As we know there has been a striking demand in recent years for filler injections and an signfiicant increase in non-core physicians and ancillary staff performing these delicate procedures. Although complications are possible with any procedure, lack of experience, poor technique and a deficiency in the understanding of anatomical patterns and subtle differences between individuals, make serious complications much more likely in the hands of someone less qualified or trained.
A recent realself.com post stated that shortly after filler injections (Restylane) under the eyes and in the glabella, the patient experienced flashes of light in their visual field with a change in vision. They inquired as to if this was possibly due to the filler injection procedure. I suggested this patient seek out immediate evaluation. Here’s why:
Symptoms of an impending injectable filler complication
Three of the most concerning symptoms after any injectable filler treatment is significant pain in the injection site, a change in skin color beyound the normal redness seen from needle injection and/or icing, as well as visual field changes such as double vision, visual pain, blurriness, decreased or loss of vision, and the inability to accomodate in light or dark. Each of these symptoms has a serious implication for impending necrosis from vascular occlusion or compression and needs to be evaluated appropriatley and treated rapidly.
Serious pain after injection is uncommon and even less common with the use of cannulas which is now my perfered method of injecting in the periorbital and forehead areas. Depot injections along the periosteum with larger gauge needs (27 gauge and beyond) can cause “bone” pain if there is too much tapping directly on the bone. I have seen patients referred for “inflammatory nodules” unresponsive to hyaluronidase or assumed to be from Radiesse and Sculptra injections that were not true nodules at all, but rather osseus inflammation and bruising from periosteal tapping. This is why a formal emergent evaluation is necessary and should not wait if a patient proclaims any of the symptoms above.
Necrosis can manifest acutely (immediate blanching and/or dusky reticulation) or late (mottled and reticulated erythema and duskiness or soley pain) in the distribution of the vessel affected. Visual changes require an immediate evaluation as the majority of cases reported in the literature with true vascular occlusion to the orbital blood supply have resulted in permanent damage despite every intervention. It is a good idea to befriend an ocluoplastic surgeon to have as backup or “on call” if this situation were to arise.
Treatment options for this complication
The best treatment is avoidence by using proper techinques:
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Aspiration before injection (should not be done with cannula)
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Using low-presure/slow injections, smaller gauge needles and larger gauge, blunt, felixible microcannulas
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Limiting the total volume of filler injected during the entire treatment session (although nobody knows the true number of what this “should” be)
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Avoid injections into pre-traumatized tissue, if possible
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Immediate referral to an oculoplstic surgeon for any concerns to avoid long-term sequale
Unfortunately, no safe, feasible, and reliable treatment exists at the current time for iatrogenic retinal embolism. The goal of treatment is to lower the intraocular pressure to dislodge the embolus into peripheral vascular circulation and to increase retinal perfusion and oxygenation to hypoxic tissues.
What can we learn from this post?
Serious complications can occur from filler injections and symptoms may procede the actual event. Patients should be made aware of these symptoms prior to any treatment and there should be formal documentation that they understand the risks, albeit rare, associated with these injectable treatments. My consent form fully documents these symptoms and serious complications for both patient care completeness as well as medicolegal protection. It is best to also take pre- and post-treatment clinical scenario photographs and document in the chart that the consent was discussed, what techniques were used, if there were any immediately complications and/or interventions, and the post-operative care instructions. In our office we routinely recommend the avoidence of exercise or manula manipulation for 24 hours (unless Sculptra was used), the use of arnica topically and orally (especially for those who bruise easily), and cooling/icing at home for three days after treatment (if there is noticeable bruising or swelling).
The most important take-home message for this realself.com post, is to educate your patients (and the public) that injectable filler treatments are not a “no consequence” procedure. Although some consider these “lunch-time” options, we really should set the standards higher and treat each as we would a surgical procedure with the cleanest enviornment possible, use of appropriate techinques for the areas being treated, and delivery of accurate pre- and post-treatment care instructions. Even more so, we must educate patients about the immediate and dealyed symptoms that may signify an impending complication that would require them to call or return to the office immediately. In this specific RealSelf case, I recommended the patient to go immediately to the local emergency room if she was unable to get a quick evaluation from her treating physician or local oculoplastic surgeon.
Dr. Jason EmerJason Emer, M.D., is a board-certified and fellowship-trained general, cosmetic and procedural dermatologist who is passionate about advancing safe and effective treatments in the field of cosmetic dermatology and laser surgery. Dr. Emer’s expertise and interests include the full range of general dermatological conditions, novel therapeutics, cosmetic face and body treatments, including aging skin, veins, body sculpting, fat harvesting and fat transfer.
