It’s complicated
Dr Ahmed El Houssieny shares his insights on complications management
The UK non-surgical aesthetics industry is projected to reach a market value of £3 billion in the next 12 months (Rare Consulting)1, with approximately 7.7 million people having received treatments in the past year. Furthermore, an estimated 13.9 million individuals are considering such treatments within the coming year.
In addition, the most popular treatments performed by BCAM members in its most recent audit were toxin injections (96%) and hyaluronic acid (HA) dermal fillers (93%).2
This surge in popularity underscores the need for heightened awareness and management of potential complications associated with these procedures.
Expected side effects of HA dermal fillers
HA dermal fillers are widely regarded as safe, with common expected side effects including mild discomfort, redness, swelling, bruising, and itchiness. These effects typically resolve within a few days post-treatment. However, understanding and managing adverse events that extend beyond these expected outcomes is crucial for maintaining patient safety and satisfaction.
Classification of adverse events
Adverse events related to soft tissue fillers can be classified based on their time of onset.3-4
- Immediate: Occurring at the time of injection, these include lumps, hematomas, infections, hypersensitivity type I, compromised muscle function, misplacement of filler, and paresthesia.
- Early: Emerging within several days post-treatment, such as nodules, infections, swelling, hypersensitivity type IV, and filler displacement.
- Delayed: Manifesting from weeks to years after the procedure, these can include chronic infections, late-onset nodules, and delayed hypersensitivity reactions.
Immediate complications tend to be things related to the injection. If you put a bolus in for example, you’re more likely to cause a lump, a bruise that’s well confined and becomes a hematoma.
Vascular complications are among the most significant concerns immediately following dermal filler injections. These complications arise when the filler unintentionally enters a blood vessel or compresses it, leading to a range of potential issues from minor discomfort to severe tissue damage.
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Types of vascular complications:
- Intravascular injection: This occurs when the filler is inadvertently injected directly into a blood vessel. This can lead to vessel occlusion, which blocks blood flow and can result in tissue necrosis or even blindness if it affects vessels supplying the eye.
- Vascular compression: This happens when the filler compresses a nearby blood vessel, impeding blood flow. This can cause ischemia and subsequent tissue damage due to reduced blood supply.
Symptoms of vascular complications include:
- Immediate pain: Often described as intense and unusual compared to typical injection discomfort.
- Blanching: Whitening of the skin over the affected area, indicating compromised blood flow.
- Mottled skin appearance: A lace-like, purplish pattern on the skin, known as livedo reticularis, suggesting reduced circulation.
- Cold skin: The area may feel colder than the surrounding tissue due to lack of blood flow.
- Delayed capillary refill: Slower return of colour to the skin after pressing it indicates poor blood supply.
Prevention strategies for VO:
- Anatomical knowledge: Comprehensive understanding of facial anatomy to avoid major blood vessels.
- Aspiration technique: Pulling back on the syringe plunger before injecting to check for blood return, which would indicate intravascular placement.
- Low injection pressure: Using minimal pressure to reduce the risk of inadvertently forcing filler into a vessel.
- Small bolus injections: Injecting small amounts at a time to minimise the risk and allow for better control.
- Cannula use: Utilising a blunt-tipped cannula instead of a needle to reduce the likelihood of penetrating a blood vessel.
Management of vascular complications:
- Immediate cessation: Stop injecting immediately if a complication is suspected.
- Massage: Gentle massage of the area to disperse the filler and restore circulation.
- Hyaluronidase injection: An enzyme used to dissolve hyaluronic acid-based fillers rapidly.
- Warm compresses: To promote vasodilation and improve blood flow.
- Anticoagulants: Consideration of medications to prevent clot formation in the occluded vessel.
- Hyperbaric Oxygen Therapy: In severe cases, this can enhance tissue oxygenation and promote healing.
In terms of early onset complications, patients may experience persistent swelling beyond three or four days. This may be an allergic reaction in which antihistamines have no role in swelling. If you are having persistent swelling, you may want to consider a short course of steroids: prednisolone 20 to 30 milligrams for four to five days. You do not need to taper that afterwards. You should be able to resolve this.
