Most filler patients get a bruise at some point, and most of them spend at least one evening looking at it and wondering whether it is the thing they read about. That is a reasonable question and it has a reasonable answer, because an ordinary bruise and a vascular occlusion behave differently from each other in four ways that you can check without any equipment.
This piece is only about that comparison. What to do about a complication once you have identified one, and the wider set of things that can go wrong, are covered in recognising a complication after injectable treatment.
What an ordinary bruise does
A bruise is blood that has escaped from a small vessel into the surrounding tissue. It appears within minutes to a few hours of the injection, usually at or very close to the entry point, and it typically looks worse on day two or three than it did on day one because the blood spreads and oxidises before it is cleared.
Four things characterise it. It is soft to touch rather than firm. It hurts about as much as you would expect a needle site to hurt, which is to say tender if you press it and unremarkable if you do not. It obeys gravity, so a bruise from a cheek injection may track downwards over a couple of days and appear somewhere you were not treated. And it changes colour in a predictable sequence, from red or purple through blue, then green, then yellow, over roughly five to fourteen days.
A bruise that is doing all four of those things is behaving normally, whatever colour it is at the moment you look at it. Size is not a useful signal on its own. Large bruises are common on the lips and under the eyes because the tissue there is thin and vascular.
What a vascular occlusion does
Vascular occlusion is filler obstructing a blood vessel, either by being placed inside it or by pressing on it from outside. The tissue supplied by that vessel stops receiving enough blood, and the signs that follow are signs of tissue in trouble rather than signs of blood in the wrong place.
The first is pain that does not fit. Not tenderness when pressed, but pain that is severe, that arrives during or shortly after the injection and does not settle, or that builds over the following hours when it should be receding. Pain that gets worse after the first day is abnormal after filler.
The second is colour behaviour that is the reverse of a bruise. The area typically blanches first, going pale or white, before turning dusky, greyish or purple in a blotchy net-like pattern rather than a solid patch. That mottled pattern is following the territory of a blood vessel, which is why it often appears somewhere adjacent to the injection site rather than at it, and why it can have a strikingly geometric edge.
The third is capillary refill. Press the area firmly with a fingertip for a couple of seconds and release. Skin with a normal blood supply goes white and then pinks up again almost immediately. Skin that is being starved refills slowly, or stays pale, or refills to the wrong colour.
The fourth is what happens next if nothing is done. Over the following days the area can develop small blisters or pustules, then a dark crust, then skin loss. By that stage the window in which the situation is most easily reversed has usually closed, which is the entire reason this comparison is worth learning in advance rather than at the point of needing it.
The comparison grid
| Sign | Ordinary bruise | Possible occlusion |
|---|---|---|
| Pain | Mild, tender when pressed, settling day by day | Severe or out of proportion, or increasing after day one |
| Onset | Minutes to hours, then stable | Often immediate, sometimes hours later, then progressive |
| Colour | Red or purple, then blue, green, yellow | Pale or white first, then dusky, grey or purple |
| Pattern | Solid patch, soft edges, follows gravity | Blotchy, net-like or lace-like, follows a vessel territory |
| Location | At or below the entry point | Can be distant from the entry point |
| Capillary refill | Normal, colour returns at once | Sluggish, absent, or returns the wrong colour |
| Temperature | Same as surrounding skin | Can feel cooler than surrounding skin |
| Day three | Looks worse in colour, feels better | Feels worse, may blister or crust |
The decision rule
The rule is simpler than the grid. If the area is soft, the pain is going down, and the colour is moving through the bruise sequence, you are watching a bruise. If the pain is going up, the colour went pale before it went dark, or the pattern is blotchy rather than solid, you are not watching a bruise and you should be speaking to the practitioner who treated you today rather than tomorrow.
Three signs mean stop reading and act now. Any change in vision, including blurring, a dark patch, double vision or loss of vision in one eye. Pain around the eye or a sudden severe headache after treatment near the eyes, nose, forehead or between the brows. And skin that is white, mottled and cool with pain that does not settle. The first two are an emergency and the correct destination is urgent medical care, not a voicemail.
