Injectables - Plastic Surgery Internal

SRPS • Volume 10 • Issue 28 • 2010
inert surface. The most common biofilm example
is dental plaque. Biofilms have impaired immune
system penetration, reduced growth rates and/
or susceptibility by quorum sensing, altered
micro-environment, altered gene expression, and
display. 132,143
Routine culture techniques might be
inadequate because they are based in the planktonic
as opposed to the biofilm model. Improving culture
results with techniques such as pyrosequencing,
polymerase chain reaction (PCR), 144 fluorescence
in situ hybridization, 145 or ultrasound sonication 146
is an essential advance that should be considered
when biofilms are suspected.
Complications should be approached in
an algorithmic manner, and early recognition is
important (Fig. 6). 132 If the injection was performed
by someone else, every attempt should be made to
determine what was injected into the site. In cases
with even very mild signs of infection, one should
assume infection is present and prove it is not. If the
wound is fluctuant, it should be needle-drained and
cultured. Cultures should be sent to the laboratory
immediately for appropriate handling. Preliminary
antibiotic regimens should consist of at least a twodrug
therapy, such as administration of a quinolone
and third-generation macrolide, to prevent further
biofilm deposition. Macrolides have been shown
to be uniquely effective, which seems to be related
to improved accumulation in the subcutaneous
fat (where the filler material typically resides),
and they might also block quorum sensing. 147
After a trial of antibiotics, intralesional high-dose
18
steroids should be considered. 116 If HA was used,
hyaluronidase should also be considered. 148 The use
of laser-assisted evacuation of filler material as an
intermediate step between medications and surgery
can be considered. 149 Excision should be the
last step. 132
ETHICS
The majority of cosmetic injectable use is off-label,
and it is illegal to commercially advertise any nonapproved
or off-label use. Off-label use must not be
experimental and should have general acceptance
by the medical community in peer-approved
publications or presentations. The patient must be
informed of the off-label use. 150
Three models for delivery of injectables by
qualified providers are available: physician delivery
model, physician extender delivery model, and
combined delivery model. The individual physician
of record is ultimately responsible to ensure that
any non-physician administering injectables
possesses the proper education and training. 151 The
American Society of Plastic Surgeons (ASPS) and
the ASAPS published the Joint ASPS & ASAPS
Guiding Principles: Supervision of Non-Physician
Personnel in Medical Spas and Physician Offices. 152
This publication provides guiding principles to
protect patients and improve quality of care. A
central registry, or filler passport, has been suggested
to maintain records while also minimizing
unqualified practitioners and unregulated
products. 132
Figure 6. Management algorithm of late and delayed complications of soft-tissue injectables (Reprinted with permission
from Rohrich et al. 132 )