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    Avoiding complications with dermal fillers

    Vascular complications from cosmetic injectables happen to even the most proficient injectors. Addressing them quickly can make the difference between reversal or a serious — even disfiguring — result.

    “The most common vascular complications are inadvertent intra-arteriolar placement of product that causes local vasoocclusion and the potential for local soft tissue necrosis,” says Boca Raton, Fla., oculoplastic surgeon Steven Fagien, M.D., who was a panelist at the discussion during “Avoiding Vascular Complications With Injectables” at the American Society for Aesthetic Plastic Surgery’s The Aesthetic Meeting 2017 in San Diego, Calif. “Even experienced injectors have caused this when injecting into areas that are felt to be ‘safer’ areas, yet for several potential reasons, an intra-vascular ‘accident’ occurs.”

    When it occurs, reversal and resolution usually are possible with appropriate and expeditious treatment. Treatment includes injectable hyaluronidase, if the vascular occlusion occurs while using injectable hyaluronic acid (HA) products, as well as other adjunctive treatments. 

    Less common but more devastating vascular complications with injectable filling agents include vision loss and potential blindness.

    What some might not realize, according to Dr. Fagien, is that vision loss and blindness can occur while injecting many areas around the face, including the nasolabial folds, the mid-face and lower eyelid and tear-trough, eyebrows, nose, forehead, temples and the lips.

    Because HA fillers are the most widely used worldwide, they have the most reported complications.

    “However, vascular complications have occurred with essentially every injectable agent, including autologous fat,” Dr. Fagien says.

    There’s a distinct advantage of using HA products, he says. It’s that most — not all — vascular complications from HA injectable products can be reversed with hyaluronidase.

    Botulinum toxin products may have a leg up when it comes to vascular complications, according to Dr. Fagien.

    “There are no long-standing vascular complications that have been reported using neurotoxins that I am aware of,” he says.

    To avoid vascular complications from injectables, cosmetic surgeon injectors should, at the very least, have a basic understanding of the target treatment region, as well as the vascular anatomy in that area.

    “A greater understanding of this usually leads to less [risk of] complications, as the injector understands which areas to avoid or what techniques might reduce the risk,” he says.

    Safe techniques include using smaller volumes and administering slower injections. It may also be advantageous in some regions to appropriately use cannulas and watch for blood in the needle hub with aspiration (in areas of higher risk), prior to injection.

    Either avoidance or proceeding with extreme caution when treating high-risk areas is always recommended. Finally, should signs of an impending vascular occlusion occur (and one must watch for those), treat it quickly for a favorable outcome, Dr. Fagien says.

    Disclosure: Dr. Fagien is a consultant for Allergan and Galderma.

    Lisette Hilton
    Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.

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