Innovative Approach to Minimize Serious Complications in Cosmetic Dermal Filling

Summary

The protocol proposes an innovative approach to cosmetic dermal filling focusing on ultrasound, icing, pressing, auxiliary gestures, and effective withdrawal to reduce the risk of serious complications like vascular occlusion. Despite the general safety of dermal fillers, accidents can still occur because of the inherent risks.

Abstract

Cosmetic dermal filling represents a significant advance in aesthetic medicine, providing non-invasive treatments with immediate and durable outcomes. Despite the generally safe nature of dermal fillers and avoidable complications with proper technique and planning, they are still risky, with potential complications varying from mild and transient to severe and enduring. This study introduces innovative strategies designed to decrease the risk of serious complications, such as vascular occlusion. These include the use of ultrasound guidance, the application of ice, auxiliary gestures, effective withdrawal, etc. Throughout our research, we observed no severe complications like embolism, skin necrosis, or ocular issues. However, minor complications such as erythema, edema, and bruising were noted. It is important to recognize that while most severe complications can be avoided with meticulous technique and planning, the inherent risk of unexpected outcomes persists in any medical procedure. Our findings suggest that with these innovative strategies, the safety of cosmetic dermal filling can be significantly enhanced, thereby minimizing the risk of severe adverse effects.

Introduction

The field of cosmetic surgery has witnessed a paradigm shift with the advent of dermal fillers, a development that has significantly altered the approach to aesthetic enhancement¹. These non-invasive treatments, designed to combat the signs of aging and fatigue, offer individuals a viable option for rejuvenation, circumventing the need for traditional surgical interventions. The appeal of dermal fillers lies in their ability to deliver immediate, long-lasting results with minimal downtime, a crucial factor that has fueled their popularity among consumers seeking to enhance their appearance safely and effectively^1,2. The growing demand for these treatments has been matched by an aggressive marketing push from pharmaceutical companies, which have positioned dermal fillers as an attractive solution for soft tissue enhancement².

Despite the widespread acclaim  and acceptance of dermal fillers in aesthetic medicine, the rise in their use has also highlighted a critical issue: the potential for adverse outcomes and complications. Documented extensively in the medical literature, these complications range from minor, temporary problems to severe, long-lasting issues^3,4,5. Factors contributing to adverse complications include the procedural aspects, the injection techniques applied, and the specific types of fillers used⁶. Among these, the technique of injection stands out as a crucial determinant of safety and efficacy, particularly with temporary fillers⁷. The prevalence of undesirable outcomes has been notably linked to the practices of inexperienced or inadequately trained practitioners, who may prioritize financial gains over patient safety, employing sub-optimal injection techniques⁷.

Recognizing the need to address these concerns, we introduce a novel set of strategies to minimize the risk of one of the most serious complications associated with dermal fillers: vascular occlusion^8,9. This condition, characterized by the obstruction of blood flow, can lead to irreversible tissue damage if not promptly and effectively managed⁹. The overall goal of our method is to enhance the safety profile of cosmetic dermal filling procedures by implementing measures such as ultrasound guidance, ice application, auxiliary maneuvers, and meticulous injection techniques. These innovative strategies are grounded in a thorough understanding of facial anatomy and filler dynamics, offering a significant advancement over traditional techniques by providing an additional layer of precision and safety.

The rationale behind the development of these techniques is rooted in the increasing incidence of complications associated with dermal fillers, necessitating a proactive approach to minimize risks. By integrating imaging technologies and refining procedural tactics, the method described in this study aims to circumvent the limitations of conventional injection techniques, thereby reducing the likelihood of vascular occlusion. Compared to existing methods, our approach offers several advantages. Ultrasound guidance, for instance, allows visualization of possible anatomic variation, enabling practitioners to avoid critical vascular structures and ensure optimal filler placement. Additionally, the application of ice and gesture maneuvers can further mitigate the risk of complications by reducing tissue swelling and facilitating smoother filler distribution.

Within the broader context of the literature on cosmetic procedures, this technique represents a significant contribution to enhancing the safety and efficacy of dermal filler treatments. By addressing the pivotal issue of vascular occlusion, the method not only improves patient outcomes but also contributes to the ongoing evolution of best practices in aesthetic medicine. For practitioners seeking to adopt the latest advancements in dermal filling, our study provides valuable insights and practical guidelines that underscore the importance of technique, planning, and patient safety in achieving optimal results.  

