Facial rejuvenation using dermal fillers represents nothing short of a "revolution," according to French oculoplastic surgeon Philippe Berros, M.D., of the Princess Grace Hospital Monaco. And as history clearly shows, no revolution comes without risk.
Dr. Berros says the type of filler used, the choice of injection equipment, the facial and orbital anatomy and the injection technique all influence the potential for risk. He has developed a technique specifically for periorbital volume regeneration called hyalurostructure that has been found to reduce those risks.1
Two considerations to keep in mind when attempting to avoid adverse events (AEs), Dr. Berros says, are the complication rate of permanent or semi-permanent fillers and possibility of a late-blooming biofilm reaction. "Complications seen during the various conferences all over the world suggest that the use of permanent or semi-permanent injection products should be contraindicated," he says. "And inflammatory and infectious nodules that may emerge years after injections confirm that biofilms can be present for a long time on foreign bodies such as nonresorbable fillers that are injected into the human body."Dr. Berros says fillers will be absorbed over time, and only the repetition of sessions helps to ensure a safer injection. "Repetition of sessions guarantees the safety of injection because it avoids a vascular or nervous compression, which is possible with a high-quantity single injection," he says.
Avoidance of these risks is preferable to repair. "The entire facial area is a delicate anatomic zone," says Dr. Berros. "Injections must be soft and slow in order to avoid filler-related embolization." He explains that oculofacial contours have the distinction of not containing hypodermic fat, which allows for filler to remain for a longer period of time. But there's also the possibility of edemas and stasis when large quantities of filler are used. "Hyaluronidase injections must be proposed to treat these overcorrections," he says.
NEEDLE, OR CANNULA? The decision to use a needle or a cannula can also impact the outcome. "Microscopic analysis of injection equipment or cannula provides surprises," Dr. Berros says. "Indeed, one may notice that many needles are as sharp as shark teeth, which may result in tissue dilacerations.
"With some cannula, the exit orifice may be too big or irregular. These defects are the cause of pain, dilacerations and hematomas during injections," he says. The choice of a needle or a cannula depends on the practitioner's habits, Dr. Berros says. He says he recently developed a technique called hyalurostructure, which injects filler with a reinforced microcannula, representing the best of both worlds.
"This appears to be a safer technique with less bruises, edemas and pain," he says. "Injections are always realized in the same anatomic chosen plan, and risks of embolus are much lower (compared to needles) due to very low risk of broken vessels."