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Fab pres20aug
This document discusses complications of dermal fillers, how to avoid them, and their management. It begins by defining filler complications and categorizing them as immediate, early, or late onset. It then discusses various types of complications including technical errors, inflammatory reactions, infections, and immune reactions. The document provides tips for minimizing risks such as obtaining informed consent, using proper technique, understanding anatomy, and following up with clients. It also reviews how to manage specific complications like nodules, granulomas, necrosis, and unhappy clients. The overall goal is to help practitioners understand, avoid, and address any adverse events from dermal fillers.
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Fab pres20aug
- 1. COMPLICATIONS OF DERMAL FILLERS, AVOIDANCE AND MANAGEMENT DrFab Equizi MB.ChB PGDip NSFA Cosmetic Doctor
- 2. OBJECTIVES • To havea practical, interactive session • To take away something useful that can be applied to your daily practice • To understand complications that can arise with fillers in the orofacial region • To learn strategies to minimise the risk of complications • To be able to recognise a complication if a problem is reported • To be able to deal with an adverse event or know who to refer to • Don’t need to be able to discuss in detail the histology and pathogenesis of a granuloma for example
- 3. COMPLICATIONS OF DERMAL FILLERS Whatis a filler complication?
- 4. COMPLICATIONS OF DERMAL FILLERS •Filler complications are events that should not occur after treatment and can be avoided with proper technique and material selection. • Complications can be categorized as – Immediate – Early – Late onset events (Rzany B 2004)
- 5. COMPLICATIONS OF DERMAL FILLERS •Another classification • Technical errors • Volume (too much or too little) • Location (wrong) • Depth (too superficial or too deep) • Product choice (inappropriate product) • Inflammatory • Infectious agent (bacterial, viral, fungal or biofilm mediated) • Immune mediated (not related to infectious agent) (DeLorenzi C 2013)
- 6. COMPLICATIONS OF DERMAL FILLERS •What makes a good filler job? • Good aesthetic result • Happy client • Recommendations based on above • Decent profit • Repeat business
- 7. COMPLICATIONS OF DERMAL FILLERS •Another view on complications • Anything which makes client ring you up and moan
- 8. AVOIDING EARACHE • Listento client, ascertain expectations, thorough medical history • Fillers are only 1 tool • Discuss price • Discuss possible adverse events • Avoid psychological issue patients, BDD • Anaesthesia • Assess and treat in an upright position • Use a mirror • Start with a biodegradable filler • Don’t inject too little or too much filler • ARRANGE A CHECK UP • If something goes wrong be accessible and understanding
- 9. BODY DYSMORPHIC DISORDER •Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • The preoccupation is not better accounted for by another mental disorder (eg, dissatisfaction with body shape and size in anorexia nervosa)
- 10. BODY DYSPMORPHIC DISORDER •BDD is commonly found in clinical settings, with studies reporting a prevalence of 9% to 12% in dermatology settings, 3% to 53% in cosmetic surgery settings, 8% to 37% in individuals with OCD, 11% to 13% in social phobia, 26% in trichotillomania, and 14% to 42% in atypical major depressive disorder (MDD). Studies of psychiatric inpatients have found that 13% to 16% of patients have DSM-TV BDD.9,50 A study of adolescent inpatients found that 4.8% of patients had BDD • Be careful, these patients can be very difficult. Never satisfied and may claim you made them worse. • Consider referral to psychiatrist
- 11. CHOOSING APPROPRIATE FILLER •A—Assess the patient a) Which areas show aging or asymmetry? b) Which areas can be easily corrected? c) Imagine how the patient will look if various areas are corrected. d) Determine the best areas of injection and proceed to next step.
- 12. CHOOSING APPROPRIATE FILLER •B—Budget a) Determine the patient’s financial budget. b) Determine the patient’s time budget. c) Refine plan in your mind about which areas are most important to treat.
- 13. CHOOSING APPROPRIATE FILLER •C—Considerations • Learn more about the patient. • What bothers the patient most? • Ask about prior experience with fillers. • Are there any religious restrictions? • Can the patient return for future treatments? • Does the patient have an event coming up? • Is the patient on anticoagulants? • Are there any concerns about outcome?
