Big or small, there are always risks when conducting aesthetic procedures, and even the most skilled or trained practitioners can cause a complication.
However, in recent years, there has been a rise in the incidence of complications, perhaps in line with more aesthetic treatments being performed than ever before.1 Alongside this rise, there has also been a greater development of technology within the aesthetic sector.
Not only has this been positive in terms of performing aesthetic treatments and giving patients great results, but now these devices are also used on the other side of the procedure – specifically when it comes to the management of complications.
In light of this, Aesthetics spoke to three aesthetic practitioners about what devices they use to manage complications, providing their tips for best practice.
Mr Benji Dhillon: Using laser for bruising
Bruising is a common side effect that can be expected after performing injectable treatments, and most of the time it is nothing to worry about. However, I’ve found that while it is something to be expected, in recent years the tolerance for it has reduced. Nowadays, patients don’t want any downtime or evidence highlighting that they have had a treatment. There are of course things that we can ask them to do prior to treatment that can help minimise the risk of bruising, such as avoiding anti-inflammatories, anticoagulants and alcohol intake amongst many, but it is never guaranteed. It’s worth noting that practitioners should be mindful of the difference between a bruise and a vascular occlusion, and to assess and treat appropriately as well as inform the patient when it is something to be concerned about.
We already treat a lot of indications using laser where we target blood, for example varicose veins, spider veins and even rosacea. Treating bruising essentially works in the exact same way. The right kind of laser or intense-pulsed light device can help to completely get rid of, or help speed up the process of resolving the visibility of a bruise. In my clinic I use the BBL Hero device which uses broadband light, an advancement of intense pulsed light, which has different filters for different skin types. It can be used in most cases across skin types. However, there is also the possibility of also using a 1064 nm laser in my practice, which may be more useful for darker skin types. The light or laser targets the components of blood, leading to its breakdown. Typically, the patient should see an improvement in the bruising by the next day.
The size of the bruise doesn’t really matter – you can treat anything from a small spot to something the size of a 10p coin. The main thing is catching it early and treating it quickly. This is because once the haemoglobin has already started to break down, there’s nothing that the device can do. So, you really need to be treating the bruise within one to two days after it has been presented.
Because of this time frame, I always offer complimentary laser or BBL treatment for bruising after injection (should they require it) during the initial consultation and procedure. Usually, the patient will then call me the next day if they are concerned. It’s also important for practitioners to add into their consent forms that bruising is an expected side effect, so that patient expectations can be managed.
When it comes to treating bruising, the main thing that I advise my patients to do for management is to ice it and follow all other post-treatment care such as reducing intake of alcohol.
Mr Dalvi Humzah: Ultrasound for filler misplacement
While most side effects from dermal filler injections are mild and nothing to worry about, there can be some more serious adverse events. One of the most serious complications that can arise following dermal filler injection is caused by injecting into a vessel, which can cause vascular occlusion, skin necrosis and in rare but serious cases, blindness.2
While even the most skilled injectors can cause complications, there are ways that they can be minimised. Ultrasound is one of the newest methods for preventing vessel obstruction and is fast becoming common practice in an aesthetic clinics. Scanning your patients prior to injecting means that you can see their anatomy, identify where the large blood vessels are, and therefore plan where your injection points are going to be. This visualisation allows you to identify where to place your needle and cannulas so that your filler does not get placed into a vessel.
After treatment, ultrasound also allows you to see whether there is normal or abnormal blood flow through the vessel and identify if you have injected safely. If a complication has occurred, ultrasound is useful for two reasons:
- You can see where the filler has been placed, so you know exactly where you need to inject the hyaluronidase. Without ultrasound and being able to visualise what is under the skin, you cannot be as accurate as to where you are targeting.
- You can see whether blood flow has resumed or not following hyaluronidase injection. This is useful so as not to overtreat, as you can see exactly when the hyaluronidase has started working. Without ultrasound, practitioners typically keep injecting and wait for the skin to go pink to know it has been rectified.
When it comes to using ultrasound, you need to be trained appropriately so that you are aware of how to interpret the image properly. There’s no point scanning but not being able to fully understand what you are seeing! I recommend going to a training course that can teach you this in advance before using it on a patient and practicing a lot so you can train your eye. Practitioners also shouldn’t have a false sense of security simply by having the ultrasound machine and should implement all other precautions for preventing complications.
You should also make sure that you buy an ultrasound device that works for you – there are a lot of different products on the market, with some of the popular brands being Clarius, VScan, Butterfly IQ, Lumify, and Sonoinject. Some of these are quite big, so if you have small hands it wouldn’t be easy to use. Some also heat up quite fast, so you may need a fan added to them to cool it down, but that can make it quite bulky. I advise that when you go to a training course, trial them all out and see what feels the most comfortable in your hands! Of course, the big conference and exhibitions such as ACE and CCR also have ultrasound companies exhibiting, so this is a good opportunity to speak to the companies first-hand.
