Injectables - Plastic Surgery Internal

SRPS • Volume 10 • Issue 28 • 2010
COMBINATION THERAPY
With the evolution of the understanding of
facial rejuvenation, combination modalities are
increasing to address the three-dimensional
face. 3,120,121 Stacking of fillers, especially permanent
on top of permanent, and large-volume injections
have been associated with more inflammation
and granuloma formation. 122 Carruthers and
Carruthers 123 conducted a prospective, randomized
study of Botox in combination with HA filler and
observed improved outcomes in comparison with
those of HA filler alone for glabellar rhytides. The
combination treatment almost doubled the duration
of response. Carruthers et al. 62 published their
consensus recommendations for botulinum toxin
and HA combination therapies in 2008.
COMPLICATIONS
Injectables available in the United States have
excellent safety profiles with rare side effects. 13,14,124
With the difficulty to treat biofilms, initial
care should be focused on prevention. The
most common complications are procedural or
technique-related as opposed to product-based,
such as inappropriate placement of injectables,
usually too superficially. 87,96,97 Adverse reactions
to injectables usually are transient and mild. 125,126
The more serious complications include foreign
body granulomas with an incidence of 0.01% to
0.1%. 115,127–130
The timing of the onset of complications can
be classified to assist in management. Commonly
classified as early and late, Rohrich et al. 15 suggested
that onset of complications be classified as early,
late, and delayed. The three time frames are defined
as approximately less than 14 days, 14 days to
1 year, and more than 1 year, respectfully, and
might correlate with the potential causes of the
complications. Early complications commonly are
inflammatory in nature, late complications usually
are secondary to granuloma formation, and both
early and late complications can be infectious in
origin and complicated by a phenomenon that is
collectively referred to as biofilms (Table 5). 15,131,132
Early complications are the most common
16
adverse events, accounting for 93% of adverse
events, and generally are inflammatory or technical
in nature. Mild early complications include
discomfort, bruising, bleeding, erythema, swelling,
pain, itching, asymmetry, lumpiness, dimpling,
allergic reaction, infection, hematoma, migration,
extrusion, and nodules, of which persistent
erythema is the most common complaint. Redness
and swelling have been noted to occur with
approximately 80% of injections. 133 Early injection
site reactions can be limited by applying ice or cold
compresses to minimize bruising and swelling.
More serious early adverse events
include allergic reactions, infections, vascular
compromise, and too superficial placement of
product. Hypersensitivity can be as severe as
angioedema and anaphylaxis. 134 Antihistamines,
topical immunomodulators (Aldara [Graceway
Pharmaceuticals, LLC, Bristol, TN], tacrolimus),
and steroid injections are effective in managing
immunological reactions. 116
Injections around the lips can trigger
herpetic outbreaks. If the patient has a history of
herpes, prophylactic antiviral treatment should be
considered, especially when injecting around
the lips. 135
Intra-arterial injection can cause injection site
necrosis and has been reported to occur in both the
supraorbital artery during glabellar injection and
the angular artery during injection of the nasolabial
folds. 136,137 The glabella is thought to be at highest
risk because the supratrochlear artery provides a
watershed area. It is always important to remember
the anatomy when using injectables. Specifically,
the supratrochlear artery runs deep (therefore,
injections should be superficial) whereas the angular
artery runs superficially (thus, injections should be
deep). Venous occlusion can also occur if excessive
product placement results in venous external
compression. This might present as dull, aching pain
and swelling with violaceous discoloration. 138
Vascular embarrassment can be minimized by
simple techniques. Always aspirate before injection.
Use lower volumes in high-risk areas. Remember
knowledge of vascular anatomy and depth planes.