This protocol is designed for Newcastle Cosmetic Doctor (NCD) and aligns with current Australian guidance on non‑surgical cosmetic procedures, including Ahpra’s forthcoming non‑surgical cosmetic procedure guidelines (effective 2 September 2025), the Medical Board/Ahpra cosmetic guidance, and Australian ophthalmology guidance for filler‑related vision loss. It integrates contemporary complication management literature and TGA information for Hyalase. Harvard‑style citations are used throughout.

1. Governance & Regulatory Framework

NCD practitioners must comply with Australian regulations on non‑surgical cosmetic procedures, maintain competency in vascular occlusion (VO) recognition and hyaluronidase use, run annual simulation drills, and keep an after‑hours escalation path visible to staff and patients (Ahpra 2023; Ahpra 2025; Medical Board of Australia 2025). 

Key sources: Ahpra – Performing non‑surgical cosmetic procedures (updated Apr 2023). Advance copies: Non‑surgical cosmetic procedure guidelines (effective 2 Sep 2025). Medical Board – Cosmetic procedures guidance hub

2. Risk Reduction (Before Injection)

• Consent explicitly covers VO and the rare risk of vision loss; document understanding (Ahpra 2023; Ahpra 2025).
• Technique: slow, low‑pressure micro‑aliquots with continuous needle movement; consider cannula in high‑risk zones; avoid high‑pressure bolus (JCAD 2018; ASJ 2024).
• Ultrasound/Doppler may assist anatomy mapping and complication response in higher‑risk or revision cases (JCAD 2021).
• Confirm VO kit stock, expiry, and staff familiarity with reconstitution/dosing (ACE Group World 2024; TGA 2024).

3. Recognition of Vascular Occlusion

Red flags: sudden severe pain, blanching/livedo, prolonged capillary refill, cool skin, and territory‑patterned mottling. Any visual symptoms (amaurosis, field loss, diplopia) constitute an ocular emergency (ACE Group World 2024; JCAD 2018; RANZCO 2024).

4. Immediate Management — Peripheral / Soft‑Tissue VO

1. Stop injecting; call for VO kit and senior assistance; begin timeline and photographs.
2. Apply gentle heat and firm massage to promote vasodilation and dispersion (ACE Group World 2024).
3. Hyaluronidase flooding: reconstitute Hyalase® 1500 IU in 10 mL 0.9% NaCl; infiltrate throughout and just beyond the ischemic field; repeat every 30–60 min until sustained reperfusion (ACE Group World 2024; JCAD 2018; ASJ 2024). Total dose is titrated to clinical response; multiple vials may be required.
4. Adjuncts: consider aspirin 300 mg stat then 75–100 mg daily for 3–5 days if no contraindications (ACE Group World 2024). Antibiotics if epidermolysis/necrosis risk per clinician judgment (JCAD 2018). Avoid routine nitroglycerin (limited evidence) (JCAD 2018).
5. Escalation: if inadequate response or progressive ischemia, consider hyperbaric oxygen therapy (HBOT) as an adjunct where available (JCAD 2018).

5. Ocular Emergency Pathway (Vision‑Threatening VO)

Any visual symptom during or after injection triggers an immediate emergency response. Call 000 and arrange urgent transfer to ophthalmology. Provide supportive first aid (e.g., high‑flow oxygen and intermittent ocular massage if advised) while expediting transfer. Clinic‑based retrobulbar hyaluronidase is controversial and should not delay transfer; specialist management is preferred (RANZCO 2024; ASJ 2024; JMIR Dermatology 2024).

6. Post‑Event Care & Follow‑up

Review at 24 h and 48–72 h; repeat hyaluronidase if re‑ischemia occurs. Provide wound care (non‑adherent dressings, petrolatum occlusion) and consider HBOT for progressive tissue risk. Maintain clear communication and daily check‑ins as needed; complete a root‑cause analysis within 7 days (Ahpra 2023; ACE Group World 2024).

