Dermal fillers are now firmly established in the non-surgical treatment of facial rejuvenation, providing volumetric and structural manipulation of soft tissues.1 With increasing use, there has been a concomitant increase in dermal filler-associated complications,2 and now, more than ever, with changes in the global situation regarding medical treatment and the pandemic, practitioners need to be aware of all related mitigating factors to deal with direct and indirect complications.3
All practitioners will need to be able to demonstrate the ability to deliver safe practice and care to deal with infection control. Complications may be viewed as occurring temporally – within hours to days following a procedure – or as delayed onset complications.4 In the past few years, specific hypersensitivity-related events seem to appear between one month to a year following an injectable procedure.5,6
In one study involving 400 patients with filler injected into the tear trough area or lips, it was indicated that 4.25% developed prolonged (up to 11 months) and recurrent (average: 3.17 episodes) late (average onset: 8.41 weeks after the injection) inflammatory cutaneous reactions compared to a reported incidence of 0.02% with previous fillers.5 Another study reported five cases of late-onset inflammatory reactions; these were related to different hyaluronic acid products.6 The hypersensitivity-type reaction appears to be related to the technology used in the manufacturing process, and the subsequent differing products of degradation.5,6 The consensus opinion regarding complications appears to relate to several factors – the seven ‘Ps’ – which will be discussed below.
1: Patient selection
There is evidence that aesthetic patients in clinics have a higher incidence of body dysmorphic disorder (BDD) than those in the general population.7 It is estimated that the prevalence of BDD in the general population is around 1-2%, while with patients presenting for cosmetic treatments, between 7-15% may exhibit symptoms of BDD when screened.7 Cosmetic medical treatments may result in no change, worsening of concerns or the development of new concerns.8,9
Given these potential issues, screening tools have been developed to identify groups of patients who would not achieve optimum outcomes. The SAGA system is a quick and efficient screening assessment that has been used in aesthetic surgery to ascertain the psychological motivation of patients and aid in patient selection.10 This system assesses the following four parameters in a patient’s journey in seeking cosmetic treatment: episodes of sensitisation, aesthetic self-assessment, peer group comparison, and avoidance behaviours. When used during the consultation it allows surgeons to establish a rapport with the patient, while giving an insight to the patient’s personality and complaint, therefore helping with patient selection for surgical procedures.
There are more direct methods of screening for BDD and further information is available regarding different scales direct from the Body Dysmorphic Disorder Foundation.11 Selection of the appropriate patient will benefit the practitioner and reduce risk of unwanted outcomes from the patient’s perspective.
2 & 3: Procedure and product
Selection of the appropriate procedure and appropriate product for the specific patient appears to be imperative in avoiding complications.12 The practitioner has to be able to communicate and discuss the relevant procedures and alternative treatment options that may be suitable for the specific patient as part of the consent pathway.
One of the main decisions the practitioner has to make is consider the desires of the patient and match this with the available treatment procedures. It is also clear that the greater the volume of filler, or the use of different fillers simultaneously, appears to increase the risk of adverse events, in particular post-treatment infections.
A review of complications by De Boulle and Heydenrych looked at factors which may contribute to dermal filler complications; they concluded that the majority of complications were related to sterility of the procedure, placement, volume, and injection technique.13 This is probably related to changes in the soft tissue environment.12,13 With this in mind, practitioners must pay particular attention to selecting patients and assess them in terms of medical comorbidities.
An in depth knowledge of regional anatomy with specific knowledge of vascular anatomy and anomalies with the use of injection techniques that place fillers in the appropriate tissue layers will mitigate against adverse events such as vascular compromise or malar oedema.14,15 Using the appropriate technique (needle or cannula) must be considered by the practitioner in placing the appropriate product in the correct layer.
Several studies have shown that needles and cannula deliver products in different patterns. The needle on the bone technique at 90 degrees results in product being placed in all layers of the facial tissues. Cannulas allow delivery into specific layers and a greater degree of control.15,16
The gauge of cannulas and needles used has also been investigated with regard to arterial wall penetration. It has been demonstrated that a 27 gauge needle has a similar arterial wall penetration to a 27 gauge needle. This study indicates that when using cannulas in the facial region, cannula diameter larger than a 27 gauge is safer and reduces the risk of intra-arterial penetration.17
Selecting patients, performing a comprehensive medical assessment, having knowledge of facial anatomy and the product to be injected, and employing correct, careful, and meticulous injection technique can help decrease the incidence of adverse events.
