Avoiding Dermal Filler Pitfalls Begins With a Mirror

LAS VEGAS — As part of her pretreatment consultation before providing dermal fillers, Dr. Ranella Hirsch hands a mirror to her patients and instructs them to advise her on their specific goals and expectations.

"I can't tell you how many times I have looked at the patient on a consult, assessed precisely what I thought the ideal aesthetic outcome is, and then be told that it's actually something completely different that they are here for me to treat," Dr. Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "A mirror is your friend."

She went on to discuss other ways to avoid potential pitfalls:

▸ Always snap before and after photographs. "There are limited legal protections," said Dr. Hirsch, a dermatologist who practices in Cambridge, Mass. "Before-and-after photographs are one of the few things that will objectively capture accurate data."

▸ Beware of unrealistic expectations. "You need to know what unrealistic expectations are and not treat those people in the first place," she said. "You're not going to make them happy and you're going to make yourself miserable in the process."

▸ Assess for medical contraindications. These include history of hypersensitivity or allergy to known filler ingredients, history of oral herpes simplex virus and keloids, and any problems with scarring. "In my office, we check for these problems three times," said Dr. Hirsch, who is the immediate past president of the ASCDAS. "And it is remarkable how many people neglect to mention these critical points until being asked repeatedly."

▸ Make sure patients can afford the services required for the outcome desired. Be wary of patients who require three syringes of product for optimal results yet only want to pay for one.

▸ Have patients fill out a consent form during every visit. Nothing is more important to the aesthetic physician than informed consent, she emphasized. "I am surprised every time I hear a physician say, 'I use the consent form that came with the job.' Should complications arise, it is critical that this has been done properly to protect yourself."

Describing her own consent forms, she noted, "It's not enough that patients sign at the very bottom of removed pages of small print. They have to sign next to each potential complication and initial it. It has to be witnessed by someone and time stamped. These are critical aspects." She advised checking with an attorney for the best relevant advice.

▸ Educate patients about common side effects. To help reduce the occurrence of purpura, Dr. Hirsch advises patients to eat a lot of pineapple preprocedure, because it contains bromelain. Another option is to take five tablets of arnica, a substance commonly used for muscle pain and bruising, the night before the procedure and another five on the day of the procedure.

Other ways to minimize bruising include applying pressure during and immediately following the injections, using topical anesthesia, mixing the filler with collagen products to stabilize platelets, adding a lidocaine wash to injectables that do not contain an anticoagulant, and using the "push ahead" technique, whereby you get the needle tip to the plane and extrude the needle ahead of the tip. By using this technique, which Dr. Hirsch attributes to Dr. Jean Carruthers, one allows the product rather than the sharp edge of the needle to create the injection plane for the product, thereby reducing tissue trauma (Dermatol. Surg. 2005;31:1604-12).

Should evidence of infection develop after the procedure, incise and drain the abscess as rapidly as possible. Culture the patient for both routine and atypical bacteria and prescribe a course of empiric antibiotics followed by specific antibiotics. "Follow up on those cultures," Dr. Hirsch advised.

If blanching or pain occurs at the injection site, stop immediately, because this can be the only sign of an impending vascular injury. Immediate administration of heat, massage, and nitroglycerin paste helps minimize or reverse permanent injury. A recent case report demonstrated that immediate administration of hyaluronidase can also be of great value (J. Drugs Dermatol. 2007;6:325-8). Once the vascular accident is managed, consider treatment with a pulsed-dye laser or intense pulsed light to improve discoloration.

Dr. Hirsch had no conflicts to disclose relevant to her presentation.

LAS VEGAS — As part of her pretreatment consultation before providing dermal fillers, Dr. Ranella Hirsch hands a mirror to her patients and instructs them to advise her on their specific goals and expectations.

"I can't tell you how many times I have looked at the patient on a consult, assessed precisely what I thought the ideal aesthetic outcome is, and then be told that it's actually something completely different that they are here for me to treat," Dr. Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "A mirror is your friend."

She went on to discuss other ways to avoid potential pitfalls:

▸ Always snap before and after photographs. "There are limited legal protections," said Dr. Hirsch, a dermatologist who practices in Cambridge, Mass. "Before-and-after photographs are one of the few things that will objectively capture accurate data."

▸ Beware of unrealistic expectations. "You need to know what unrealistic expectations are and not treat those people in the first place," she said. "You're not going to make them happy and you're going to make yourself miserable in the process."

▸ Assess for medical contraindications. These include history of hypersensitivity or allergy to known filler ingredients, history of oral herpes simplex virus and keloids, and any problems with scarring. "In my office, we check for these problems three times," said Dr. Hirsch, who is the immediate past president of the ASCDAS. "And it is remarkable how many people neglect to mention these critical points until being asked repeatedly."

▸ Make sure patients can afford the services required for the outcome desired. Be wary of patients who require three syringes of product for optimal results yet only want to pay for one.

▸ Have patients fill out a consent form during every visit. Nothing is more important to the aesthetic physician than informed consent, she emphasized. "I am surprised every time I hear a physician say, 'I use the consent form that came with the job.' Should complications arise, it is critical that this has been done properly to protect yourself."

