Complications and errors during injection procedures: what should a specialist be prepared for?

Svetlana Korkunda, Ph.D., Associate Professor, Department of Combustiology, Reconstructive and Plastic Surgery, Kharkov Medical Academy of Postgraduate Education (Kharkiv)

Injection cosmetology techniques (mesotherapy, contouring and the use of botulinum toxin type A), having gone through stages from enthusiastic enthusiasm to disappointment in recent years, are currently at the stage of conscious use and, undoubtedly, are subject to analysis and discussion of the results. Today, patients are more confident in turning to specialists skilled in injection technologies. And those who already have experience in use increase their requirements for the drugs used, the quality of the result achieved, the duration of its action and the minimization of side effects. This leads to an increase in standards in carrying out such manipulations, that is, an aesthetic medicine specialist must constantly improve his knowledge and skills.

An important legal aspect is working with legal drugs. In this case, responsibility for the quality of the drug lies not only with the doctor performing the procedure, but also with the manufacturer or its official distributor. Nevertheless, mesotherapy, contouring and the use of botulinum toxin type A (like any other invasive manipulation) are fraught with the development of complications and side effects.

Complications can be classified according to different criteria:

• general complications (characteristic of all techniques);
• private complications (typical for each individual);
• complications caused by the doctor (iatrogenic errors, violation of the procedure protocol by a specialist);
• complications arising due to the patient’s fault (non-compliance with recommendations in the post-procedure period).

Common mistakes when performing injection procedures

The most common mistake that aesthetic medicine specialists make is that during the initial consultation they do not conduct a full examination and collection of the patient’s medical history , and treatment begins immediately after examining the facial area. But in order to ensure a good result after the procedure, the cosmetologist must obtain maximum information about the patient’s health status (in his words), collect an allergy and cosmetic history, find out what drugs were used previously (this is especially true for fillers), when they were performed previous procedures, etc.

A complete examination of the skin of the entire body at the initial consultation is necessary in order to obtain additional clinical information about the condition of the skin and soft tissues, skeleton, type of distribution of subcutaneous fat, and the presence of certain formations on the skin. In this case, it is necessary to register all this data in the patient’s card or in the photo. On the one hand, the collected information will reflect all the characteristics of your patient, which is very important for drawing up the correct treatment algorithm, and on the other hand, it will allow the patient to avoid complaints regarding the ineffectiveness of treatment, etc.

After examining the patient, the specialist must “make a diagnosis” - professionally tell the patient about his skin problems and offer appropriate correction options. A common mistake at this stage is prescribing procedures not for medical reasons . For example, overweight patients with thick skin or excess skin should not be prescribed lifting programs. Despite their proven effectiveness, these procedures will give minimal results in this category of patients, and the doctor, undoubtedly, after the end of treatment will be faced with absolutely justified claims from the patient.

Thus, the treatment plan must be strictly individualized. It is necessary to take into account not isolated problems of the face or body, but be based on an analysis of all of the above and, if necessary, include consultations with related specialists or various examinations. Underestimation by a specialist of the etiopathogenetic aspects of the manifestation of certain changes in the skin and soft tissues and, accordingly, an incorrect prognosis of therapy, first of all, indicates the lack of qualifications of the cosmetologist, and secondly, will lead to an unsatisfactory or short-term result and conflict with the patient.

Registration of informed consent and photo documentation of the original picture allows for the prevention of legal complications , since in this case the patient shares a measure of responsibility for his actions during treatment. Changes in the skin during some types of exposure (for example, during mesotherapy) occur gradually and gradually, and the patient does not always notice an improvement - in this case, comparison with the first pictures will prove the effectiveness of the treatment.

Complications of a psycho-emotional nature include a discrepancy between the result obtained and what was expected for the patient. This situation can arise either if he has characterological characteristics, or if the procedure is carried out not according to indications. So an assessment of the patient’s psychological status should also be carried out by a specialist and influence the development of a treatment plan.

Allergic complications of injection techniques pose a fairly serious threat to both the health and life of patients and the career of a doctor, and the best measures to prevent them are strict adherence to procedure protocols, conducting allergy tests and using proven and certified drugs.

The actual technical complications of injection techniques are microhematomas, pain and infectious complications.

Microhematomas can rather be attributed to the side effects of invasive techniques - and it must be remembered that the risk group in this case are smokers, women in menopause and during menstruation, patients with rosacea, as well as those who take anticoagulants (for example, aspirin for headaches or herbal remedies for varicose veins). Therefore, these risks should be assessed and discussed during the initial consultation.

