Joel Cohen, MD; Director, About Skin Dermatology and DermSurgery; Englewood and Lonetree, Colorado
Dermatologists across the country are using dermal fillers on a daily basis and the products available in the US are believed to be safe and effective provided that they are used correctly. In his presentation, Dr. Joel Cohen discussed the importance of understanding, avoiding and managing dermal filler complications. Filler complications can be stratified into something that doesn’t look very aesthetic when it is superficially or inappropriately placed to situations involving skin necrosis and infection. Regarding aesthetics, Dr. Cohen commented that unfortunately many patients are still walking around with features due to inappropriate use of dermal fillers, which can create an artificial look. This has resulted in patients tending to shy away from using fillers. Dermatologists need to be aware of the agents available and what has been reported as well as different injection techniques.
The key for clinicians, with regards to dermal fillers, is to make things appear natural. Dr. Steve Mandy wrote a review in April 2007 in Dermatological Surgery which reviewed the lip and how important is to place the filler in the right area so that it looks natural.
Injecting the Infra-Orbital Area
Many people prefer different agents to be used in this area and it is important to keep in mind that, in general, this is a very deep injection. If one is to inject superficially, then there is a risk to having the appearance of nodules. There are various hyaluronidase agents available, for example, Vitrase, Amphadase, compounded hyaluronidase, and Hylenex (human hyaluronidase that is currently off the market) . Most of these products are of animal origin, so it is important to do a skin test.
Other issues regarding superficial injection include Artecoll and Artefill. Research has shown that there was not consistency in the particle size of Artecoll; therefore, they were easily ingested which could lead to fibrosis. Some people have had great experiences with Artefill as there is much more consistency in the particle size.
Radiesse (calcium hydroxyappetite) became available in 2003/2004, and many clinicians initially believed that it could be used anywhere. However, we have learned that it can’t be used in the lips. Sculptra (poly-L-lactic acid) has shown great results as a volumizing dermal filler for the cheeks. As is the case with all dermal fillers the key to success is knowing how it should be injected. Careful attention needs to be paid to reconstitution time, volume of injection per location, and the proper injection depth. Sculptra requires longer reconstitution times (at least eight hours prior); higher volume reconstitution, i.e., mix the solution with 5+ cc of sterile water and add 1 cc 1% lidocaine prior to injection; and, inject deeper, i.e., into high fat. It is also important to be careful to avoid injecting precipitate at the end of the syringe. Following these simple points will help in avoiding SQ papules.
Dr. Cohen and others wrote a protocal on the management of visible granulomas following periorbital injection of Poly-L-Lactic Acid in Plastic and Reconstructive Surgery.
Bruising and swelling happens to many patients. It is unfortunate, but it does happen from time to time. There are some things that patients can avoid, such aspirin. Patients on anticoagulants also have to be managed; however, it can be done. There is also a whole list of vitamins that can potentially interfere with bleeding; so again, something to keep in mind. Clinicians need to be realistic with their patients, so that can expect some bruising and/or swelling which may last up to ten days. It is really important to talk with your patients prior to the procedure.
What can patients do to minimize bruising and what to do when it occurs?
Dr. Kevin Smith wrote an article on the role of ice. Not only will ice decrease pain, it also decreases the bruising and swelling. There are also agents that patients can rub directly onto their skin. Topical Arnica has not proven to be very effective however, oral Arnica may also help regarding swelling and bruising. What is most practical and most helpful solution to resolving bruising quickly in Dr Cohen’s experience is to use a pulsed-dye laser to treat bruising.
At 2 days post-filler
- 7.5 J
- 6 ms
- 10 mm spot 1
There is really about a two-day window to treat patients who experience significant bruising. There are also other devices that can be used such as IPL, which is done at short pulse durations (10 ms).
Injection speed is something else that clinicians need to consider. A clinical trial with Glogau, et al, they found that if healthcare providers inject quickly, it could actually lead to more bruising and swelling (about .3 cc per minute). The study also found that a fan-like injection leads to more bruising and swelling.
Dermatologists need to be aware of potential infection, as it can occur. Treatment includes I & D of the suspected infection, culturing the material, and initiating oral antibiotics.
Necrosis is another important issue to be aware of. There are certain areas that clinicians must pay a particular interest in, e.g. the glabella. It is important to watch the skin as you inject. You should aim superficial and medial, and aspirate. Regarding treatment of a pending area of necrosis if you identify sudden blanching of the skin following injection is to immediately apply warm gauze, repeatedly tap the injected area, apply nitro paste to the treatment site immediately while the patient isin the office and heparin treatment (low MW, SQ). Regarding impending necrosis, hyaluronidase in multiple stabs along and perhaps into the adjacent artery has shown to be a novel treatment. It is very important as a healthcare provider to intervene immediately and not “wait and see what happens” in the cases of impending necrosis.
Sudden blindness has also been reported with different injectable agents around the eyes. Healthcare providers should inject shallow in this area and be extremely careful, keeping the facial arteries in mind.
The risk of sensitivity with the newer agents is extremely low.
In conclusion, clinicians must pay careful attention to the injection site area, take all precautions, and talk to their patients in order to set realist expectations.
- Karen JH, Hale EK, Geronemus RG. A simple solution to the common problem Ecchymosis. Arch Dermatol. 2010;146(1):94-95.