if not promptly addressed, according to an expert explaining the signs of an impending disaster at the Skin of Color Update 2021.
Dr. Hassan Galadari
The most serious of the adverse events stem from vascular compromise, which is often signaled immediately by sharp pain and blanching of the skin, according to Hassan Galadari, MD, assistant professor of dermatology at the United Arab Emirates University, Dubai.
“Swift and aggressive treatment is required to avoid irreversible changes,” said Dr. Galadari, warning that blindness and vision impairment can be permanent, and that other events associated with vascular compromise include stroke and other types of embolism, as well as tissue necrosis.
To be swift, Dr. Galadari advised an immediate halt of injections and then a series of steps to abort the vascular insult. The goal is to encourage blood flow to prevent clotting and dissipate the filler.
“Massage the area like crazy. Keep on massaging. The more you massage the better. You are recruiting blood into that area so it remains viable,” Dr. Galadari said.
Hyaluronidase injections helpful
Warm compresses should also be applied for periods ranging from 5 minutes up to an hour, he added. In patients treated with hyaluronic acid, he also commonly introduces hyaluronidase injections of 200-500 IU diluted in lidocaine or saline. The injections are placed 2-3 cm apart and repeated every hour until signs and symptoms improve.
“Flush all of the filler out,” he said, emphasizing the urgency for reversing risk of vascular adverse events.
To sustain blood flow and avoid clots, he also recommends initiating aspirin with maintenance doses sustained over several days. Sildenafil to further improve conditions of blood perfusion can be “considered.”
The risks of vascular compromise, like other complications from filler injections, are low, but they are not zero, and the opportunity to prevent irreversible changes depends on acting quickly, according to Dr. Galadari.
“To prevent embolism, recognize the danger zones,” he advised, identifying the glabella region as the site of highest risk. The risk of vascular compromise from injections into the nasal region is lower but higher than injections of the nasolabial fold and forehead, which are associated with a relatively low risk.
Slow injections reduce risks
Some basic strategies he recommended for preventing vascular compromise included slow injections while keeping pressure low and using small volumes of filler per shot. Fractionated treatment and microdroplet techniques can be appropriate depending on the site of injection.
“Delivery of the filler by cannulas rather than by needles is preferable,” according to Dr. Galadari, who noted that a task force from the American Society for Dermatologic Surgery recently endorsed this approach as part of other recommendations to avoid complications of injectable fillers.
The Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database suggests that adverse events of any substantial severity from filler injections, not just those involving vascular compromise, occur at a rate of 1 per 3,600 cases. However, MAUDE is a passive surveillance system dependent on reports provided by clinicians and others, so this event rate might be an underrepresentation.
In the MAUDE database, complication rates are listed for each of the available filler products and show a variation in rates not just overall but also for each of the major types of complications, which include skin-specific complications such as nodules, discoloration, and inflammation, as well as neurologic adverse events, infection, and vascular compromise, Dr. Galadari reported.