Dr Sharan Uppal advises on how to stay calm and take care of your mental health after causing a vascular occlusion
In 2020, after six years of aesthetic practice, I caused my first vascular occlusion (VO) during a hyaluronic acid dermal filler treatment. I had planned to address multiple facial areas, with the goal of achieving a rejuvenated, fresh-faced look.
I began by treating both the patient’s temples with a needle to periosteum approach, 1cm along and down from the temporal fusion line (aspirations were negative). Following this, I wanted to create more seamless transitions, so used a cannula, entering over the zygoma to treat the lateral orbital fat compartment. Aspirations with a 25 gauge cannula were all negative too.
The whole treated area looked perfect, with normal skin colouration and my patient was comfortable throughout. It was only as I retracted my cannula to remove it that an immediate swelling appeared just lateral to the tail of the brow, which I recognised to be a haematoma. I then noted pallor over this area and at the superior aspect of her forehead, just below the frontal hairline (nowhere near where I’d treated).
I realised, from the geographical pathway of pallor, that I was dealing with an occlusion of the superficial temporal artery and one of its smaller branches.1 In retrospect, it was most likely caused by my cannula having impaled a vessel en route to my treatment area, providing a path for the filler to enter an artery.2 Then the retraction of the cannula, at the end of treatment, allowed the previously impaled area to bleed (hence the haematoma). Only moments passed between the above signs and my next assessment, finding a delayed capillary refill time (CRT) of five seconds over the territory of the supraorbital artery.3 I knew what could happen next if there was further tracking of the filler emboli: the potential for blindness!4
I diagnosed and dealt with what I was seeing immediately, using hyaluronidase, as per my emergency reversal protocol.5 Thankfully, my patient had a good outcome, with no necrotic or visual sequelae. However, the week following the VO was definitely up there as being one of the more stressful weeks of my life. I imagine any clinician who has dealt with this type of complication, regardless of their level of experience, will be able to resonate with this.
After my initial shock, a surprising calmness followed. I can only liken it to the mode we go into when applying an airway, breathing, circulation, disability, exposure (ABCDE) approach with a critically ill patient. This allowed me to methodically make my assessment of my patient’s CRT and identify the arterial pathway that had been impacted. Below, I outline what I believe to be the prerequisites for making a calm assessment.
I have undertaken many practical in-depth injectable and facial anatomy training courses and I have further supplemented my knowledge using online resources. As a visual learner, I found viewing the anatomy on a cadaver particularly helpful, consolidating my theoretical knowledge with a more three-dimensional understanding.5
I regularly refresh my knowledge in how to recognise and manage a VO. There are many great resources available to aesthetic clinicians, and I have attended a comprehensive complications training course and regularly review online training resources.
Your emergency kit and guidelines should be in an easy to access location. The very simple step of ensuring emergency drugs are in stock and in date makes a significant difference to one’s state of mind, and the clinical outcome when dealing with a complication.6
A willingness to acknowledge a complication may have occurred is vital. We all have that little voice that wants us to bury our head in the sand and hope everything will sort itself out. That voice tends to be louder when we do not know how to handle a situation, risking one passing off findings as the result of a more minor inconvenience.
As per the General Medical Council guidelines, you should communicate openly and honestly with your patient.7 This begins during the initial consultation; for this patient I had explained the side effects and risks that can occur during and after a dermal filler procedure, using non-medical jargon and checked my patient’s understanding to ensure informed consent.8 This essential pre-requisite allows for easier explanation if a complication does later follow and also helps protect you medico-legally.
As I checked my patient’s CRT, I also kept talking to her about what I was doing and why I was doing it, which builds the patient’s confidence in the management strategy and reduces the element of fear created by the unknown.
Dealing with a complication as a lone practitioner can make even the most experienced clinician feel vulnerable. Forethought and planning into how and where you will access clinical support, should it be required, allows you to feel part of a network.
During the emergency reversal procedure there was an added complexity – my patient told me she needed to return home for childcare reasons. I explained honestly that I needed to see the skin perfusion improve before it was safe for her to leave, otherwise her skin was at risk of necrosis, which could lead to scarring. At this point I could see the potential ramifications were beginning to register with my patient and she was becoming quite anxious.
My inner voice was giving me good advice, telling me I needed to remain calm, stay professional, and keep showing her that I cared. I managed to get another half an hour with her to inject more hyaluronidase. Her CRT improved and I was happy for her to leave and for her to return within a few hours so that I could review again.
When working with growing pressure and patient anxiety, clinicians need to ensure that they do the below, which are principles applicable to any aspect of medicine.9
Once my patient had left the clinic, I slumped in my chair and took a moment to process what had happened, before reaching out to my colleagues with the before and after videos (permission was granted for this).
They replied very quickly asking if I was ok, and instantly, I didn’t feel alone! Then came their clinical reassurance that I’d taken the correct steps and giving me emotional support, making me feel relieved and grateful.
I appreciate that I am in a fortunate position, as although this complication occurred in my aesthetic clinic (where I work solo) I also work for a larger clinic, hence I’m part of a clinical team to whom I was able to reach out to. Further to this I hold a membership with complications networks, which I recommend all aesthetic clinicians join.10,11
The worry for my patient didn’t just end there. At the review later that day, I added further hyaluronidase to the couple of localised areas where the CRT was four seconds, with a positive outcome.
That night I barely slept, my internal dialogue questioning myself: was it my technique? What could I, and will I, do differently in the future?
Then there was an additional anxiety. I had a busy couple of days ahead, including more temple hollow treatments. I wondered whether I wanted to risk putting myself through this again, and if I didn’t treat, what would that mean for me going forward?
I considered never treating any of the higher risk areas ever again. Especially because I had followed ‘the safety rules’ – aspirating and using a 25 gauge cannula with comprehensive training, knowledge and ample experience treating this area. While we all know these are not going to 100% guarantee prevention of a complication, deep down we don’t think it will happen to us. As acknowledged by nurse prescriber Linda Mathur in another Aesthetics journal article, aesthetic complications can have a huge impact on not just the patient, but the practitioner.12
Whilst my internal dialogue was running, so was the higher part of my consciousness. I reminded myself that I love my job, that aesthetics has given me a sense of purpose, and that I make a positive difference to the lives of my patients.
The concern for my patient remained in the background all day, every day for about a week. Until I could see her come through the other side, with no further sequelae. I reviewed her daily in the first week and the lines of communication were open for her through calls/text. I’m happy to add that I have since completed her treatment and she has remained under my care for future treatments.
Most of us arm ourselves with knowledge, techniques and protocols to reduce the risk of complications like VO and to be able to need to. This is absolutely the correct thing to do. However, what’s not often talked about is how mentally and emotionally drained you feel in the week(s) following a VO, even when successfully managed.
Your knowledge and skills are tested, your professionalism and ethics are tested, but more than any of that it’s your RESILIENCE that is truly put to the test. In order to manage this event correctly, practitioners need to learn how to recognise and manage a VO, build up a strong support network, and maintain a strong sense of self and purpose through self-development practices.
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