Who to contact, and in what order
The practitioner who treated you is first, because they know which product went where, in what volume, and by which route, and because reversal of a hyaluronic acid filler is time critical and depends on that information. This is why the question of who answers the phone out of hours belongs in the consultation rather than in the emergency, and why a clinic that cannot tell you the out of hours route before treating you has answered the question by not answering it.
If you cannot reach them and you have any of the three signs above, go to urgent care. Take the product name and the treatment date with you if you have them. Suspected adverse incidents involving medicines and medical devices can also be reported to the MHRA through the Yellow Card scheme, which is a reporting route rather than a route to treatment.
Two things that are neither
Not everything abnormal after filler is one of these two. Infection usually declares itself over days rather than hours, with spreading redness, heat, increasing swelling, tenderness and sometimes fever, and it looks angry rather than dusky. Delayed inflammatory nodules can appear weeks or months after treatment, often following an illness or a dental procedure, as firm lumps with swelling around them. Both need the clinic, neither is a bruise, and neither behaves like an occlusion.
Ordinary swelling is also not a bruise and not a complication. It peaks in the first 48 hours, is symmetrical with the treatment rather than patchy, and is covered alongside the rest of the normal timeline in aftercare in the first six weeks.
What this does not cover
This is a comparison, not a diagnosis. It cannot be made safely from a description on a page, and nothing here replaces being looked at by the person who treated you. It covers dermal filler specifically. Botulinum toxin does not cause vascular occlusion, because it is a small volume of liquid medicine rather than a gel occupying space, and its own set of unwanted effects is different. It does not cover surgical procedures, and it does not tell you what treatment you will be offered, because that is a clinical decision made in person.
Sources
- Medicines and Healthcare products Regulatory Agency, the UK regulator for medicines and medical devices
- MHRA Yellow Card scheme, for reporting suspected side effects and device incidents
- General Medical Council, standards and guidance for registered doctors
- Joint Council for Cosmetic Practitioners, the voluntary register for non-surgical practitioners
- British Association of Dermatologists, patient information on skin and skin procedures
Frequently asked questions
How quickly does a vascular occlusion show itself?
Often during the injection or within minutes, but a delayed presentation over the following hours is well recognised. The pattern matters more than the clock: pain that increases after the first day, or skin that blanched before it darkened, is abnormal at any point in the first week.
Is a large bruise more worrying than a small one?
Not by itself. Bruise size depends on which vessel was caught and how loose the tissue is, which is why lips and the area under the eyes bruise dramatically. What matters is whether it is soft, whether the pain is settling, and whether the colour is moving through the normal sequence.
What does mottled skin actually look like?
A blotchy, net-like or lace-like pattern of pale and dusky areas rather than a single solid patch of colour. It often has a surprisingly defined edge because it follows the area supplied by one blood vessel rather than the area a needle touched.
Can I check capillary refill myself?
You can do the simple version. Press firmly on the area for two seconds and let go. Normal skin blanches and pinks up almost at once. If colour returns slowly, does not return, or returns dusky, that is a reason to contact the clinic rather than to wait and see.
Does botulinum toxin carry the same risk?
No. Vascular occlusion is a filler problem, because filler is a gel that can sit inside or press on a vessel. Botulinum toxin has its own unwanted effects, including asymmetry and eyelid or brow heaviness, and those are covered separately.
What if it is the middle of the night?
Use the out of hours route the clinic gave you at consent. If you have vision changes, eye pain, a sudden severe headache, or pale mottled cool skin with pain that will not settle, do not wait for morning and do not wait for a call back. Seek urgent medical care.
Should I put ice on it?
Ice is routine aftercare for ordinary swelling and bruising in the first day, following the clinic's instructions. It is not a treatment for a suspected occlusion and it should never be used as a reason to delay a phone call, because cold constricts vessels.
Is a lump a few weeks later the same thing?
No. Firm lumps appearing weeks or months after filler, sometimes after an illness or dental work, are a different category and are managed differently. They still need the clinic, but they are not an emergency in the way that pale, painful, mottled skin on the day of treatment is.