Nurse prescriber Lynn Lowery shares a case study of a lip complication that she successfully treated and describes how practitioners can avoid similar scenarios
Dealing with a complication is one of the most difficult experiences within the aesthetic setting. However, it presents even more of a challenge when the patient presents to you with a complication from another clinic, as you may not ever have the full clinical information of the previous treatment. In my professional opinion, best practice is to send the patient back to the treating practitioner. However, this is not always a possibility for a number of reasons: the patient may not have confidence in the original practitioner, they may feel worried that their complication may not be treated seriously by the practitioner, there is a potential for misdiagnosis if they do not have the training, or the practitioner may not be available.
In addition, other patients may present to you following a referral from their treating practitioner as they feel unable to deal with the situation. Whatever the circumstances for a patient’s presentation to your clinic, it is important to gain as much valuable information as possible about the procedure from both the patient and practitioner. Complications are easier to manage if there are details of a full medical history, timeline of treatment, products used and the technique of delivery. These incidents are distressing for all parties and the patients are usually feeling generally unwell and distressed.
A 52-year-old female patient was injected by a different aesthetic practitioner with 1ml of a well-known hyaluronic acid (HA) dermal filler into the lips using a needle. A dental block was administered prior to the lip augmentation for pain management. At the time of the injection, what appeared to be a large haematoma appeared to the left superior lateral tubercle. The practitioner had massaged the ‘lump’ upwards and outwards and advised the patient that it may bruise. The following day, the patient became concerned about the appearance of her lip, which was causing her slight discomfort and had an appearance of a bruise, so she contacted her treating practitioner (Figure 1). After a review that day, the patient was told by the practitioner that it was just a bruise and the blood supply was fine and so she was sent home.
Two days following treatment, the patient was feeling very unwell with increased pain. She contacted her practitioner for a review and again she was informed that the blood supply was fine. Note that the Aesthetic Complications Expert (ACE) guidelines state that, ‘Severe pain is not a feature of dermal filler treatment and if the patient complains of severe pain in the subsequent hours after treatment, this should alert the practitioner to the risk of an impending necrosis’.1,2
The patient continued to worry for the days following because the pain was increasing and she was unable to eat or drink. She tried contacting her practitioner for the next two days but could not get through as they had gone on holiday.
Five days after her original dermal filler treatment, the patient decided to seek additional help and was seen by a nurse in her local GP surgery. She was prescribed doxycycline for five days as the nurse didn’t know what the problem was and suspected it could be an infection. They also advised that the patient go back to her original practitioner.
Patient presenting to my clinic On the same day as visiting the local GP surgery, the patient came to my clinic after she was referred to me from the ACE Group forum, a closed Facebook group only available to ACE members. The patient allowed me to examine the lip, despite extreme pain; she was tearful and feeling generally unwell (Figure 2). Unfortunately, I had no access to her clinic notes so I had to take a comprehensive medical history and timeline of events from the patient, discussed above. The patient was able to determine that the practitioner had used a needle for the treatment.
Upon my examination, I noted extreme discolouration. This colour distribution was the biggest indicator to help me identify that she was experiencing impending necrosis due to the dermal filler injection, which had caused a vascular occlusion. I suspected that the vascular occlusion was due to the dermal filler being directly injected into the superior labial artery, which lies between the mucous membrane and the orbicularis oris. I determined that the only solution was to dissolve the filler to regain tissue perfusion as soon as possible and limit the depth of the necrosis. I explained at length the cause of the vascular occlusion, the use of hyaluronidase in vascular emergencies, and the fact that this was our best chance of limiting the tissue damage and subsequent skin discolouration post occlusion. The patient agreed with my advice and consented to the treatment. A patch test was performed on the forearm of the patient prior to treatment, which was negative.3 Lidocaine was injected to the area of necrosis due to the extreme pain; necrotic skin tissue is characterised by extreme pain due to the interrupted blood supply causing the cells to be acidic.4
Once the patient felt the anaesthetic effect, I then examined the tissue damage more extensively. The tissue had partial thickness damage, meaning that it only extended into the first two layers of the skin epidermis and dermis, and the patient still had full muscle function to the orbicularis oris. Capillary refill time was extremely delayed and the skin discolouration had started to develop slough to the superficial dermis, which was able to be debrided with ease. According to ACE Group guidelines, devitalised tissue must be removed to decrease wound bacterial bioburden and to allow healthy tissue to regrow.5
Early recognition and treatment is extremely important to limiting the subsequent damage to the tissue in the event of a vascular occlusion
I administered 1500 units of hyaluronidase dissolved in 2.5mls of bacteriostatic saline to the necrotic area, including the oral mucosal surface, as per ACE Group guidelines.5 The patient was administered 300mg of aspirin immediately after the treatment as a precaution for any localised coagulation around the occlusion and to limit platelet aggregation; although this is anecdotal evidence, I felt it was appropriate due to the time delay. This hyaluronidase treatment was repeated twice and the patient was sent home with a prescription for analgesia.