Lumps can also become more apparent, and hematomas can fail to resolve. If this happens, you may consider treatments such as laser. They may help dissipate a hematoma infection.
Another thing that can happen is if you’re a little bit deep when using a cannula on the chin or on the cheek, you can traumatise the muscle and impair muscle function. Your patient may come back and say, “I’m having difficulty talking. I’m not smiling properly.” This is just muscle trauma that will resolve. If you are unlucky and happen to touch a nerve with a cannula, you may likely get some paraesthesia that will resolve on its own as well.
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Causes and types of infections
Incidences of acute infection are rare (0.04-0.2%), although a lot will be underreported.5
They can stem from several factors, including poor disinfection at the time of injection, injecting through an infected sebaceous gland, reduced skin immunity, and bacteremia.
Types of infections include cellulitis, which manifests as painful, hot, swollen red skin possibly accompanied by blisters and systemic symptoms like fever and malaise, and abscesses, characterised by painful, warm masses containing pus, potentially leading to systemic symptoms.
- Cellulitis: Typically presents within three to seven days as painful, hot, swollen red skin, possibly accompanied by blisters and systemic symptoms like fever and malaise. Treatment involves the use of oral antibiotics, such as Flucloxacillin or Amoxicillin, with alternatives for penicillin-allergic patients.
- Abscesses: Developing seven to 14 days post-treatment, abscesses appear as painful, warm, fluctuant masses. Management may require oral or IV antibiotics and possibly surgical intervention for incision and drainage.
Strict aseptic techniques, comprehensive patient education, and meticulous aftercare are important to mitigate these risks. Ensuring needle channels are closed before applying makeup or touching the treated area is essential to prevent infections.
Effective treatment protocols
Early detection and prompt management of complications are paramount.
Patient education is also very important. Tell patients that if you do have a problem, it’s not enough to send a picture on social media. If you recommend they come in, they have to come in. It is important to understand that things like infection, vascular compromise, lumps, nodules etc can happen. But if they come in early, we may be able to intervene and deal with it. If they live far away and they’re not prepared to travel again; maybe that’s a reason not to treat them.
Prophylactic measures and early detection are crucial for managing infections.
One of the key things that I’ve learned is that bacteremia can be a serious problem with filler injections. So even if you are considering doing a treatment on someone who’s had recent dental procedures, you want to wait at least two weeks before or two weeks after seeing a hygienist. It also makes sense that if someone’s immunocompromised, i.e. they have had a recent vaccine, they are going to be at higher risk, so avoid treatment.
For cellulitis, oral antibiotics such as flucloxacillin or amoxicillin are recommended, with alternatives like clarithromycin for penicillin-allergic patients. Abscess treatment may require oral or IV antibiotics and, in some cases, incision and drainage.
If it is an abscess, know where your regional oral maxillofacial unit is and get in touch to liaise with them. They have guidelines that they follow. If it’s a small abscess, just puncturing it with a needle is fine. But if it’s a larger one, you may need an incision and drainage. The patient may need oral/IV antibiotics.
Future directions in complications management
I believe there is a need for improved patient risk management, the development of local and national guidelines, enhanced microbiology support, and the establishment of a central register for complications. These steps will foster better outcomes and safer practices within the industry.
References
https://www.rare.consulting/blog/how-the-uk-medical-aesthetics-market-is-evolving
https://bcam.ac.uk/media/news/37/bcam_2023_annual_clinical_review/#:~:text=Top%20treatments&text=The%20top%20five%20treatments%20most,an%20increase%20of%205%25)
Funt D and Pavicic T. Clin Cosmet Investig Dermatol 2013;6:295–316
Signorini M, et al. Plast Reconstr Surg 2016;137(6):961–71
https://www.acquisitionaesthetics.co.uk/wp-content/uploads/2022/01/Acute-Infection.pdf