Vascular occlusion can be a scary event for both patients and practitioners. Dr Adam Radford discusses how to minimise the risk of occlusion and infections, alongside treatment protocols for Hyalase and emergency complication resolution. He runs an advanced aesthetics complications aesthetics course, utilising in-depth anatomy knowledge gained through his NHS medical and dental training.
What are the Symptoms of Vascular Occlusion After Filler?
On his training course, Dr Radford teaches the five key warning signs of vascular occlusion. Early signs of vascular occlusion include pain, pale skin or white blanching after filler and prolonged capillary refill. These symptoms are commonly seen within minutes to an hour of an occlusion occurring. Later signs of an occlusion are perishingly cold skin and purple mottling or livedo reticularis. These symptoms are commonly associated with an older or more advanced occlusion and tend to occur around 4-6 hours post-treatment.
How To Avoid Vascular Occlusion:
Dr Radford shares his 6 top tips to help minimise the risk of vascular occlusion.
- Maintain a thorough knowledge of anatomy and know where the facial danger zones are.
- Aspirating for the correct time, according to the product that you are using is also vital.
- He advises not to inject too much in one treatment session, for example keep lip filler to 1ml or less per treatment.
- Know your injection depths for every product that you are using.
- Use cannulas where appropriate as they are designed to glide through vessels rather than pierce them. It is better to use cannulas when injecting into the mid-depth of the face to minimise the risk of injecting into a danger zone.
- Be aware of anatomical variation between individual clients. Vessels can present in different patterns in different people. A classic example is the three variants of the lip arteries. Submucosal is the most common vessel pattern, with the labial artery sitting closer to the lip border. In the intramuscular variant, the artery goes through centre of the lip, while the subcutaneous variant is the most complex to navigate when performing lip filler. This variant occurs in around 1 in 100 clients will have the artery running very superficially across the vermillion border.
Can Profhilo Cause Vascular Occlusion?
If you’re wondering ‘can skin boosters cause vascular occlusion?’ Dr Radford explains that if they are injected correctly at an intradermal depth, there are no major arteries present so the risk of VO should be minimal. Skin boosters that are more liquid in consistency such as Jalupro and Sunekos do not require aspiration, whereas thicker gel substances like Seventy Hyal 2000 and Profhilo can be aspirated to be cautious, however the treatment is not subcutaneous so it is down to practitioner preference. As a general rule it is unlikely that skin boosters will cause a vascular occlusion.
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How To Mix Hyalase for Emergency Filler Dissolving:
According to the ACE guidelines for vascular occlusion, you can perform up to four cycles of emergency dissolving in the event of an occlusion, spaced an hour apart with heat and massage for an hour, to try and disperse the blockage.
Dr Radford recommends mixing a vial of Hyalase with 2ml of saline with the aim of reducing pain and normalising the capillary refill. He explained that 9/10 occlusions are resolved with 1-2 vials of Hyalase but you can use up to four vials, as per the ACE guidance.
If you are dealing with a delayed vascular occlusion, purple mottling may remain for up to a few days even after successful emergency dissolving. Therefore, you should not use resolution of purple mottling as a benchmark for a successful dissolve. Shop Emergency Medications on Fox Pharma here.
What To Do if Hyalase Fails:
If you have completed four rounds of Hyalase and the occlusion is not responding to treatment, it is likely to be a refractory vascular occlusion, where the filler has migrated from the injection site. In this instance you may not be dissolving in the correct location.
At this stage, you should seek specialist help from a local medical aesthetics specialist or a local plastic surgery unit. If you are not a prescriber, these clinics are likely to be able to prescribe high dose antibiotics to reduce the risk of infection. They are also more likely to have access to hyberbaric oxygen or can refer the patient for this treatment. These oxygen chambers floor the skin with high-powered oxygen to help reverse small areas of necrosis, while working to prevent the spread of necrosis. Ultrasound technology is a key tool in specialist aesthetics intervention. The ultrasound is focused along the artery to locate the vascular occlusion, in order to perform precise, targeted dissolving.
In these situations it is vital to contact a specialist with access or referral to these interventional treatments as quickly as possible to prevent the spread of infection and necrosis. Patients who present with a vascular occlusion that has not been treated promtly should take a course of antibiotics. If the skin is without oxygen, this increases the risk of anaerobic bacterial infection.
What are the Side Effects of Hyalase?
Dr Radford explains that the main risk of using Hyalase is that it can trigger allergic reactions, or in the most extreme cases anaphylaxis. Typically, mild or moderate swelling and the formation of a rash are the most common side effects of a Hyalase allergic reaction. Another side effect of using Hyalase is that it is intended to remove HA, meaning that it can also dissolve hyaluronic acid in the natural tissues. This can result in tissue dehydration, volume loss and a degree of natural tissue destruction.
Can The NHS Help With an Aesthetics Complication Emergency?
