The Last Word: A&E training for aesthetic complications

With an increasing number of non-surgical aesthetic treatments being performed each year, there is inevitably an associated increase in the number of complications.^1,2 These can range from minor complications, such as temporary swelling and bruising, to the serious – vascular occlusion or necrosis. A recent complaints report conducted and published by independent accreditation body Save Face found that out of 613 adverse filler outcomes, nearly 4.5% were due to infection, and approximately 1% represented vascular occlusion or impending necrosis.³

With the ongoing regulation debate that this specialty is all too familiar with, we find ourselves left with a heterogenous market of mixed skills and mixed backgrounds. One would hope that those undertaking such procedures have the insight to learn how to recognise and treat any complications that may arise from their treatments. Sadly, this does not appear to be the case, as demonstrated by the complaints report, which found 83% of complications were caused by non-medics.³

But, where do patients with these complications go? Often it is their original aesthetic practitioner, but as mentioned, this relies on their ability to both prevent, recognise and treat complications. If the patient is unhappy with the conclusion of their practitioner, still concerned, it is out of hours, or they are simply scared and anxious, they will often seek assistance elsewhere.

The aforementioned report found that, whilst the majority of patients with complications were either ignored by the practitioner who had treated them or sought out corrective procedures by other practitioners, nearly 6% of those attended either their GP or Accident and Emergency department, which I will refer to as the Emergency Department (ED) for the rest of the article.³

The argument

A 2013 Department of Health review found that, over a 15-month period at the Chelsea and Westminster Hospital in London, 12 patients presented to the ED needing treatment for complications following cosmetic procedures, incurring a cost of £43,000.^4,5 For one individual, their adverse reaction to facial filler resulted in a five-night hospital stay and a reported cost to the NHS of £4,028.4,5 As the NHS does not recover funds from private healthcare providers following treatments, it could be argued that it should not have to bear responsibility for providing care for procedures that have gone wrong.⁶ Additionally, the NHS is already under considerable strain, both financially and in terms of workforce. The four-hour target, which expects 95% of patients to be seen within that timeframe, has not been met since July 2015.⁷ Clinical staff remain stretched to deliver safe, effective care due to the mismatch in supply and demand.⁸ The total number of ED attendances exceeded 2.2 million in July 2019 – the highest number ever recorded. The average number of ED attendances per day reached over 73,000.⁷

With this in mind, many argue that it should primarily be the original injector who manages the adverse event and refers to if necessary. However, the reality is that patients will still present to the ED, and in my opinion, the ED therefore needs to be able to deal with the wide variety of presentations that walk through that door.

However, it is important to note that emergency doctors or advanced clinical practitioners may not know which product has been used, or be aware that in some unfortunate cases the practitioner has used unofficial sources. Compounding this is the rise of those self-injecting filler, using substances ranging from hyaluronic acid to cooking oil. These patients will have no other care pathway apart from their GP or ED for their self-inflicted complications. The Department of Oral and Maxillofacial Surgery (OMFS) in London recently published an article detailing such a case, where a 24-year-old female presented with a four-week history of suspicious upper lip swelling.⁹ She was referred by her GP on the urgent head and neck cancer referral pathway. It was only when they reviewed her electronic patient records in more detail that they discovered she had presented to the ED four weeks prior complaining of lip swelling post self-injection of dermal filler purchased over the internet. She was unable to name the product used, or the website she ordered from, and as a result it was unknown whether the filler was permanent or non-permanent. Fortunately, the swelling self-resolved with conservative management, but this still cost the NHS £323.17 for one ED attendance and two OMFS clinic appointments. She did not undergo any imaging or further investigations once they discovered her previous presentation, but had this not been available, the costs incurred could have been significantly higher. It also meant this patient inappropriately took up an urgent cancer slot.⁹