Describing her own consent forms, she noted, "It's not enough that patients sign at the very bottom of removed pages of small print. They have to sign next to each potential complication and initial it. It has to be witnessed by someone and time stamped. These are critical aspects." She advised checking with an attorney for the best relevant advice.

▸ Educate patients about common side effects. To help reduce the occurrence of purpura, Dr. Hirsch advises patients to eat a lot of pineapple preprocedure, because it contains bromelain. Another option is to take five tablets of arnica, a substance commonly used for muscle pain and bruising, the night before the procedure and another five on the day of the procedure.

Other ways to minimize bruising include applying pressure during and immediately following the injections, using topical anesthesia, mixing the filler with collagen products to stabilize platelets, adding a lidocaine wash to injectables that do not contain an anticoagulant, and using the "push ahead" technique, whereby you get the needle tip to the plane and extrude the needle ahead of the tip. By using this technique, which Dr. Hirsch attributes to Dr. Jean Carruthers, one allows the product rather than the sharp edge of the needle to create the injection plane for the product, thereby reducing tissue trauma (Dermatol. Surg. 2005;31:1604-12).

Should evidence of infection develop after the procedure, incise and drain the abscess as rapidly as possible. Culture the patient for both routine and atypical bacteria and prescribe a course of empiric antibiotics followed by specific antibiotics. "Follow up on those cultures," Dr. Hirsch advised.

If blanching or pain occurs at the injection site, stop immediately, because this can be the only sign of an impending vascular injury. Immediate administration of heat, massage, and nitroglycerin paste helps minimize or reverse permanent injury. A recent case report demonstrated that immediate administration of hyaluronidase can also be of great value (J. Drugs Dermatol. 2007;6:325-8). Once the vascular accident is managed, consider treatment with a pulsed-dye laser or intense pulsed light to improve discoloration.

Dr. Hirsch had no conflicts to disclose relevant to her presentation.

LAS VEGAS — As part of her pretreatment consultation before providing dermal fillers, Dr. Ranella Hirsch hands a mirror to her patients and instructs them to advise her on their specific goals and expectations.

"I can't tell you how many times I have looked at the patient on a consult, assessed precisely what I thought the ideal aesthetic outcome is, and then be told that it's actually something completely different that they are here for me to treat," Dr. Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "A mirror is your friend."

She went on to discuss other ways to avoid potential pitfalls:

▸ Always snap before and after photographs. "There are limited legal protections," said Dr. Hirsch, a dermatologist who practices in Cambridge, Mass. "Before-and-after photographs are one of the few things that will objectively capture accurate data."

▸ Beware of unrealistic expectations. "You need to know what unrealistic expectations are and not treat those people in the first place," she said. "You're not going to make them happy and you're going to make yourself miserable in the process."

▸ Assess for medical contraindications. These include history of hypersensitivity or allergy to known filler ingredients, history of oral herpes simplex virus and keloids, and any problems with scarring. "In my office, we check for these problems three times," said Dr. Hirsch, who is the immediate past president of the ASCDAS. "And it is remarkable how many people neglect to mention these critical points until being asked repeatedly."

▸ Make sure patients can afford the services required for the outcome desired. Be wary of patients who require three syringes of product for optimal results yet only want to pay for one.

▸ Have patients fill out a consent form during every visit. Nothing is more important to the aesthetic physician than informed consent, she emphasized. "I am surprised every time I hear a physician say, 'I use the consent form that came with the job.' Should complications arise, it is critical that this has been done properly to protect yourself."

Describing her own consent forms, she noted, "It's not enough that patients sign at the very bottom of removed pages of small print. They have to sign next to each potential complication and initial it. It has to be witnessed by someone and time stamped. These are critical aspects." She advised checking with an attorney for the best relevant advice.

▸ Educate patients about common side effects. To help reduce the occurrence of purpura, Dr. Hirsch advises patients to eat a lot of pineapple preprocedure, because it contains bromelain. Another option is to take five tablets of arnica, a substance commonly used for muscle pain and bruising, the night before the procedure and another five on the day of the procedure.

Other ways to minimize bruising include applying pressure during and immediately following the injections, using topical anesthesia, mixing the filler with collagen products to stabilize platelets, adding a lidocaine wash to injectables that do not contain an anticoagulant, and using the "push ahead" technique, whereby you get the needle tip to the plane and extrude the needle ahead of the tip. By using this technique, which Dr. Hirsch attributes to Dr. Jean Carruthers, one allows the product rather than the sharp edge of the needle to create the injection plane for the product, thereby reducing tissue trauma (Dermatol. Surg. 2005;31:1604-12).

Should evidence of infection develop after the procedure, incise and drain the abscess as rapidly as possible. Culture the patient for both routine and atypical bacteria and prescribe a course of empiric antibiotics followed by specific antibiotics. "Follow up on those cultures," Dr. Hirsch advised.

If blanching or pain occurs at the injection site, stop immediately, because this can be the only sign of an impending vascular injury. Immediate administration of heat, massage, and nitroglycerin paste helps minimize or reverse permanent injury. A recent case report demonstrated that immediate administration of hyaluronidase can also be of great value (J. Drugs Dermatol. 2007;6:325-8). Once the vascular accident is managed, consider treatment with a pulsed-dye laser or intense pulsed light to improve discoloration.

Dr. Hirsch had no conflicts to disclose relevant to her presentation.