Many members of the aesthetics industry will have come across the following photos on various forums and social media recently. The photos, which have been shared by Facethetics with permission from Dr Alaa Aref from Renew Clinics in Saudi Arabia, show a patient suffering from a necrosis which ultimately resulted in the loss of part of her lip. Dr Aref came into contact with the patient after she’d been treated by an unlicensed, non-medical practitioner who did not realise that a complication had occurred. As you will see from the photos, unfortunately it was too late to save the left side of the patient’s bottom lip, however, Dr Aref did what she could to minimise the damage to the rest of the lip.
We appreciate that these photos can be extremely scary to those practitioners who are new to the industry, or even those who have been practising for longer, however, we share them to make you aware of what can happen when complications are not correctly identified and treated, and to highlight why it is absolutely VITAL that aesthetics training doesn’t just teach practitioners how to carry out a treatment, but also how to deal with the complications that can arise from said treatment as well. If the practitioner who originally treated the patient in the photos above had had a better knowledge and understanding of complications, this entire case could have been avoided.
What is necrosis?
The definition of necrosis is;
”The death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply.”
There are a number of reasons why necrosis of the tissue may occur, however, within the realm of aesthetics, we most commonly see necrosis as a very serious side effect to the incorrect injection of dermal fillers. If dermal filler is accidentally injected directly into a blood vessel, the filler can block the vessel, therefore cutting off the blood supply to that particular area. This is known as a vascular or arterial occlusion. If an occlusion goes untreated and the tissue continues to be starved of blood and oxygen, it ultimately becomes necrotic and, as seen in the photos above, it will eventually fall away.
It is important to note that while necrosis is a very real and serious complication of dermal filler treatments, actual occurrences are quite rare. Reports suggest that for all dermal filler treatments, only 1 in 100,000 result in a necrosis.
How to avoid occlusions and necrosis
As part of a dermal filler training course, practitioners will learn all about the correct injection technique, which will of course include needle depth and placement. Knowledge of the anatomy of the face and structure of the blood vessels underneath the skin, combined with a proper understanding of injection technique, will contribute hugely to ensuring that vascular occlusions do not occur during treatment, thereby preventing necrosis.
Other techniques that practitioners can employ to help them avoid vascular occlusions are;
Aspiration - this is when the practitioner pulls back on the plunger of the syringe at each new injection point before injecting. This is to see if any blood is drawn up by the needle - if it is, this would indicate that the needle is currently inside a blood vessel and that the practitioner must re-position before injecting. While aspiration is not 100% accurate, it is a safety procedure that many practitioners consider to be absolutely vital.
Using a cannula instead of needle - depending on the area of the face being treated, a cannula may be preferable to a needle anyway, however, the other benefit of using a cannula is that it is far less likely to pierce and enter a blood vessel as it has a blunt tip, unlike a needle, which is obviously sharp.
Identifying an occlusion or necrosis
While the aim is obviously to avoid an occlusion or necrosis completely, even the most skilled and experienced practitioners will likely experience this at some point in their careers, so it is extremely important to be able to identify when something has gone wrong. The four main things to look out for are;
Pain - the patient is likely to experience severe pain. It is important to remember though that if any kind of anaesthetic has been used during treatment, this sensation may be reduced.
Prolonged blanching - the affected area may appear pale or white, even after the removal of the needle.
Discolouration - the area may also turn dusky or purple, although this is more likely to happen several hours after the treatment.
Cool to touch - again, this may happen later. Due to the lack of blood being supplied to the area, it may feel cooler than the surrounding areas.
Treating an occlusion or necrosis
If a practitioner does identify that an occlusion or necrosis has occurred, there are a number of steps that they must take as soon as possible;
Stop treatment - as soon as the practitioner recognises the signs of an occlusion, the treatment must be stopped immediately.
Massage - manipulating the area may remove any obstruction in or around the vessel.
Heat - applying heat will encourage vasodilation as well as increasing blood flow to the area.
Hyaluronidase - if using a HA filler, hyaluronidase can be injected to dissolve the product, thus removing the obstruction.
Of course, this blog post only provides a brief overview of how to avoid, identify and treat this particular complication, however, for a practitioner to carry out dermal filler treatments safely, they must be well versed in all of the complications and contraindications surrounding this treatment, something that they will only learn about during a proper, in-depth aesthetic training course.
Facethetics Training will be running a Complications Workshop on Tuesday 7th May from 5pm until 8pm. This will be a relaxed, informal session,where our Lead Educator Yvonne Senior will lead a discussion on complications, providing a safe and supportive environment for delegates to share their own experiences with complications, ask questions and build upon their existing knowledge. Tickets are £83 plus VAT - contact firstname.lastname@example.org to secure your place.
For more information on managing necrosis, we highly recommend this document from ACE Group.