My experience

Having been an emergency department registrar in my previous NHS life, I would not have felt adequately equipped to correctly deal with complications from fillers – dissolving lip filler certainly wasn’t covered by my specialist training syllabus! Burn victims, anaphylactic shock, sepsis – yes; visual loss secondary to filler-related retinal artery occlusion – no. Even now, working full time in aesthetics, differentiating a true complication from something benign can still be challenging. This is highlighted by the fact that some aesthetic-related complications have a very small window before tissue necrosis or even visual loss can occur.¹⁰ Failure to recognise and commence treatment within these timeframes can lead to devastating consequences for the patient, who may already have presented late to the ED. Not to mention, likely cause further costs to the NHS in the future. Whilst I did not encounter any filler-related complications during my years in the ED, having spoken with colleagues across Manchester, where I practised, the overwhelming response has been that, although the number of filler-related complications presenting to the department may be very low, there is a definite lack of education regarding management in this area. One of my colleagues working within ED has experienced ‘a few lip disasters’ over the past few months, with the majority of cases presenting as infection, although there have also been several with anaphylaxis from either a substance in/used with the filler or from hyaluronidase. She noted that there appears to be an increasing number of these presentations, and the majority have been from non-medic injectors, which perhaps explains their presentations to the ED – especially when you combine that with the data from Save Face where 35% of patients with complications were ignored by the person who treated them. The majority of these are something ED staff can manage and refer on as part of standard training. However, it’s possible for some ‘infections’ to be secondary to underlying occlusion, and therefore the underlying cause may be missed and further damage may occur if this is not something staff are aware is a possibility. This was recently highlighted in a case where a beauty therapist used a needle-free device to administer lip filler. The patient (who was also a nurse) experienced immediate pain and knew something was wrong, but the practitioner did not know what to do, even though she recognised something was wrong. The patient therefore self-presented to ED, only to be discharged with a diagnosis of lip haematoma. The following morning, symptoms worsened with discolouration tracking up the nose – clear signs of a vascular occlusion. Fortunately, she found an aesthetic nurse prescriber who was able to administer hyaluronidase and antibiotics with a successful outcome.¹¹

I believe the ED staff were not unreasonable in their diagnosis, as the number of cases presenting remains low currently, and it is not something that they receive training on as part of their core competences. As aesthetic practitioners, we should be far more aware of signs and symptoms of potential complications in our daily treatments. I believe the issue lies more in a lack of exposure and education for the emergency staff, as this is something that is out of their usual scope of presentations. However, this case demonstrates that, whilst it should ideally be the treating practitioner who provides the majority of complication management, ED should at the very least have an awareness of filler complications, as well as algorithms for management to ensure prompt treatment and better outcomes.

The solution

It is for this reason that I have started to undertake teaching sessions with doctors in the various Manchester emergency departments, with the aim of increasing awareness of the various presentations of filler complications, and providing them with a treatment algorithm, which is outside the scope of this article. There have also been similar sessions provided in other parts of the country, and this is something I would encourage other practitioners to provide throughout the rest of the UK.

I should also mention the work that the Aesthetic Complications Expert Group has been achieving in order to help support registered practitioners who may encounter a complication.¹² Another important factor to consider is the initial treatment consultation, where patients need to be adequately educated on possible side effects, how to recognise them, as well as emergency contact details. This would help to reduce inappropriate ED presentations, whilst hopefully reducing the time someone with a complication takes to get in touch, as every minute counts. I would argue that a rushed consultation without a detailed discussion of possible adverse events, no matter how concerning or off-putting they might sound to the patient, results in them being unable to provide valid informed consent for the treatment – something that may result in legal implications for the practitioner should such a complication arise. To conclude, emergency care and the work of emergency departments is one of the pillars on which our NHS is built.⁸ Whether patients present with minor or life-threatening conditions, staff aim to deliver high-quality patient care for all. It is my belief that medicine as a whole is a multi-disciplinary modality, and it is just as important for private practitioners to support their NHS colleagues as well as each other in providing the best patient-centred care possible.