Managing complications in facial aesthetics
As non-surgical facial aesthetic treatments continue to rise in popularity, Harry Singh considers the possible risks and complications, and how to steer clear of them
As health professionals, dentists are committed to providing the highest level of care and work hard to keep their patients safe. Even then, there are potential risks and complications when it comes to administering facial aesthetic treatments, something we must be vigilant about.
As always, informed consent is key, and I suggest using the Montgomery consent process rather than Bolam, individualising your explanations to the patient and areas being treated. Share all the common side effects, such as swelling, bruising and lumps, and let the patient know that certain areas of face are more high risk, such as the temple and tear troughs.
Following treatment, clinicians should make themselves available and ensure the patient knows how to make contact, including out of hours. Normal advice can be given over phone, but, if you have any doubts whatsoever, see the patient as soon as possible. The good news is most side effects are temporary and short-lived.
Botulinum toxin is one of the most popular non-surgical facial aesthetic treatments, with the BBC reporting around 100,000 injections are carried out each year. Meanwhile, Saveface, a professional standards authority, indicated in 2017-18 there were 224 complaints made by patients concerning their botulinum toxin treatment. Yes, this represents a relatively small percentage, but the truth is, that’s 224 complaints too many.
With botulinum toxin, the more common problems that can arise include:
- Raised eyebrows – caused by under-treating the frontalis
- Eyebrow ptosis – caused by over-treating the frontalis or under-treating the glabellar complex
- Eyelid ptosis – caused by an unwanted spread of toxin downwards
- Wonky smile – caused by over-treating laughter lines, especially too low down
- Bruising – caused by injecting into a blood vessel.
When we know the possible pitfalls, we can, of course, take steps to avoid them. Taking each of the above in turn, it is simple to ensure we don’t fall into the trap many unregistered practitioners practically dive into.
Consider the following:
- Raised eyebrows – treat the lateral aspects of the frontalis
- Eyebrow ptosis – under-treat the frontalis and make sure all muscles are treated in the glabellar complex
- Eyelid ptosis – create a finger block on the orbital rim to prevent downward diffusion and tell the patient not to exercise for 24 hours
- Wonky smile – do not inject too low down and baby-step your dosages in this area
- Bruising – never inject into a blood vessel.
Alongside botulinum toxin, dermal fillers are the most popular non-surgical facial aesthetic treatments in the UK. Like botulinum toxin, in the right hands excellent results can be achieved, but there remains the possibility of complications:
- Lumps – caused by injecting at too superficial a level and administering too much, too fast
- Bruising – caused by injecting into blood vessel
- Vascular occlusion – caused by injecting too much filler into or next to a blood vessel, resulting in compression of the blood vessel. This leads to a restricted blood supply to the skin and, in rare cases, tissue necrosis.
To avoid these problems, make sure you are at the right depth, using a suitable particle-sized product, inject small quantities, administer the filler slowly and, to avoid bruising, use cannulas.
As for vascular occlusion, it is essential you know how to reconstitute Hyalase and are able to administer it. Where vascular occlusion is suspected, treat with Hyalase and then refer to a specialist for follow-up care, if needed.
While on the subject of Hyalase, it is essential to have a ‘filler crash kit’. Treat it on a par with a medical emergency kit. Contents should include:
- Antibacterial cream
- LMX4 cream
- Arnica cream
A practical approach
All the risks and complications associated with non-surgical facial aesthetics can be assessed and avoided by:
- Understanding the anatomy
- Baby-stepping – for example, under-dosing
- Injecting slowly and in small quantities
- Injecting at the right depth
- Using cannulas.
Beyond the clinical aspects of treatment, keeping excellent notes is incredibly important should a patient decide to make a complaint. You want to detail everything said and done, the complication, your differential diagnosis, your treatment plan and follow-up care.
To secure the well-being of your patients and the reputation of your practice, make sure you have dotted the ‘i’s and crossed the ‘t’s, both clinically and administratively.