Complications Flashcards
High risk areas for vascular occlusion
Glabella
Forehead
Nose
Periocular
Perinasal
Temple
Vasovagal physiology
bradycardia
hypotension
arterial vasodilation
autonomic neural response
hypothalamic activation from stress or pain
Anaphylaxis adrenaline dose
500mcg of 1:100 (1mg/ml) IM
can be repeated after 5 minutes up to 3 times
Bruising risk factors (5)
antiplatelet
anticoagulant
NSAIDs
Vitamine E
High doses of garlic
Botox complication (non-cosmetic)
headache
Flu like symptoms
Cause of diploplia
lateral rectus palsy
lateral canthal injection diffusion
Cause of blurred vision
lower eyelid laxity stopping draining of tears
Cause of dry eyes
diffusion of toxin into lacrimal gland from deep periorbital injection
Causes of lower eye lid ectropiom
infraoribtital toxin causing lack of tone in palpebral portion
urgent opthalmology referral required to prevet corneal damage
Symptoms of systemic toxin overdose
dysphagia
slurred speech
muscle weakness
resp muscle paresis
Causes of toxin treatment faulure
Inproper product storage
true patient resistance
Inappropriate use - static lines
Calcium channel antagonist
Correcting medial brow ptosis
assess if there is still medial corrugator activity
if yes treat between 2-4 weeks to counterbalance medial frontalis fibre treatment
Managing adverse outcome
Document - identify reason for outcome
Liase with GP in needed
Refer to specialist services if needed
Make plan for continued care/ further review
Description of common side effect
Mild
Transient - resolve within 10 days
Does not require further intervention
Contents of emergency kit
Adrenaline 1:1000 x 4
Hyaluronidase 1500 units x 10
Associated consumables
Bacteriostatic saline 30mls x 2
Aspirin 75mg
Glucose gel/tablets
Loratidine 10mg
Warm Pack
BP monitor
Saturation probe
guaze
syringes
needles - 30G
Which governing body to report complications to?
MHRA (medicines and healthcare products regulatory agency)
Description of adverse events
Common reactions that have persisted
Rare
Moderate to severe effects
Anaphylaxis, necrosis, vascular compromise, scarring
Complication severity
Low - unlikely to result in complication, internvention unlikely
Moderate - may have complication, monitor
Major - immediate intervention essential
Examples of delayed filler complication (5)
Product migration
inflammatory nodules/granulomas
Oedema
Hypersensitivity related swelling
Chronic Infection
HSV activation
Examples of Early filler complications (5)
Infection
Swelling
Nerve damage
Tyndall effect
Muscle/expression change
HSV activation
Examples of immediate Filler complications (5)
Vascular event
Anaphylaxis
Bleeding
Vasovagal episode
Skin changes
Factors for nodule formation
Disease that creates immune mediated response
e.g Influenza
Anterograde embolism vs retrograde
Distally to terminal arteries
vs
Moves in opposition to blood flow
Venous complications
Congestion and compartment syndrome
Where are the labial arteries most at risk
In the midline - higher risk of subctaneous arteries
Factors affecting needle aspiration (6)
Primed needle
Product viscosity
Length of time
Needle length
Steadiness of hands
Amount of negative pressure
Conservative management of VO
Firm massage for 5 mintuutes
Warm compress for vasodilaton
Firm tapping over occluded area may dislodge emboli
Skin changes with filler
Neovascularisation from trauma/tissue expansion - treat with laser if resistant
Hyperpigmentation - Fitz IV-VI
Rosacea flare
Scarring from other complication (ifection/VO)
Filler biofilm
Aggregation of microorganisms on implanted filler
formed by extracellilar matrix of polymeric fibrinogen and fibronectin
resitant to abx penetration
First line abx for infection
Flucloxacillin 500mg QDS PO
or
Clarithromycin 500mg BD PO
Malar oedema
May resolve over 2-3 weeks
Encourage lymphatic drainage and cold compress several times a day
Avoid steroids
Type IV hypersensitivity
Delayed reaction mediated by cellular response
