Introduction
The non-surgical cosmetic sector has experienced explosive growth in recent years, with a predicted compound annual growth rate (CAGR) of 14.5% from 2022 to 2030. The International Society of Aesthetic Plastic Surgery’s annual Global Survey revealed a staggering 57.8% increase in non-surgical procedures over the past four years. However, there is a global acknowledgment of the lack of structure and consistency in post-graduate training in this field. The cause of this can be largely attributed to its occurrence outside the traditional teaching hospital setting. This minimally invasive facial aesthetic procedure surge has been correlated with a notable increase in reported aesthetic medicine complications.
For the United Kingdom, the unregulated landscape of aesthetics has created a hazardous situation for both clinicians and patients. Currently, there are no restrictions on who can perform these treatments and no qualification requirements for practitioners. It is critically important for those aspiring to work in aesthetic medicine to ensure adequate training and competence. This will help in recognizing and managing complications.
Moreover, clinicians operating in emergency settings must also be familiar with recognizing, initially managing, and escalating these complications. The primary objective of this literature review is to provide a comprehensive summary of the current evidence regarding complications. This is most likely to be present in Emergency Departments, along with the development of guidelines for clinicians working in this demanding context.
Complications Presenting to Emergency Departments
Incidence and Severity of Complications
In general, the incidence of complications in non-surgical cosmetic procedures is low, and most reported adverse events are mild. Risk can be minimized through careful patient and product selection and proper placement. However, it’s important to note that serious complications can and do occur. Ideally, complications from private non-surgical cosmetic procedures should rarely present to NHS Emergency Departments. Ethical and qualified medical professionals should be able to manage complications and have appropriate referral networks in place when necessary. Existing guidelines, such as those from organizations like Aesthetic Complications Group (ACE) and Complications in Medical Aesthetic Collaborative (CMAC), focus on complication management by medical professionals using safe and regulated products.
Challenges in Regulation and Patient Access
The lack of regulation in the UK poses challenges for patients seeking help for adverse events. The NHS currently does not collect data on how many cosmetic complications are treated in Emergency Departments. However, many published case reports of patients presenting with complications in Emergency Departments involve either non-medical practitioners or self-injection. It’s crucial to differentiate between complications that can occur even with proper procedures and those resulting from inappropriate use of injectables, with the latter being more common.
Complications Caused by Non-Medical Professionals
The Consumer Complaints Report for 2017-2018 published by Save Face revealed that 83% of complications were caused by non-medical professionals. In these cases, there is a possibility that non-legitimate or illegally sourced products were used. Emergency medicine clinicians need to be aware of this possibility because the use of unregulated products can complicate the management of adverse events. Furthermore, if medical devices like fillers or threads have not been placed in regulated environments, there is no guarantee of proper hygiene and infection control, increasing the risk of infections or abscess formation.
Self-Injected Fillers and Online Resources
A recent review of complications resulting from self-injected fillers has shown that this is a widely discussed phenomenon on online forums, with multiple self-injection video tutorials easily accessible. While there are few published case reports on self-injected fillers, their prevalence on the internet suggests that this is an underreported phenomenon. Patients have been known to self-inject substances like hyaluronic acid, as well as unconventional substances such as olive, almond, or sesame seed oil.
These factors underscore the importance of proper regulation and awareness among medical professionals and emergency clinicians in managing complications related to non-surgical cosmetic procedures.