7. VO Emergency Kit (Each Treatment Room)

• Hyalase® (hyaluronidase) 1500 IU vials × multiple; 0.9% NaCl; syringes; 18–30G needles/cannulas; gloves; swabs; timer; warm packs.
• Aspirin 300 mg; oral antibiotics as per clinic policy.
• Printed wall algorithm and ocular pathway with emergency contacts; access to ultrasound/Doppler where available.
• TGA product information to verify storage, handling and contraindications for hyaluronidase (TGA 2024; NPS MedicineWise 2020).

Sources

1. Australian Health Practitioner Regulation Agency (Ahpra) 2023, Performing non‑surgical cosmetic procedures, viewed 3 Oct 2025, https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-procedure-guidelines.aspx
2. Australian Health Practitioner Regulation Agency (Ahpra) 2025, New cosmetic procedure guidelines (advance copies) – effective 2 September 2025, viewed 3 Oct 2025, https://www.ahpra.gov.au/sitecore/content/Dental/News/2025-06-03-New-cosmetic-procedure-guidelines.aspx
3. Medical Board of Australia 2025, Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures, viewed 3 Oct 2025, https://www.medicalboard.gov.au/codes-guidelines-policies/cosmetic-medical-and-surgical-procedures-guidelines.aspx
4. Royal Australian and New Zealand College of Ophthalmologists (RANZCO) 2024, Filler Blindness Guidelines, viewed 3 Oct 2025, https://ranzco.edu/wp-content/uploads/2024/06/RANZCO-Filler-Blindness-Guidelines_2024.pdf
5. Aesthetic Complications Expert (ACE) Group World 2024, Management of a vascular occlusion associated with cosmetic injections (v2.5), viewed 3 Oct 2025, https://uk.acegroup.online/wp-content/uploads/2024/01/Vascular-Occlusion-v2.5.pdf
6. Aesthetic Complications Expert (ACE) Group World 2024, The use of hyaluronidase in aesthetic practice (v3.1), viewed 3 Oct 2025, https://uk.acegroup.online/wp-content/uploads/2024/01/ACE-Group-Hyaluronidase-v3.1.pdf
7. Beleznay, K., Humphrey, S., Carruthers, J. & Carruthers, A. 2024, 'Update on blindness from filler: review of prognostic factors and management', Aesthetic Surgery Journal, 44(10):1091–1106, viewed 3 Oct 2025, https://academic.oup.com/asj/article/44/10/1091/7649223
8. Glynis et al. 2024, 'Use of hyaluronidase in aesthetic practice: a comparative/consensus study from ASCD 2022', Aesthetic Surgery Journal, 44(6):647–656, viewed 3 Oct 2025, https://academic.oup.com/asj/article/44/6/647/7585836
9. De Lorenzi, C. 2018, 'Management of a vascular occlusion associated with cosmetic injections', Journal of Clinical and Aesthetic Dermatology, viewed 3 Oct 2025, https://jcadonline.com/management-vascular-occlusion/
10. Complications in Medical Aesthetics Collaborative (CMAC) 2021, Guideline for the management of hyaluronic acid filler‑induced vascular occlusion, JCAD, viewed 3 Oct 2025, https://jcadonline.com/cmac-guideline-hyaluronic-vascular-occlusion/
11. Fazel‐Zarandi, M. et al. 2024, 'Hyaluronidase for dermal filler complications: a scoping review', JMIR Dermatology, viewed 3 Oct 2025, https://derma.jmir.org/2024/1/e50403
12. Therapeutic Goods Administration (TGA) 2024, HYALASE hyaluronidase 1500 IU powder for injection ampoule – ARTG 27749, viewed 3 Oct 2025, https://www.tga.gov.au/resources/artg/27749
13. Sanofi‑Aventis Australia 2024, Australian Product Information – Hyalase (hyaluronidase), viewed 3 Oct 2025, https://medsinfo.com.au/api/documents/Hyalase_PI?format=pdf
14. NPS MedicineWise 2020, Hyalase – consumer medicine information, viewed 3 Oct 2025, https://www.nps.org.au/medicine-finder/hyalase-injection
15. NSW Health 2023, Cosmetic procedures – regulatory overview and review documents, viewed 3 Oct 2025, https://www.health.nsw.gov.au/patients/cosmetic/pages/default.aspx