Prior to treatment, you always need to make it clear to the patient what adverse events to watch out for – while some vascular occlusions, for example, can occur straight away, if you aren’t using ultrasound some may not be obvious until after the patient has left the clinic. So, advise them what might indicate an issue and ensure they are provided with an emergency number to contact should they suspect a problem.
Ultrasound is also great to help progress your skills. If you inject without ultrasound, you can reflect on where you have injected by scanning afterwards to see where your product has ended up. It really can allow you to become more accurate and precise when injecting.
Dr Preema Vig: Radiofrequency microneedling for surgical scarring
Scars will form any time a cut or incision is made in the skin, and the role of a scar is to close a wound in the skin as quickly as possible. Many of our patients will experience the formation of scar tissue on the body after plastic surgery, which may contract and tighten for six to 12 months following the initial procedure. During this time, the scar may become dry and irritated, and can also negatively affect the patient’s self-confidence due to its appearance.
Scars tend to heal as a fine line and they may be barely visible. However, when a scar doesn’t heal in as fine a line, it can fall into one of the following categories:4
- Flat and widened scars – common in areas of constant motion
- Raised and widened/keloid scar – these grow and spread resulting in unsightly firm nodules
- Raised and widened/hypertrophic scar – appear similar to keloid but do not spread beyond the borders of its original shape
It is common for younger and more healthier patients to have formed more scar tissue than older patients, as their bodies may have a bigger scar response to tissue.5
Over the last five to seven years, the aesthetic industry has seen an advancement in technology and device development, which in turn has seen the introduction of new procedures and systems that combine more than one modality for optimal results.
Microneedling has long been used to successfully treat scarring, which involves creating micro-punctures in the skin, helping to break down old scar tissue and stimulate fresh new collagen and elastin. While this has produced good results, I have found that these can be further boosted when supported with radiofrequency (RF) energy.
In my clinic I use the Secret RF machine, a device that combines the two modalities to work on most types of scarring. It uses microneedles to deliver radiofrequency energy into varying levels of the skin, including the deeper layers, where the treatment is most beneficial. The amount of energy released can be customised and delivered at targeted depths, ranging from 0.5mm-3.5mm. For surgical scarring, you would vary the depth and customise the number of treatments.
In general, patients can see results for surgical scarring after a minimum of three treatments due to the unique nature and depth. However, this will vary between individuals and will depend on components such as the age of the patient, the quality of their skin and their lifestyle (for example whether they are a smoker, what their diet consists of, what their health levels are, etc).
It’s important to note that not everyone is suitable for a RF microneedling treatment, so a thorough consultation should be held where patients can disclose their full medical history and lifestyle factors.
Contraindications for this treatment include:
- Pregnancy, cardiac pacemakers or implantable medical devices, as well as patients who are undergoing treatments for skin cancer or have a history of cancer
- Lactation period
- Active viral, fungal or bacterial skin infections
- Unregulated diseases (diabetes, Hashimoto’s, etc.)
- Anticoagulants intake
- Isotretinoin intake as this leads to a tendency to develop keloids
- Purulent, pinkish acne and all active forms of acne
- Active skin lesions in the course of lichen planus, atopic dermatitis or seborrheic dermatitis
- Open wounds in the treatment area
- Recent trauma
- Ablative aesthetic treatments including peels and CO2 laser
If a patient is not suitable for RF microneedling, I would refer them for CO2 laser treatment to help with their surgical scarring instead.
In conjunction with RF microneedling, I also advise that my patients adhere to a cosmeceutical topical home care routine, as well as appropriate skin preparation before treatment. This helps to minimise any inflammation, hyperpigmentation in the skin and speed/support healing. I recommend using the iS Clinical Super Serum and iS Clinical Brightening Complex.
1. Amelia Hill, Botched Cosmetic Procedures on the Rise, 2022, <https://www.theguardian.com/ lifeandstyle/2022/mar/01/botched-cosmetic-procedures-on-the-rise-says-campaign-group>
2. Haneke E, Managing Complications of Fillers, 2015, <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4728901/>
3. Millicent Odunze, Overview of 3 types of surgery scard, 2022, <https://www.verywellhealth.com/ plastic-surgery-bad-scars-2710210#:~:text=A%20scar%20that%20does%20not%20heal%20as%20 a,may%20remain%20flat%2C%20but%20become%20widened%20with%20time.>
4. Whitney Palmer, Being Older Helps Skin Heal with Less Scarring, 2018, <https://www. dermatologytimes.com/view/being-older-helps-skin-heal-less-scarring>
5. Cutera, data on file