Swelling and Oedema
Transient swelling post procedure is expected in injectable treatments. Injection volume and technique can increase the risk of swelling, which occurs more frequently around the peri-oral and peri-orbital region.4 Oedema can be a manifestation of a hypersensitivity reaction or transform into a chronic problem.5 Mild to moderate oedema can initially be managed conservatively with the addition of anti-histamines (Loratadine 10mg OD) and ibuprofen to reduce inflammation.7
Chronic oedema presents a more difficult management problem. There are several factors that contribute to the formation of chronic oedema, including the type of filler used, the injection technique, patient factors, and the co-existence of other complications such as infection of granulomas. In general, hyaluronic acid (HA) fillers are generally well-tolerated.4 However, HA injections into the infraorbital hollow are associated with malar oedema.5, 16 Patient factors such as lower eyelid blepharoplasty, previous filler injection, and poor lymphatic drainage can increase the risk of oedema in this area.17 This can be refractory to treatment, lasting days or months, or even becoming permanent.5 Initial management includes head elevation, the use of cold compress, and the use of steroids and injection of hyaluronidase.5, 7
Hypersensitivity reactions.
Dermal fillers can trigger either type I or type IV hypersensitivity reactions. The incidence of type I hypersensitivity reactions and anaphylaxis is low, and anaphylaxis should be managed as per the Advanced Life Support (ALS) algorithm.18 Mild hypersensitivity reactions may only require symptomatic treatment, including the use of antihistamines to reduce inflammation and cold compress to reduce swelling.5 In more severe cases with significant swelling or persistence, systemic corticosteroids may be indicated.5 Delayed or type IV hypersensitivity reactions often present as nodules, which are discussed below.
Abscesses
Abscesses are painful collections of exudates underneath the skin that form secondary to infection, typically bacterial in nature. Risk factors include general risk of infection such as systemic illness and immune compromise. Abscesses that occur post-filler procedures typically occur within the two weeks after treatment. These are often caused by pathogens commonly found on the skin: Staphylococcus aureus and Streptococcus pyogenes.19 Both the Aesthetic Complication Expert Group (ACE)20 and an international consensus group4 recommend incision and drainage within 48 hours, culture and sensitivities, and broad antibiotic cover (Co-amoxiclav +/- macrolide/quinolone) until specific sensitivities are confirmed. Most of the literature supports the use of hyaluronidase in the cases of abscess, as the filler can act as a growth medium for the bacteria.19
Nodules
Nodule formation can result from various factors, including infection, biofilm formation, or a Type IV hypersensitivity response.5, 21 Nodule is a descriptive term, rather than a diagnosis, and the aetiology is still poorly understood.22 Several patient factors have been posited as increasing the risk for nodule formation, including a history of hypertrophic scars or keloids and autoimmune disorders.16 Nodule formation is one of the most common adverse events related to fillers.6, 13 Permanent filler increase the risk of nodule formation, as lifetime risk increases as these products remain in the body.13 Nodule formation secondary to poly-L-lactic acid fillers are resistant to most therapies, and usually require surgical intervention for successful treatment.21 Calcium hydroxylapatite fillers may response to intralesional steroid injections, but usually also require surgical intervention for definitive treatment.21
For HA fillers, the most effective way to manage these is to remove the allergen. So treatment with hyaluronidase with steroids is usually recommended. Antibiotic coverage may or may not be necessary, but is typically recommended because it can be difficult to clinically distinguish nodules secondary to biofilm formation or hypersensitivity reactions. Type IV reactions have also been reported to present with indurations and abscess-like sterile collections. For nodules that are resistant to treatment with antibiotics, steroids, and hyaluronidase, intralesional steroid injections or surgical excision may be necessary.7
Vascular Occlusion
Vascular occlusion (VO) refers to the partial or complete blockage of vascular supply. This typically can occur due to intravascular injection or extravascular compression. Although rare, VO can lead to severe complications, including skin necrosis or visual loss. Some evidence from small studies suggests that VO may be more severe when non-hyaluronic acid (HA) fillers are used.
Recognition and Initial Presentation
Recognizing and promptly managing VO is crucial to minimize adverse outcomes. Typically, the initial presentation is painless blanching, which can be subtle. This blanching then progresses to painful, reticulated patches. After several days, livedo reticularis may appear, followed by blisters and crusting. In some cases, necrotic eschar may develop with ulceration. High-risk areas include the glabella, as it is a watershed site with limited collateral circulation.
