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Protocols essential to minimize vascular compromise from soft tissue fillers

Established office-based protocols for both immediate and ongoing care are critical for timely and effective resolution of potential vascular compromise and side effects should they arise from soft tissue fillers, according to researchers.

The authors of the paper, published in the Journal of Clinical and Aesthetic Dermatology (Sept. 2014; 7(9):37–43), referenced eight cases of vascular compromise that occurred among 14,355 injections at their clinics in a 10-year period spanning Jan. 2003 to Jan. 2013 as well as four cases of compromise that arose from a trial of an experimental particulate filler.

“I think we can all improve patient outcomes and our understanding of what is really going on by sharing our experiences. And because we have a practice that has quite a high volume of injectable treatments, we have experience with more of these complications than lower-volume practices,” says Dr. Shannon Humphrey, cosmetic dermatologist and clinical researcher at the Carruthers & Humphrey Cosmetic Clinic in Vancouver and director of Continuing Medical Education in the Department of Dermatology and Skin Science at the University of British Columbia, and one of the paper’s authors.

While the complication rates seen in the clinic were low—0.05% in regular practice—the authors note this is still a higher rate than is reported in the literature. Dr. Humphrey says this is due to a change in how physicians are using fillers.

“Over time we know the pattern of soft tissue fillers has changed from filling superficial lines to now really revolumizing the face. We do not think of a line anymore, we think of 3D anatomic structures, which involves treatments that have two characteristics,” she said. “One is injecting in much deeper planes where the vascular plexus and larger arteries are present. And B, it involves using larger volumes of filler.

“Whereas superficial creases take half a syringe or one syringe, there are patients who are having pan-facial treatments with multiple syringes of treatment. And I think both of those things increase risk of vascular compromise,” said Dr. Humphrey.

Of the 12 total patients who experienced vascular compromise, eight were compromises that occurred in the nasolabial folds or the lip, two were in the malar cheek, one at the nasal ala, and one in the glabella. In the nasolabial folds, the angular artery and lateral nasal artery are points of risk for occlusion, the authors note. As well, the minimal collateral circulation in the glabellar region increases risk in that site.

Safe injection practice recommendations

“There is considerable debate about whether vascular compromise occurs exclusively from intravascular injection or also from compression around the vessel. But we actually do not know,” says Dr. Humphrey.

Because of this uncertainty, Dr. Humphrey and her colleagues make recommendations for safe injection practices that reduce the risk of either potential source of compromise. These include taking detailed patient histories; using reversible filler products to increase the chance of resolving any compromise that might occur without sequelae; taking extra care in known high-risk areas, including splitting the volume over multiple injection sessions; aspirating before injection where possible; and using smaller gauge needles where practical.

As well, Dr. Humphrey suggests using cannulae instead of needles if practical, and emphasizes that a strong, foundational understanding of facial anatomy is more important than ever as the practice of facial filling is moving to these larger volumes placed more deeply.

“In the past, it would have been easier to have some basic training and then learn as you go. For example, if you are filling a very superficial line,” says Dr. Humphrey. “However there is much more education of both technique and particularly the facial anatomy that is required before starting to inject using a more revolumizing approach.”

Use of cannulae may reduce vascular compromise risk

As for cannulae, “the concept behind a blunt-tipped cannula is that there is no sharp tip, so the likelihood of lacerating or injecting into a vessel would be theoretically reduced,” says Dr. Humphrey. There hasn’t been any controlled or comparative data that she’s seen to confirm increased safety from injections using cannulae, says Dr. Humphrey, but “from a common sense perspective it makes sense.”

Dr. Humphrey says she switched to using a cannula, particularly in high-risk areas, roughly two years ago. “I always use a cannula in the nasolabial fold with consideration or respect of the angular artery. Then, in other areas I use a combination of needles and cannulae,” she added.

While the authors feel their recommendations will help clinicians reduce risk of vascular compromise in their practices, they say that it does not eliminate risk. Consequently, the authors write that it is important to set up an office protocol for not only immediate but also long-term care of patients with vascular complications.

“While the current body of evidence does not allow us or any authors to be really definitive about what the absolute best management is,” says Dr. Humphrey, “you still need to be ready to identify the complication and manage it to the best of your abilities in your practice.”

Each patient in this series had differences in the treatment plan for their vascular complication, but all achieved full resolution of symptoms, the authors reported.

“I would hope [clinicians] would all take the time to prepare their own protocol, have it written down, have it readily accessible to their staff,” says Dr. Humphrey.

Dr. Humphrey recommends that clinicians review the protocol with their staff ahead of time prior to a potential incident. She also recommends that clinicians make sure that they have all of the equipment accessible that is required to implement that protocol immediately.

“We do know that improving patient outcomes from this potentially very serious complication is all contingent on early recognition and management,” Dr. Humphrey concluded.

- Previously published in The Chronicle of Cosmetic Medicine + Surgery (Nov. 2015; 5(2):19).

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