The pain of injections is well known - the use of application or conduction anesthesia can significantly reduce the degree of sensitivity, but, according to the French school of mesotherapy, anesthesia during mesotherapy reduces its effectiveness. In any case, this situation must be resolved individually.

Infectious complications are classified into bacterial and viral. The formation of pustular elements at the injection sites indicates either gross violations of the rules of asepsis by the doctor, or a violation of the post-procedure period by the patient. So the key to the development of such complications is strict adherence to the protocol and full informing of patients. Viral complications include, first of all, exacerbation of herpetic infection - most often in the perioral zone or when working in the torso area. Prevention of this condition will include a thorough history taking and assessment of the risk of developing such manifestations.

Complications after mesotherapy

An insufficiently pronounced effect from the therapy or no result at all is possible if drugs are incorrectly selected to correct a particular problem or, as mentioned above, if procedures are prescribed incorrectly.

A more complex problem is the development of inflammation or deeper changes in the skin if the composition of the meso-cocktail is violated or the use of drugs not indicated for intradermal administration (calcium chloride, fat emulsions, etc.). Such situations arise mainly either due to ignorance of the pharmacological properties of the drugs used, or due to the carelessness of the doctor who mistakenly put the wrong drug into the syringe.

When working with hyaluronic acid (HA) preparations , papules may be present for a long time . Normally, depending on the concentration of HA, papules should disappear within 12–72 hours. If the degree of skin dehydration is underestimated and HA drugs are administered, papules can remain on the skin even longer and cause at least aesthetic problems, and in the case of constant injury by the patient’s hands, there is a possibility of developing inflammatory complications. The use of high concentrations of HA preparations on the skin of the lower eyelids, especially with fatty hernias, is fraught with prolonged swelling in this area and increased tissue sagging after regression of the edema. Therefore, working with HA preparations requires compliance with the application protocol in accordance with the recommendations of each specific manufacturer and taking into account the condition of the skin.

The use of antihomotoxic drugs (AGD) during mesotherapy may cause dissatisfaction with the results in some patients, which may be due to the slower development of the clinical effect from working with drugs of this group. This situation is due to the mechanism of action of AGTP - reprogramming the functioning of the skin and extracellular matrix and a gradual transition of the functioning of skin cells to a younger level. That is, the clinical result develops at an individual speed, depending on the initial condition of the skin. The undoubted advantage of working with AGTP is the safety and overall healing effect on the body.

Claims of a weak clinical effect are also often found when correcting lipodystrophy. The reason for the dissatisfaction of such patients is the underestimation of the etiological mechanisms of the pathology and inflated promises. Mesotherapy for lipodystophy without correction of endocrine problems is obviously doomed to poor results. Moreover, the use of lipolytics, by definition, affects adipose tissue, destroying and rebuilding it - in this case, the patient’s body volume decreases, but the weight decreases slightly (if only mesotherapy is performed), since the fat is quite light. And patients expect to lose their kilograms and, not receiving this, express dissatisfaction. True, at the same time, they always note an improvement in the quality of the skin itself and, often, with a full selection of drugs, a decrease in the feeling of heaviness and swelling of the legs. Therefore, a specialist prescribing a lipodystrophy correction program must understand the etiopathogenesis of this pathology, all treatment methods and prognosis for each patient.

Complications when using botulinum toxin type A

The most common mistake when working with botulinum toxin type A (BTA) preparations is non-compliance with the protocol for working with the drug , namely:

• improper dilution, which leads to insufficient effect or a very strong block of facial muscles;
• administration of the drug not in the correction zone - facial asymmetry, impaired eyelid closure, ptosis of the upper eyelids, BTA getting into the extraocular muscles (visual impairment), articulation disorders and difficulty eating when administered in the perioral area;
• discrepancy between the dose of the drug and muscle strength in a certain area: in men, an insufficient dose causes a mild block; An overdose is possible, which is manifested by ptosis of the tissues of the forehead and glabellar region when BTA is administered in several adjacent areas.

Failure by the patient to comply with the conditions of the post-procedure period (improper body position immediately after BTA administration, drinking alcohol in the coming days, thermal procedures or any stimulating procedures) causes the likelihood of complications or significantly shortens the duration of the drug in the skin. Proper informing of patients and general differentiation (who can undergo such procedures and who should not) is the key to preventing complications due to violations of the post-procedure period.

