facial skin ischemia attributable to vascular occlusion with dermal fillers and injectable materials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A total of 243 cases were identified, with 738 digital clinical photographs retrieved. The facial artery (58% of cases) and ophthalmic artery (48% of cases) angiosomes were most commonly affected. The frontonasal and angulonasal territories were the most common facial skin segments injured by filler-induced vascular occlusion. Cutaneous involvement of the ophthalmic angiosome was significantly associated with neuro-ophthalmologic complications [vision loss, 39% versus 0.8% ( P = 0.00001); stroke, 8% versus 0.8% ( P = 0.0085)]. Injuries with greater cutaneous surface area or cross-angiosome involvement were associated with a higher incidence of severe visual deficits and bilateral stroke. Facial skin necrosis attributable to vascular occlusion is a rapidly growing problem that has remained poorly characterized in the literature. This study provides the largest descriptive analysis of published photographic reports of skin ischemia to date and proposes a novel scoring system and grading classification to aid in future reporting.