While knowing the anatomy is critical for successful cosmetic filler use, that’s not the only thing that will prevent filler-related complications or help physicians to better manage those problems once they occur, according to Joel L. Cohen, M.D., director of AboutSkin Dermatology and Dermsurgery in Greenwood Village and Lone Tree, Colo.
Dr. Cohen, associate clinical professor of dermatology, University of Colorado, and assistant clinical professor of dermatology at University of California, Irvine, talked about avoiding and managing filler complications at the August 2017 Masters of Aesthetics symposium in San Diego.
One such complication can result from antiseptic skin prep.
A review article published January 2017 in Dermatologic Surgery has questioned the safety of chlorhexidine as an antiseptic skin prep, according to Dr. Cohen.
Corneal injury has occurred with its use. And, in February 2017, the FDA released a warning about a growing number of rare but serious allergic reactions reported with skin antiseptic products containing chlorhexidine gluconate.
But used safely — meaning not around the eyes — chlorhexidine is among the most effective antiseptics for prepping head and neck dermatologic surgery patients, according to Dr. Cohen, who was among the authors on a paper published August 2017 in JAMA Dermatology, comparing postsurgical infection rates for different skin preps.
“In a large dermatologic surgery trial, we found chlorhexidine had the lowest incidence of infection,” Dr. Cohen says.
Dr. Cohen says that he carefully uses chlorhexidine on the face but does not use it around the eyes or eyebrows.
“From a safety perspective, as we’re prepping a patient, we can have patients close their eyes. We use isopropyl alcohol first and then carefully chlorhexidine to regions of the face except around the eyes,” he says.
Around the eyes, Dr. Cohen uses Betadine (povidone-iodine, Purdue Pharma) or Techni-Care (Chloroxylenol, Care Tech Laboratories), but he says Betadine does cause some temporary orange-ish discoloration to the skin. While Techni-Care wasn’t used in as many cases in the recent report as chlorhexidine, it, also, had a low incidence of infection, he says.
“There have been a couple of circumstances in the past few years when Techni-Care has not been available, but it is back on the market now,” he says.
Artery and Vessel Patterns
Beyond understanding the typical distributions of arteries and underlying vessels, it’s important for providers to be aware of other potential patterns arteries and vessels might have, according to Dr. Cohen.
Korean researchers published findings in October 2014 in Dermatologic Surgery, looking at the angular artery. They found the facial artery’s course can be classified into four categories, including traversing the lateral side of the nose; traversing the cheek and tear trough area; traversing the medial canthal area through an ophthalmic artery branch; and an absent angular artery, according to the study’s abstract.
“After that, it’s really paying attention to — looking at — the skin, while we’re injecting. Then, if we see the skin blanching, we can stop, immediately,” Dr. Cohen says. “The immediate sign [of vascular compromise] typically is blanching. Sometimes it can be pain. Pain usually occurs when the struggle for blood supply starts to happen and that may be a day or so later.”
A Question of Cannula
Some providers believe cannulas reduce or eliminate vascular occlusion risk.
A paper published March of this year in Dermatologic Surgery documented two cases in which cannulas got into blood vessels when aspirating prior to filler injections. These physicians got a flashback of blood when they pulled back on the plunger, according to Dr. Cohen.
“I think the point of the article is that you can potentially get into a vessel even with cannulas. But a larger cannula, like a 25g or 23g, may be less sharp and less likely to get into a vessel,” Dr. Cohen says.
Having the needed supplies to immediately address a potential filler complication can mean the difference between a temporary and permanent injury.
“We don’t just use localized, small doses of hyaluronidase anymore to treat possible impending necrosis,” Dr. Cohen says. “One has to have hyaluronidase in sufficient quantities to deliver several hundred units at a time. We treat the whole region of the course of a vessel within a region of vascular compromise.”
In the case of impending necrosis, he says, physicians often start with 200 or 300 units of hyaluronidase; wait 45 minutes or an hour; then, deliver another 200 or 300 units. Dr. Cohen was lead author on a paper on the topic published in 2015 in the Aesthetic Surgery Journal.
According to Dr. Cohen, a soon-to-be-published case study suggests that a dermatologist successfully managed a patient who had filler-induced visual compromise with a retrobulbar injection of hyaluronidase.
While more research needs to be done on that front, learning how to do a retrobulbar injection could be an important step in providers’ ability to reverse potential blindness from fillers, Dr. Cohen says.
Some researchers have also recently been investigating the very rare occurrence of delayed nodules from different hyaluronic acid products, according to Dr. Cohen.
“We don’t really understand what these are,” Dr. Cohen says. “Very often, these are not red, or hot and tender, which you would expect if it were an infection or even a biofilm. If this was a sensitivity-type of reaction, you would expect it in many different areas. Typically, that would be red, as well. Rather, these rare bumps tend to be noninflammatory nodules that present a few months after product.”
Until researchers develop a better understanding of how to treat these, Dr. Cohen says providers can try potentially effective treatments, including hyaluronidase to dissolve the nodules, or intralesional steroid or intralesional 5-fluorouracil injection, or a combination of the two.
“I think there’s definitely more to come on that topic,” he says.