- 14. CHOOSING APPROPRIATE FILLER •D—Device a) Assess pros and cons of available fillers. b) Match attributes of fillers to what was learned in steps A, B, and C. c) Choose the appropriate device. d) Discuss the plan with the patient.
- 15. WHY DO ACHECK UP? • To compensate for variables out of your control – Bruising – Swelling • To get the best possible result • To get a follow up photo • Clients are reassured knowing they have a follow up appointment, less likely to ring up bleating the next day • To avoid the risk of them consulting another practitioner • Gives you the opportunity to make any corrections and preserve your reputation • Gives you the opportunity to show them the before and after photos side by side and build up a library
- 16. IMMEDIATE ONSET COMPLICATIONS (0-2DAYS) • Under/over correction • Implant visibility – Tyndall effect – Nodules • Immediate hypersensitivity – Anaphylaxis reported with bovine collagen (Mullins RJ 1996) • Vascular compromise – Glabella – Alar triangle – By direct injection into vessel or pressure of excessive swelling/filler on vessel
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- 18. EARLY ONSET COMPLICATIONS (3-14DAYS) • Persistent nodules – Localised accumulation – Inflammatory – Infective • Reactivation of herpes (esp lips) • Atypical infections (eg mycobacteria) • Angioedema • Lymphoedema
- 19. DELAYED ONSET COMPLICATIONS (>14DAYS) • Persistent erythema/telangiectasia • Granulomas – Foreign body reaction – Type 4 hypersensitivity ? Foreign proteins ?biofilm – Permanent fillers eg PMMA – Nodules from PLLA (Sculptra, from poor mixing, incorrect placement) • Migration – Silicone – Lesley Ash
- 20. IMPENDING NECROSIS • Blanching •Blue-grey mottling • Pain • Massage • Hyalase (if HA and don’t bother with allergy test) • Warm compresses • GTN paste • Aspirin/heparin • If tissue breakdown antibiotics and wound management
- 21. NODULES/GRANULOMAS • Nodules – Massage –Hyalase – Incision – Injections of saline (Ellanse PLLA) • Red, fluctuant – Antibiotics – I+D, C+S – Clarithromycin and Ciprofloxacin for biofilm • Granulomas – Hyalase if HA – Injections steroid/5-FU • CONSULT A COLLEAGUE
- 22. ALGORITHM FOR LATEONSET NODULES
- 23. AVOIDING COMPLICATIONS • Obtaininformed consent • Know your own abilities/limitations • Explain risks, complications and limitations of procedure/product • Discuss any off label uses • Appropriate antisepsis/hand washing/skin prep • Clinical photography, don’t inject without a photo • Avoid injecting large amounts of product • Know your anatomy • Avoid important neurovascular structures • Aspirate before injection
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- 26. UNDERLYING STRUCTURES: INNERVATION • Thefacial nerve (cranial nerve VII) is responsible for control of the majority of the facial muscles, including those in the perioral area • The buccal and mandibular branches control the perioral muscles Temporal branch Zygomatic branch Facial nerve Cervical branch Mandibular branch Buccal branch
- 27. HYALURONIDASE • Enzyme todissolve miss-placed HA filler • Can resolve HA granulomas • Derived from goat testicle (Hyalase) – Allergy test required, small dermal injection on forearm and check for allergic reaction after 30mins) • 1500u in vial, mix with 1ml saline • Inject into filler in 0.05ml aliquots • Filler dissolves almost instantly, best after 48 hours • Review/refill 1-2 weeks
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- 39. TIPS TO MINIMISERISK OF INTRAVASCULAR INJECTION • Aspirate • Slow injection, low pressure • Move tip of needle to deposit filler in a line as opposed to a single deposit • Incremental injections 0.1ml aliquots • Small volume syringes • Smallest needle possible for filler • Repeated treatments with smaller volumes as opposed to 1 large volume treatment • Pre treatment with Botulinum Toxin • Use a cannula • Topical vasoconstrictor, LA+adrenaline • Stretch tissues to straighten tortuous vessels
- 40. MANAGING AN UNHAPPYCLIENT • Be accessible – Don’t ignore calls, block numbers, block on social media • See the client as soon as you can • Be open and honest – No bullshitting – Don’t blame client – Don’t blame product • Apologise and offer a solution • If in doubt refer to a colleague • All of these should avoid the complaint escalating
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