Preventing aesthetic complications

Pitfalls with Botox (botulinum toxin A, Allergan) treatments can include over-injection - which impairs facial expressions - and imprecise injections leading to ptosis, says Ranella J. Hirsch, M.D., a Cambridge, Mass.-based dermatologist in private practice.

Preventing an upper lid ptosis caused by migration of toxin through the orbital septum is "straightforward," she says. To do this, Dr. Hirsch recommends keeping injections 1 cm above the eyebrow and not crossing the mid-pupillary line.

With hyaluronic acid (HA) fillers, Dr. Hirsch says novice injectors who inject too superficially can create a bluish tinge as a result of the Tyndall effect. Should this occur, she says, "We have described successful treatment with a Q-switched 1,064 nm Nd:YAG laser (Hirsch RJ, Narurkar V, Carruthers J. Lasers Surg Med. 2006 Mar;38(3):202-204). Another option is hyaluronidase, which works extremely well."

To prevent necrosis with HA injections, Dr. Hirsch adds, "It's very important to proceed with extreme caution in the glabellar area, which is a high-risk area." Should one notice early vascular infarction with potential tissue necrosis, she recommends using heat, massage and nitroglycerin paste - and potentially hyaluronidase - for the affected area.

Reducing bruising

Reducing injection site bruising begins with having patients eat a lot of fresh pineapple before treatments because it contains an enzyme (bromelain) that aids the process. During the procedure, she says, "Work slowly - working quickly causes a lot more tissue trauma and bruising."

Dr. Hirsch says she utilizes the push-ahead technique as described by injectables pioneer Jean Carruthers, M.D., which involves inserting the needle tip into the plane, and then extruding the product ahead of the needle tip. "In other words," she explains, "one is actually letting the product direct its own way."

Laser complications

Laser complications can include scarring, discoloration and textural changes.

"The main reasons behind laser complications are that people either don't understand how lasers and light interact with tissue, they use very poor technique or don't pay attention to the details of the skin" such as tanning, Dr. Hirsch says. Examples of poor technique include skipping areas, stacking pulses inappropriately or holding the handpiece improperly, she adds.

"For instance," Dr. Hirsch says, "if one has a cryogen spray delivering cooling and one misaligns it so that the cryogen doesn't line up with the laser pulse, one can create injury from both the cryogen spray and from the laser treating unprotected skin."

Device malfunctions

To account for potential device malfunctions, whatever the device, Dr. Hirsch says, "We usually have a backup. In my office, we precool with ice - it's cheap, it's reliable and one can see what one is doing."

Additional preventive measures include paying close attention to patient discomfort - an early indicator of excessive fluence being delivered - and repeatedly re-checking skin temperature throughout the treatment, Dr. Hirsch says.