Measures to prevent these complications include strict compliance with the protocol for working with BTA, taking into account the individual characteristics of the skin, soft tissues of the face and the structure of the facial skull, as well as positioning the procedure for using BTA not as an isolated technique, but as part of a program of complex effects on the skin of various technologies in order to improve the quality therapy and prolongation of its results.

A positive point regarding the assessment of complications of BTA use is the time-regulated effect of the drug (3–6 months on the face) and the possibility of correcting an insufficient dose by additional administration of BTA or blocking an overdose with antagonist drugs.

Complications with contour plastic surgery

Errors during contouring may be related to the characteristics of the drugs used and the procedure itself.

The use of stable biopolymers that do not dissolve in the skin presupposes a fairly high professional level of contouring, since the error can only be corrected if the volume of the injected drug is insufficient. When overcorrection or pronounced asymmetry is obtained, it is quite difficult to achieve an optimal result. Biopolymers are capable of migration, can cause significant swelling at the injection site during pregnancy, form granulomas or provoke ischemic phenomena in the skin and mucous membranes. Removing biopolymers by interstitial administration of hormonal drugs is not entirely justified: in this case, disorganization and atrophy of one’s own healthy tissues, and not the biopolymer, occurs. Correction of excessive administration of such drugs is possible surgically, but this does not guarantee an ideal result and has its own surgical risks.

Biodegradable drugs, first of all, must be biologically safe, that is, preference should be given to drugs synthesized in the laboratory rather than those obtained from animals. The less the human body reacts to the injected drug, the longer it remains in the skin. The time that HA preparations “stay” in the skin depends on the physicochemical characteristics of the HA molecule, the quantity and quality of cross-links - the longer and more bonded the molecules, the longer the period of their biodegradation. The development of allergic and inflammatory reactions to the administration of biodegradable drugs is possible in the case of a burdened allergic history (which the patient may not be aware of), as well as in case of violation of the procedure protocol or the post-procedure period.

The administration of a drug of a certain density (HA concentration) must correspond to the skin type, zone and depth of administration. The thinner the skin and the shallower the depth of the wrinkle, the more “light” the drug should be used, and the administration is quite superficial (but still intradermal). Accordingly, for thick skin, deep wrinkles and depression areas, dense preparations are used at a sufficient depth.

Too superficial injection of HA leads to the formation of strings and swellings - in this case, you can try to remove excess drug from the injection site or knead it thoroughly. Injecting fillers into the eyelid area can cause long-term swelling.

Frequent lip contouring, especially with a 27G needle, can provoke cicatricial changes in the skin of the red border.

Hypocorrection in any zone is not a mistake and is easily eliminated by additional administration of the drug after 2 weeks.

Hypercorrection may require the introduction of hyaluronidase (but not hormonal drugs) into the site of excessive HA administration, but in any case, after a certain time, as a result of the spontaneous breakdown of the HA molecule, this complication will be leveled out.

Insufficiently deep injection of calcium hydroxyapatite may appear as white stripes at the injection site - in this case, all that remains is to wait for its biodegradation.

A very important role in the prevention of complications during contouring is played by a thorough analysis of the facial relief and assessment of the quality of the skin and soft tissues.

A very common mistake is assessing an isolated area (for example, nasolabial wrinkles), rather than the entire face as a whole. It is also important to make a correct diagnosis and explain to the patient what skin texture problems he has. If there are nasolabial folds, a height gradient between the upper lip and cheek, and pronounced zones of depression in the corners of the mouth, it is not enough to just carry out contour plastic surgery - it is necessary to carry out extensive and long-term work with the facial skin itself, and in some cases, a referral for consultation to a plastic surgeon.

Another problem for a specialist in aesthetic medicine today is working with patients after other “specialists” who perform contouring with unknown drugs. The patient says that he was injected with a filler, but he does not know what kind, and he was not given a brand with the name of the drug. In such a situation, it is worth finding out what they said and promised - the drug was introduced forever and for some time, what color it was, etc. It is known that in the presence of biopolymers, the introduction of other drugs in this zone is not indicated. If a biodegradable drug is administered, you should wait until it is completely absorbed.

The post-procedural period for contour plastic surgery differs little from other injection techniques, and its violation by patients can lead to inflammatory complications.

The system for training new specialists and the work of those already practicing must be strictly regulated within the framework of the country’s legislation. Maintaining medical records, compliance with counseling and treatment protocols are both organizational and methodological measures and means of legal protection. Competently informing patients, working with certified drugs, and clearly defining indications and contraindications for injection techniques will significantly reduce the risk of complications during their implementation.

First published: Les Nouvelles Esthetiques Ukraine, No. 3 (67), 2011