A team led by dermatologists at Mayo Clinic has mapped every published report of hyperbaric oxygen therapy used for dermal filler-induced vascular occlusion, and the headline finding is about the shape of the evidence rather than the treatment. Across 24 included studies, the authors found no randomized trials, no prospective studies, and no controlled comparisons — only case reports, small case series, and narrative reviews.
The review, published in the Journal of Clinical and Aesthetic Dermatology, is a scoping review conducted under PRISMA-ScR: a structured mapping of what has been reported, explicitly not an efficacy study. “As a scoping review, this study does not aim to determine efficacy but rather to summarize how HBOT has been reported and applied in clinical practice,” the authors write.
Why filler occlusion is an emergency
Vascular occlusion happens when filler enters or compresses a blood vessel and blood flow stops. It is rare — the review cites an estimated incidence of 0.01 to 0.05 percent of procedures — but the denominator is enormous. American plastic surgeons performed more than 3.4 million dermal filler procedures in 2023 alone. The nasolabial folds, nasal dorsum, glabella, and forehead carry the highest risk.
The time pressure is what makes the condition frightening. When the eye is involved, vision loss “typically occurred immediately or within 10 minutes following the injection,” the authors note, and while the conventional window for reperfusion runs to about 90 minutes, some reports suggest retinal ischemia may become irreversible within 10 to 15. A 2024 literature review cited in the paper counted 365 cases of partial or complete vision loss following filler injection.
Standard management is not in dispute. For hyaluronic acid fillers, the review states plainly, “prompt administration of hyaluronidase is the cornerstone of treatment,” supported by warm compresses, vasodilators, aspirin, corticosteroids, and urgent ophthalmology referral where vision is threatened.
What clinicians actually did with hyperbaric oxygen
Where HBOT appears in these reports, it appears as an add-on. “HBOT was consistently reported as an adjunctive intervention and was administered alongside established therapies, including hyaluronidase, antiplatelet agents, vasodilators, corticosteroids, and thrombolytic therapy,” the authors write.
The parameters varied widely. Reported pressures ranged from 2.0 to 3.0 ATA, sessions from 60 to 120 minutes — most commonly 90 — generally delivered daily, with session counts left to clinical judgment. Timing was the loosest variable of all: treatment began anywhere from within the first 24 hours to as late as 11 days after the procedure, and several reports did not specify it.
That inconsistency is the review’s central complaint. “There is no standardized treatment protocol specific to FIVO, and most current recommendations are extrapolated from protocols for compromised grafts, flaps, or other ischemic injuries,” the authors write. “The optimal timing, pressure, session duration, and number of treatments remain undefined, and practice patterns vary widely across institutions.”
The authors do offer a starting point — 5 to 15 consecutive sessions at 2 to 3 ATA, at least 60 minutes each — but label it candidly as opinion, “based on the author’s clinical experience,” not a conclusion drawn from the reviewed literature.
The outcomes cannot be credited to oxygen
Most reported cases improved without lasting damage. Four did not, developing scarring, reduced sensation, hyperpigmentation, or impaired visual acuity — and in those four, treatment began 11, 5, 3, and 6 days after the procedure. The authors suggest earlier treatment may do better, which is a reasonable hypothesis and nothing more; four cases cannot establish an association.
The deeper problem is attribution, and the authors state it without hedging:
“Furthermore, most reported cases of FIVO have been managed using a multimodal therapeutic approach, including hyaluronidase, antiplatelet agents, thrombolytic therapy, and HBOT administered concurrently. As a result, clinical improvement cannot be attributed solely to HBOT, making it difficult to determine its isolated therapeutic effect.”
Every patient who recovered also received the treatment that is known to work. There is no published success rate for HBOT in this setting, no time-to-resolution figure, and no controlled comparison — and any percentage quoted elsewhere is not coming from this literature.
Off-label, on both lists
HBOT chambers are Class II devices cleared by the FDA through the 510(k) pathway, and the cleared indications on current clearances run to 13 conditions: air or gas embolism, carbon monoxide poisoning, gas gangrene, crush injury and acute traumatic ischemias, decompression sickness, selected problem wounds, exceptional blood loss anemia, necrotizing soft tissue infections, refractory osteomyelitis, delayed radiation injury, compromised grafts and flaps, acute thermal burns, and intracranial abscess.
Filler-induced vascular occlusion is not among them. Neither is any cosmetic or aesthetic complication.
The Undersea and Hyperbaric Medical Society’s list of 15 approved indications does not include it either, though two entries sit close: central retinal artery occlusion and compromised grafts and flaps. Those are precisely the categories from which filler protocols have been borrowed. Using HBOT for filler occlusion is off-label — which is legal and sometimes clinically reasonable, but it means no regulator or society has evaluated the evidence and found it sufficient.
What the aesthetic societies say
The Complications in Medical Aesthetics Collaborative addressed this directly in its 2021 guideline: “The level of evidence supporting the use of HBOT in acute filler complications is generally weak.” The group added that any benefit “and the stage at which it offers benefit remains unquantified,” and stated that hyperbaric oxygen is “not evidence-based ancillary therapy for cross-linked hyaluronic acid filler in early management of vascular compromise,” while still recommending it for particulate fillers on the grounds that all available measures should be attempted.
The American Society for Dermatologic Surgery’s task force on filler adverse events mentions HBOT only descriptively — among treatments that “have been attempted” — and issues no graded recommendation for it.
Real risks, real barriers
Hyperbaric oxygen is not consequence-free. The review catalogs barotrauma to the ears and sinuses as the most common harm, with tympanic membrane rupture, and rarer but serious events including pulmonary barotrauma, arterial gas embolism, oxygen toxicity seizures, and lens changes after cumulative exposure beyond roughly 100 sessions. The FDA’s August 2025 letter to health care providers flagged reports of chamber fires causing serious injuries and deaths, while noting that serious adverse events with these devices are rare.
Access and cost compound the problem. The authors point to “limited access in nonhospital or aesthetic practice settings, which can delay initiation, as well as the high cost of HBOT, limited insurance coverage, and the absence of robust data on long-term outcomes.” A treatment whose presumed benefit depends on starting within 24 hours is a poor fit for a med-spa several counties from the nearest accredited chamber.
The defensible reading
The paper’s own conclusion is the safest summary: HBOT “has been reported as an adjunctive intervention in selected cases of FIVO, but evidence remains limited to low-level observational data, highlighting the need for standardized protocols and prospective studies.”
For anyone weighing this in practice, the review is unambiguous about sequence: HBOT “should not replace first-line interventions such as prompt hyaluronidase administration and urgent ophthalmologic referral in the case of ocular compromise.” Oxygen is the thing you consider after the emergency has been addressed, not instead of addressing it.
Sources
- Ramirez LV, Gayle EP, Ormaza A, et al. Hyperbaric Oxygen Therapy in the Management of Dermal Filler-Induced Vascular Occlusion: A Scoping Review. J Clin Aesthet Dermatol. 2026;19(5):17-27
- PubMed — Hyperbaric Oxygen Therapy in the Management of Dermal Filler-Induced Vascular Occlusion: A Scoping Review (PMID 42459244)
- Murray G, Convery C, Walker L, Davies E. Guideline for the Management of Hyaluronic Acid Filler-induced Vascular Occlusion. J Clin Aesthet Dermatol. 2021;14(5):E61-E69 (CMAC)
- UHMS — Hyperbaric Oxygen Therapy Indications (15th Edition approved indications list)
- FDA — Follow Instructions for Safe Use of Hyperbaric Oxygen Therapy Devices (Letter to Health Care Providers, August 2025)