4 & 5: Preparation and prevention
Associated with the factors discussed above, scrupulous cleansing of the skin prior to dermal fillers has been shown to reduce rates of infection.18 One study’s recommendation was based on using 70% isopropyl alcohol, povidone-iodine or a chlorhexidine containing solution.18 Over the last few months, the global COVID-19 pandemic has resulted in a re-evaluation of the skin cleaning protocols.
A review of the disinfection effect of different solutions on inanimate surfaces has shown that surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite was effective against coronaviruses within one minute. Other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate are less effective.19 These studies, together with recommendations regarding topical skin cleansing18 will now need to be considered in detail as clinicians re-enter into medical aesthetic practice. Formal guidelines on infection control will be required with appropriate risk assessment of their clinical environment. The recent guidelines from the JCCP/sk:n recommend the use of solutions containing ethyl alcohol, or a hypochlorite solution as skin prep.3
6: Procedural checklists
Within the sphere of surgery, the use of checklists has been instituted to reduce adverse events. In a non-surgical setting, such checklists may be of value. The view is that a form of dermal filler checklist or assessment may decrease infective and other adverse events; until recently no such checklist was available.
A recent development has been the use of an assessment tool for facial injections – the Assessment Cosmetic Injection Safety Tool (ACIST). This enables practitioners to identify a patient’s potential for adverse events. This tool assess four areas: medical and social history, adverse event risks and eliminators, warning indicators and instructions, and cosmetic plan postponement. In a preliminary study of 100 patients desiring injection of cosmetic fillers, 32% required additional nursing action or further discussion related to their medical and social history and 68% required that the nurse injector consult with the medical director. Of the 68% requiring medical director consultation or intervention, 4% had indications for delaying or avoiding cosmetic treatment injections. A summative assessment with the cosmetic injection specialist revealed a positive experience with the overall effectiveness of the ACIST. Using such an assessment it was possible to successfully identify factors to reduce or prevent potential dermal filler adverse events.20
7: Photo-documentation
The old saying goes, ‘A picture is worth a thousand words’. In facial aesthetics, clinical photography is imperative in recording patient presentation and progression with treatment. It is also very useful in marketing and advertising.21 In recording photographs of patients or videos, a written informed consent is mandatory. This must include information as to what purpose the photographs are being taken, such as for medical notes, presentations, lectures and social media.
It is advisable to prepare the patient prior to photography by arranging the hair away from the face, remove all facial makeup and jewellery and consider appropriate background and lighting. Specific views, frontal, oblique and lateral views with and without animation should be considered. Practitioners should ensure consistency between the photography parameters for their before and after images.22
3D photography and analysis is a novel and accurate way of recording patient’s facial and body contours and track changes with time and age. These systems allow analysis, planning and tracking changes following treatments. Several systems are available such as those by Canfield, Crisalix and QuantifiCare. These systems can enable adverse events to be accurately followed and provide accurate discussion of changes in soft tissue contour.23
Reporting adverse events
Adverse events will occur in any practice and when it occurs, the practitioner should have all necessary protocols to deal with general and specific problems e.g. vascular compromise or blindness.24,25 Such protocols are important and practitioners should have them set up to institute as soon as these specific complications occur. Note keeping and reporting to appropriate monitoring bodies e.g. the MHRA (Yellow Card) is considered good medical practice and mandatory.25
Ultimately, in order to avoid complications, the practitioner will need to have carefully evaluated the patient, have an in-depth knowledge of anatomy, understand the properties of the specific fillers used and deliver these products appropriately. In the current circumstances, all practitioners will need to have taken a thorough risk assessment of their treatment pathways, as well as safety considerations, for their staff and patients.
Specific groups such as the British College of Aesthetic Medicine, the British Association of Cosmetic Nurses and the Joint Council for Cosmetic Practitioners have produced guidance for practitioners to consider instituting for this enhanced infection control policy, which is discussed more on by clicking here.3,26,27,28