The patient had showed a good result to the first dose of hyaluronidase (Figure 3), although the patient didn’t feel any change to the aching or gum discomfort. In my experience, the patient is the best indicator if you have resolved the occlusion as the pain should be relieved. The morning of the following day, which was six days following the original filler procedure, I reviewed the patient and because she still had extreme pain and the skin was still discoloured, I administered another 1500 units of hyaluronidase. I also arranged for the patient to attend the local hyperbaric chamber following this treatment. Oxygen therapy has been used successfully to treat retinal artery occlusions, and is thought to be an efficacious adjunct in dermal filler complication scenarios due to a variety of mechanisms, including oxygenation of ischaemic tissues, reduction of oedema, amelioration of ischemic/reperfusion injury, and promotion of angiogenesis and collagen maturation.6 I have personally found it to be effective in the reperfusion of tissue, limiting its damage. In the evening of the same day, I saw the patient again and repeated the hyaluronidase treatment and another 1500 units were given. I also prescribed acyclovir for five days due to the patient’s history of herpes, because she said that she could feel the start of an outbreak. At this stage, the patient was feeling generally unwell, nauseous, tearful and tired (Figure 4), which,in my experience, is normal at this stage. The pain was still severe and was radiating to the eye and ear, eating was also a problem as any clenching or grinding of the teeth was also very painful.
I advised the patient to consume high calorie drinks via a straw. On the third day of intervention, seven days following the original treatment, the patient underwent another hyperbaric oxygen therapy session and I reviewed again (Figure 5). I decided that a transdermal drug delivery treatment would be beneficial to help the healing because it has anti-inflammatory and anti-bacterial properties. I used the Plasma Shower device, which I have used previously to minimise the build-up of toxins from necrosis.
The review eight days following the original procedure and four days after my interventions revealed a much healthier perfused tissue with limited slough (Figure 6). I decided that another Plasma Shower treatment would be beneficial to help with the bacteria and inflammation.
The patient’s pain was now minimal, although there was still some disruption to the nerve with the patient reporting a numb feeling to the superior border and perioral tissue. The patient continued taking oral antibiotics and acyclovir and was reviewed six days later. As shown in Figure 7, the patient did not have any residual skin discolouration, although she continued to have sensation difficulties to the left perioral tissue. The patient continues to have open access to our clinic, should she require any further treatment.
In my opinion, this patient’s complication worsened as it went undiagnosed for several days and was allowed to develop. Early recognition and treatment is extremely important to limiting the subsequent damage to the tissue in the event of a vascular occlusion. Practitioners should be confident in their understanding of the difference between bruising and the dusky discolouration of a vascular occlusion.7,8 The patient’s distress was unfortunately made worse as she could not get hold of the practitioner while they were on holiday. The GMC states ‘You must make sure that your patients know how to contact you or another named suitably-qualified person if they experience complications outside your normal working hours’.2 While the practitioner had given the patient the name of someone to contact, this was over an hour away and the patient did not feel able to travel.
I felt it was important to refer the patient back to her original practitioner on their return from holiday and recommend that others do so too; everyone can make a mistake and the practitioner was very concerned about the wellbeing of the patient. Unfortunately, the lines of communication had broken down and the patient will no longer communicate with the original treating practitioner, although I did make sure that they were updated with the patient’s journey and progress.
Practitioners need to ensure that they are trained in the management of complications, which include anatomy and management skills. They should also establish a good solid network of colleagues they can trust and rely on when needed to assist them in the event of a complication.
1. Martyn King, Management of Necrosis, ACE Group, 2014. <http://acegroup.online/wp-content/uploads/2016/01/Necrosis-v1.4.pdf>
2. Guidance for doctors who offer cosmetic interventions, GMC, 2016. <https://www.gmc-uk.org/-/media/documents/Guidance_for_doctors_who_offer_cosmetic_interventions_210316.pdf_65254111.pdf>
3. Martyn King, The Use of Hyaluronidase in Aesthetic Practice, ACE Group, 2014. <http://acegroup.online/wp-content/uploads/2016/01/ACE-Group-Hyaluronidase-v1.2.pdf>
4. Adrienne J. Headley, Necrotizing Soft Tissue Infections: A Primary Care Review, American Family Physician, 2003. <https://www.aafp.org/afp/2003/0715/p323.html>
5. ACE Group, Guidelines. <http://acegroup.online/guidelines/>
6. Impending Necrosis After Injection of Hyaluronic Acid and Calcium Hydroxylapatite Fillers: Report of 2 Cases Treated With Hyperbaric Oxygen Therapy. American Society for Dermatologic Surgery. 2014; 40:9:1049-1052
7. Kenneth Beer, Jeanine Downie, & Jacob Beer, A Treatment Protocol for Vascular Occlusion from Particulate Soft Tissue Augmentation, J Clin Aesthet Dermatol. 2012 May; 5(5): 44–47
8. Bruna Souza Felix Bravo, Laila Klotz De Almeida Balassiano, et al., Delayed-type Necrosis after Soft-tissue Augmentation with Hyaluronic Acid, J Clin Aesthet Dermatol. 2015 Dec; 8(12): 42–47.