Management of Vascular Occlusion
The cornerstone of vascular occlusion management is the use of hyaluronidase. While it is common practice to perform a hyaluronidase skin test in case of type I hypersensitivity reactions, there is no evidence base for this, and it contradicts the guidelines of the British Society of Allergy and Clinical Immunology.
High-Dose Pulsed Hyaluronidase Protocol
The high-dose pulsed hyaluronidase method has been described in the literature with successful outcomes. This protocol recommends repeated administration of relatively high-dose hyaluronidase hourly until resolution. Clinicians should treat to effect rather than use a specific dose, and they may repeat hyaluronidase administration every 15-20 minutes. Although this protocol does not endorse ancillary treatments, as described below, they are still recommended in most standard guidelines, particularly in cases of late presentation.
Ancillary Treatments for Vascular Occlusion
Ancillary treatments may be of benefit, especially in cases of late presentation:
Nitroglycerin paste can aid in increasing vasodilation, although there is some controversy surrounding its use due to the potential for shunting and disruption of deeper vascular supply.
Administering 300mg of aspirin is recommended to prevent platelet aggregation and reduce inflammation, minimizing blood clotting in the occluded vessels, although direct evidence is lacking. This can be followed by one baby aspirin (75mg OD) for one week post-occlusion.
The literature also describes the use of low molecular weight heparin to prevent thrombosis, as well as medications like sildenafil and tadalafil to increase vasodilation.
In some cases, treatment with hyperbaric oxygen can be considered to attempt to deliver oxygen deep into the tissues to improve viability. However, there is controversy surrounding its efficacy and suitability.
If the occlusion has progressed to the point of necrosis, careful wound debridement and care become critical for successful management.
These measures are essential in managing vascular occlusion complications resulting from facial injections.
Visual Loss
Visual loss is a rare but severe complication of facial injections, characterized by occlusion of the ophthalmic or retinal artery leading to blindness. Immediate recognition and management are crucial, given the time-sensitive nature of interventions.
Presentation and Specialist Intervention
The typical presentation includes sudden-onset pain and blindness. In such cases, specialist intervention is of utmost importance and should be initiated as soon as possible. Transfer to an appropriate medical unit should be the priority, even for non-ophthalmology trained clinicians.
Immediate Actions While Awaiting Transfer
While awaiting transfer to a specialist unit, several immediate actions can be taken to mitigate the situation: Administer 300mg of aspirin to the patient, position the patient in a supine position with the head raised at an angle of 15-46 degrees, reduce intraocular pressure by administering 0.5% timolol eye drops, utilize a rebreather bag to induce hypercapnia and hypoxia, promoting retinal blood flow and vasodilation, and initiate ocular massage, which can dilate the retinal artery and help dislodge potential emboli. This involves applying pressure to the closed eyelid for five seconds, releasing for ten seconds, and repeating for five minutes. Visual acuity should be checked after three sets of ocular massage. Consider sublingual glyceryl trinitrate to further enhance vasodilation.
Focus on Intraocular Pressure and Perfusion
Ophthalmology-trained clinicians should prioritize reducing intraocular pressure and improving retinal vessel perfusion. Options to reduce intraocular pressure include IV acetazolamide (500mg), IV mannitol, steroids, and anterior chamber paracentesis. While retrobulbar and peribulbar hyaluronidase treatments lack consistent evidence, some case reports suggest success with 1500u of hyaluronidase in 4mL saline, administered with a 25G retrobulbar needle. These measures are crucial in managing visual loss complications resulting from facial injections.
Conclusion
Medical aesthetic treatments can potentially lead to serious complications, highlighting the need for comprehensive training and regulation in this field. It is crucial to have robust guidelines in place to enhance patient safety and outcomes. These guidelines should be readily accessible for emergency department clinicians, who are increasingly dealing with complications from aesthetic treatments.