Protocol

This study was carried out in accordance with the clinical ethics committee guidelines of the First Affiliated Hospital of Zhejiang University. Written informed consent was obtained from all participating patients. Sites of dermal filling generally include the tempora, tear trough, nasolabial fold, and chin. Patients with contraindications, like active skin infections, unrealistic expectations, or a history of related allergies, autoimmune diseases, bleeding disorders, and keloid scarring, were excluded.

1. Preoperative steps

1. Take photographs of the intended injection areas from multiple angles.
2. Perform an ultrasound (B-mode) examination of the intended injection sites (Figure 1) to delineate the course of major vessels for potential anatomical variations and to identify any remaining fillers in individuals who have previously received filler treatments¹⁰.

2. Pre-injection preparation

1. Apply ice packs to the intended injection areas for 3-5 min (as long as it is bearable) before the procedure to promote vasoconstriction and reduce pain.

3. Patient positioning

1. Have the patient sit in a semi-upright position.
2. Disinfect the intended injection sites three times with iodine (Figure 2).

4. Auxiliary gesture

1. Use the non-injection hand to apply pressure on the major vessel marked while performing the injection movement (Figure 3)

5. Injection techniques

1. Penetrate the skin with an empty needle/cannula.
   1. Use 30-32 G needles for finer injections and more superficial placements, like the lips, fine lines, and tear trough.
   2. Use 25-27 G cannulas for their flexible and even distribution in areas like the cheeks, jawline, or nasolabial folds) or one pre-loaded with saline or lidocaine (0.5%).
2. Penetrate the recommended needle/cannula and withdraw for 5 s (Figure 4).
   NOTE: The angles of penetration during injections are indeed contingent on a variety of factors, such as the specific injection sites, the types of fillers being used, and the choice between needles or cannulas. Additionally, the desired effects the practitioner aims to achieve play a significant role in determining these angles.
   1. Only proceed with the injection if no blood is aspirated. In cases of significant resistance or blood aspiration, reposition and attempt the same injection techniques.
   2. Inject fillers slowly while withdrawing the needle/cannula. Determine the injection technique-linear threading, fanning, serial puncture, or bolus injections-based on the specific injection sites and the type of filler used^11,12.

6. Immediate post-injection

1. Perform gentle massage and pressure on the injection site to ensure the even distribution of the dermal filler or to slide it to the desired location (Figure 5).
   NOTE: The time for the massage or pressure is flexible as long as the filler is evenly distributed or precisely positioned in the desired area.

7. Symmetrical balance

1. In cases where injections are administered bilaterally, allocate roughly 1/5 of the total injection volume to account for and correct any potential asymmetries, ensuring symmetrical balance in the final result. This reserved volume acts as a buffer, allowing adjustments to be made to achieve harmony and proportion between both sides, enhancing the overall aesthetic outcome.

8. Post-operative care

1. Take photographs from multiple angles again.
2. Apply antibiotic ointment on the penetration site.
3. Apply ice packs across a sterile gauze and compress the injected area for 15 min.
4. Instruct the patient from getting the treated area wet for 4-6 h and refrain from vigorous rubbing or massaging the injection site for the first 3 days.
5. Advise follow-up in 1, 3, and 6 months.

Results

In the study, 50 patients seeking cosmetic enhancement were selected. The areas treated included temporal depression (5, needles 30 G), tear troughs (19, needles 32 G/ cannulas 30 G), nasolabial folds (22, needles 30 G/ cannulas 27-30 G), cheek depressions (2, cannulas 27-30 G), and chin (2, needles 30 G) (Table 1). A variety of needle and cannula sizes were chosen based on the treatment area and the type of dermal filler used. Deep filling (as support) is usually injected with 30 G needles, while superf...

Discussion

Cosmetic dermal filling stands out as a continually evolving and popular field in aesthetic medicine, driven by factors such as its non-invasive nature, immediate results, minimal downtime, and versatile functions in reducing wrinkles and restoring volume^1,2. The appeal also lies in its achievement of natural-looking and long-lasting results¹. The ongoing and anticipated rise in popularity can be attributed to innovations in filler formula...

Materials

Name	Company	Catalog Number	Comments
Hyaluronic Acid	YVOIRE	CFDA(A)20163131804	Serves as a supporting role; Supplied with the injection needles (30–32 G)
Hyaluronic Acid	Imeik	(01)08800050200083	Serves as volume filling; Supplied with the injection needles
Cannulas	Conpuvon	20200017	For volume filling
Ultrasound	Philips	EPIQ-5/US120C1632	Detect anatomic variations or remaining fillers from previous treatments