Management of Vascular and Ischemic Complications in Aesthetic Injectables: A Retrospective Study of 52 Consecutive Cases and Proposal of a Standardized Rapid-Response Protocol

Abstract

Vascular occlusion and ischemic complications after aesthetic injectable procedures are uncommon but may be disastrous, and can result in skin necrosis, permanent scarring, blindness or stroke. In this retrospective study, 52 consecutive real-world cases were analyzed and treated between January 2022 and December 2025 and assessed the safety and efficacy of a new standardized Rapid-Response Protocol created by the author. The MARYNA Rapid-Response Protocol of immediate high-dose pulsed hyaluronidase (450-1500 IU, every 30-60 minutes) combined with vigorous massage, universal antiplatelet therapy, ultrasound guidance when available, adjunctive vasodilators, and dedicated ocular emergency pathway were used to treat all cases of vascular or ischemic complications (primarily hyaluronic acid fillers, 92.3%). Clinical and photographic outcomes were measured at standardized intervals at a maximum of 90 days. Early intervention (within 4 hours of symptom onset) occurred in 73.1% of cases and resulted in 100% full recovery without permanent sequelae. In total, 94.2% of patients had no cutaneous necrosis, scarring, blindness, or cerebrovascular events and achieved full recovery. The mean hyaluronidase dose was 875 IU. Late presentations (>12 hours) were associated with a slightly increased rate of mild atrophic scarring (5.8% overall). There were no adverse reactions to hyaluronidase. The MARYNA Rapid-Response Protocol provides superior practical results and provides a basic and easily reproducible, evidence-based algorithm that can be immediately embraced by aesthetic practitioners around the globe. These results confirm that aggressive, timely and standardized intervention can minimize the permanent complications of aesthetic injectables to the levels of near zero, which is the new standard of patient safety in the area.