T-lymphocites
Inflammatory nodules
DO NOT RESPOND TO ANTIHISTAMINES, can be treated with oral steroids, tapering dose
What to do if unsure of hypersensitivity vs infection
Treat with abx first
Then weaning steriod course
May need to dissolve to remove underlying trigger
Type I hypersensitivity
IgE mediated - mast cell activation - fast onset
atopy, anaphylaxis, allergy, angioedema
Responds to antihistamines
Nerve damage
rare
trauma through laceration, compression, occluding exiting foramen
Bells palsy management
Artificial tears
steroids
Eye patch
Nodule management
Firm massage if occur immediately
Aspiration if delayed
Cause of inflammatory module
Biofilm infection of filler
Management of inflammatory nodule
Two weeks of abx, up to 4 weeks
Macrolide - clari 500mg BD
Tetracycline - minocycline 100mg BD - anti inflammatory properties
Dual antibiotic therapy
add doxycycline 100mg BD or ciprofloxacin 500mg BD
If infection of filler not improving
Punch biopsy and culture
Surgical excision
Intralesional antibiotics
Hyaluronidase dissolving
Granuloma character
Red firm papules or nodules
Subdermal
Appear within 6 months of treatment
Usually non-biodegradeable products, not HA
Hyaluronidase intradermal patch test
Should not be used to delay treatment in vascular compromise
30 units (0.2mls) in the forearm and compare with a saline control
observe for 30 minutes
Photographs pre and post test
Positive reaction in Hyaluronidase patch test
Wheal and flare
increase in size by 50%
Wheal increase by over 8mm
Hyaluronidase dose
Large volume protocol
1500 units in 10ml dilution
What to do in context of positive hyaluronidase patch test
If treatment still needed - referred to a specialist for further consideration of treatment
with resuscitation facilities
How many units in a vial of hyaluronidase
1500 unit
Origin of UK hyaluronidase
ovine (sheep)
Storage of hyaluronidase
2-8C improves quality and longevity
Room temperature stability is guaranteed for 12 months
Once opened use immediately
Large volume, low concentration reconstitution
1500 units in 10mls of saline
non-emergency scenarios
Small volume, high concentration
1500 units in 1-2mls of saline
Emergency vascular occlusion
When would higher doses of hyaluronidase be needed
Highly cross linked HA
Higher doses of HA
Multiple prodcts
Nodules
Product injected over 6 months ago
Reconstitution of hyaluronidase
Water or saline
Add 1ml to ampoule to dissolve powder - draw and expel syringe.
Add 1ml of reconstituted product to remaining dilutent and mix
Hyaluronidase injection technique in VO
cannula or serial needle punctures along the course of vessel
Cannula use can prevent bruising which would mask visual feedback
Massage to disperse product
How often can Hyaluronidase be repeated
hourly until clinical resolution
Hyaluronidase after care
Observe patient for 30-60 minutes after treatment
Arrange F2F appointment 24-48 hours
if signficant skin changes prescribe abx prophylactics
Follow-up with patient every few hours that same day
Where to report complications
MHRA Yellow card scheme
Manufacturer
Signs of VO
Skin changes
Strong pulse upstream to affected area
Most common cause for non-inflammatory nodule
Product misplacement
Nodule excision - when & how
Recently placed
Superficial placement
Large bore needle 21G
Small incision and squeeze
Delayed onset inflammatory nodule signs and causes
Tenderness
Erythema
Warmth
Discrete border
Low grade biofilm - can lead to chronic inflammation and granuloma formation
Retinal artert occlusion immediate management
Stop treatment, supine position
Occular massage
Rebreathe in paper bag - increase CO2 and vasodilaton
Sublingual GTN
Emergency eye casualty referral
Time to cause permanent visual loss in rentainal occlusion
12-15 minutes
Retinal artery occlusion treatment
Specialist eye unit
Retrobulbar injections by specialist
injection of hyalase into supratrochlear or supraorbital arteries
