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    Cosmetic physician outlines basics of hyaluronic acid and other popular fillers

    Knowing the specific characteristics of a filler and the potential complications that can arise and how to deal with those complications is crucial in performing effective and safe filler procedures, says Joseph E. Hkeik, M.B.B.S., F.R.A.C.G.P., F.F.M.A.C.C.S., D.P.D.

    "Filler treatments have become one of the most popular noninvasive cosmetic procedures performed in the aesthetic practice, and with appropriate training, the results achieved can be remarkable. However, many beginner cosmetic physicians who do not have appropriate training regarding the filler products and injection techniques they use may quickly get in over their heads, which can result in treatment complications," says Dr. Hkeik, a cosmetic physician and director and founder of All Saints Cosmedical Clinic, Sydney.

    Though many fillers are effective in the treatment of lines and wrinkles of varying depths and useful in volume replacement, reversible fillers such as hyaluronic acid (HA) products are the most frequently used fillers used today. According to Dr. Hkeik, the HAs are popular not only because they can achieve excellent cosmetic outcomes, but also because they are resorbable and the physician can reverse an over-correction soon after injection.

    "If you realize an over-correction on the day of the procedure, one can try to aspirate the material back into the syringe or try to squeeze the filler back through the puncture hole of the needle, back to the skin's surface. The HAs are particularly forgiving in that one can inject hyaluronidase in the target area, breaking down the filler and reversing the effect of the HA," Dr. Hkeik says.

    WARNING SIGNS The typical side effects associated with filler treatments can include local erythema, edema, bruising and some tenderness following injection. These are all typically very minor, but other more serious complications can occur, many of which are usually associated with the use of improper injection techniques, Dr. Hkeik says.

    Local skin necrosis is one complication that can be related to improper injection technique and can occur when injecting the glabellar region or the nasolabial folds, he explains. When injecting any filler product, Dr. Hkeik says he will always aspirate right before injection in order to help avoid injecting the filler material into a vessel. Failure to aspirate may result in vessel occlusion and subsequent skin necrosis at the target area.

    Local blanching occurring after the injection of HA filler could also be due to a vascular occlusion. In a scenario where vascular occlusion is suspected, Dr. Hkeik says it's best to reverse it by applying nitrate paste and hot packs to the area. These will increase the local circulation and hopefully remove the concentration of local filler product. If these attempts fail, hyaluronidase injection may reverse the occlusion, he adds.

    "As the face loses volume in layers, we should replace that lost volume in layers and slowly inject the filler across the whole target area. One should always try to keep the needle moving through the tissue and use a threading and fanning technique, depositing minutes amount of the filler along the way as needed. These will help you get a good spread of the filler throughout the target area," he says.

    Hyaluronic acid fillers are also particularly hydrophilic, Dr. Hkeik says, meaning that they will absorb water after injection. Although this effect can result in a greater voluminization of the targeted area, the swelling of the target area could also increase the risk of extraluminal vessel impingement and possible occlusion.

    "Similar to other filler products, the HAs have a range of moieties across the different products available, allowing the physician to aesthetically treat a range of lines, folds and wrinkles of all depths. Knowing the characteristics and individual properties of the filler you are using is extremely important in helping to avoid potential complications," he says.

    Physicians who are just starting out with filler treatments should always undertreat the target area, he says. Though currently available fillers are all effective, he advises beginners to use the HAs.

    "One needs to have an intimate knowledge of the anatomy where one injects and be aware of the complications that can occur, which are often related to the product one uses as well as injection technique. Do not try to be overly zealous in your aesthetic treatments because it can come back to haunt you and your patients," Dr. Hkeik says.

    Disclosures:
    Dr. Hkeik reports no relevant financial interests.

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