Dr Radford advises that most A&E doctors do not have specialist training in aesthetics and waiting times can impede efforts to resolve a complication quickly. If the practitioner has performed four dissolves, an hour apart with an hour of heat and massage and the occlusion is not resolving, they should refer the patient to a plastic surgeon or specialist medical aesthetics doctor.In the most extreme cases, if a patient presents with a severe vascular occlusion that has been left untreated, resulting in advanced necrosis, the patient should be referred to plastics or maxillofacial surgery. In these rare cases of advanced necrosis, a plastic surgeon may need to perform a skin graft. The NHS website states that patients can attend A&E if the complication results in an urgent medical issue, however the first point of contact should be their practitioner.
Elective vs Emergency Dermal Filler Dissolving
It is vital that practitioners differentiate protocols between emergency and routine elective dissolving. Dr Radford stresses the importance of completing a training course that covers both emergency dissolving for vascular occlusions and routine dissolving.
He explained that most of the complications he has witnessed after Hyalase injection have occurred where the practitioner has mixed an emergency concentration of the solution to perform a routine dissolve for migration.
An emergency concentration of Hyalase would be a 1500 unit ampoule of Hyalase mixed with 2ml saline. This is far too strong of a dose for routine dissolving, as the ACE guidance advises to mix 10ml saline for routine dissolving and patch test beforehand. Some practitioners may even use 15ml of Saline to be extra cautious. By using a less concentrated solution of Hyalase and waiting the full two weeks after dissolving, the practitioner can assess the success of the dissolve, whilst significantly minimising the risk of side effects. Dr Radford re-iterated, ‘less is more with Hyalase when it comes to routine dissolving.’
Can You Dissolve Filler and Re-fill in the Same Session?
A recent trend has emerged on social media that involves dissolving the lips then taping around the border and re-filling. Some practitioners are skeptical of this methodology, as Dr Radford explains ‘we would need to wait a period of time to see what the evidence is for that particular treatment route.’
He stated that in his personal opinion, he doesn’t perform dissolving and refilling within a short period of time. Hyalase works for up to two weeks after injection to dissolve hyaluronic acid-based dermal fillers. Therefore, the new dermal filler injected would be affected by the presence of Hyalase at the injection site.
How Long Does Hyalase Take To Work?
Dr Radford explains that the general rule of re-filling at two weeks post-dissolve does not allow enough time for connective tissue healing, ‘if we inject too quickly after dissolving, e.g. after two weeks, you can get re-migration as the connective tissue barrier has not healed.’ This means that the filler is likely to migrate back outside the border of the lips and problems can reoccur.
How Long After Dissolving Lip Filler Can You Refill?
Dr Radford’s advice is to wait 6-8 weeks after dissolving before re-filling the lips. That way, patients will get much better results from their treatment as you are injecting when there is proper connective tissue healing.
Can a Patient be Treated Again After An Allergic Reaction To Lip Filler?
Dr Radford explains that the patient is unlikely to be able to undergo further treatment following an allergic reaction to fillers. He suggests getting referred to an allergy clinic where an expert can patch test substances.
However, an allergic reaction lip filler is extremely rare, as HA is naturally present in the body’s tissues. He argued that there are a hierarchy of treatments when it comes to the risk of allergic reactions. Most commonly, patients react to Hyalase, pigments and dyes in permanent makeup and lidocaine, whereas reactions to dermal fillers and Botox are extremely rare. Alongside reducing the risk of allergic reactions, non-lidocaine dermal fillers are associated with significantly less swelling post-treatment. A dental block can be used to reduce discomfort during lip filler treatments when performed by a trained practitioner.
Aesthetics Complications Expert Tips:
- Know your anatomy
- Attend an advanced complications course
- Continue your education and learn from the skills of other practitioners
- Try and stay calm, trust your training
- Maintain a solid emergency kit and keep the emergency dissolving protocols in your kit for easy access
- Follow the steps of the protocol precisely, like a cooking recipe to avoid feeling panicked or overwhelmed (he teaches the ACE aesthetics complications protocols)
- Have a complications buddy system e.g., another practitioner that you can discuss complications with and who you can refer patients to if ever you are unavailable
How To Minimise The Risk of Aesthetic Treatment Infections
- Decontaminate the skin thoroughly
- Remove any makeup to avoid bacterial contamination. Use alcohol wipes and wipe until the wipe is completely clean.
- A cannula should touch nothing from the box to the infection site as they are a key source of infection – so you should be especially cautious with cannulas.
- Pick your target audience – e.g. clients on immunosuppressant medicine, steroid medication or who have poorly managed diabetes may be unsuitable for treatment
- Consider delaying treatment until a patient’s medical condition is under better control and ask them to consult their healthcare professional before seeking aesthetic treatments
- Don’t inject through areas of the skin that seem infected and only inject through healthy skin
- Act Shop POMS on Fox Pharma here.
For more information on Dr Radford’s advanced aesthetics complications course, click here. For more on vascular occlusions click here. Fox Pharma is committed to innovation, safety and quality above all else.