The Last Word on Fillers Free

Physicians have learned a great deal about the utilization of injectable soft-tissue fillers for facial shaping and rejuvenation, but there remain important unanswered questions with respect to safety. The most dreaded complications of these procedures are those resulting from vascular occlusion. Such complications, although rare, can be both serious and life-altering. They include vision loss, skin necrosis, and central nervous system problems such as stroke. In the literature, estimates of the incidence of vascular occlusion resulting from injection of soft-tissue fillers range from 0.05% to 0.001%.^1,2 However, with the increased popularity of injectables and increased reporting of outcomes, the frequency of complications is rising. Other factors may include a growing number of injectors who lack high-level training and the types and standards of facilities at which treatments currently are conducted.³ But even impeccably trained physicians practicing in the best clinical environment are not immune to complications. It is likely that many, regardless of experience, will encounter some type of serious injection-related complication in the course of their careers.¹ Until an accurate and noninvasive method for 3-dimensional (3D) visualization of facial arteries becomes available on a practical clinical basis, injectors will continue to rely on statistical probability regarding vessel location despite significant variability among patients.⁴

Several excellent articles and commentaries appearing in this issue of Aesthetic Surgery Journal (ASJ) provide important perspectives on frequency of injection complications, techniques that may help reduce risks, and measures to treat some of the most dreaded outcomes.^4-7 Researchers and clinicians continue to gather and analyze data, and progress is being made in our understanding of how injector technique and patient anatomy impact outcomes. Overall, fillers have an excellent safety record, and physicians can offer these treatments with the knowledge that most patients will be pleased with the result. Nevertheless, as with every medical procedure, it is imperative to inform patients of all potential risks. This can be particularly challenging when patients are continually barraged with messages in the media that make filler injections seem like a no-risk alternative to surgery.

The incredible rise in the popularity of injectable fillers⁸ is due to many factors, including their versatility and effectiveness in achieving a variety of objectives, from minimizing lines to reshaping facial features. But a large part of their success can also be attributed to marketing and the impact of media and internet “influencers” who are open about discussing how fillers have changed their looks—in some cases, quite dramatically. Fillers are largely responsible for what has been termed “the Instagram face”: high cheeks, full lips, and sharp jawlines.

Corporate direct-to-consumer advertising campaigns have been conducted masterfully, with advertisements that are among the slickest around. It is easy to see how one can be persuaded by the energetic background music, frolicking high-fashion models, and generally upbeat message portrayed in these high-budget productions. In the background, of course, is the obligatory rushed announcement of potential risks of treatment. This type of advertising format is not unique to injectable filler products. It is, in fact, the way most serious medications are now marketed to the general public, along with an “ask your doctor” tagline. I am not suggesting there is anything wrong with manufacturers making their products attractive to consumers. That is their job. However, it falls to the doctor to inject (pardon the pun) the appropriate dose of reality into patients’ understanding of what filler products can achieve and, importantly, the risks, however slight.

Many in the public believe injectables to be a 100-percent-safe alternative to surgery. As one contributor to the popular online BuzzFeed News writes: “Results that used to require spending tens of thousands of dollars on surgery (and risking its sometimes-grisly consequences) are now available to anyone with half an hour and a couple thousand dollars to spare. The relative ease of injectables—especially compared to surgery—are likely part of why ‘having work done’ is now treated by many as a piece of lifestyle content, as shareable as a shopping trip or session in a makeup artist’s chair, and no longer as a source of shame . . . There’s a comforting aura to it, this notion that injectables are about more than just vanity—they’re aligned with the things you do for your actual health.”

As to who is qualified to perform injections, the BuzzFeed article says: “[Injectable treatments] are a natural fit at plastic surgeons’ offices . . . or at dermatologists’ offices. But since payments for these procedures usually don’t go through insurance, they’re also an easy and lucrative payday, making them a popular side dish–type option everywhere medicine is practiced, from GPs’ offices to dentists or even OB-GYNs. The availability and popularity of these kinds of treatments have helped create new categories of medical practitioner and treatment centers.” ⁹ The article goes on to mention the growing popularity of medical spas. There is no mention of training or the possibility of any serious complications associated with filler injections.

Is it any wonder that patients may enter your office (if they seek the services of a doctor at all) with the idea that there is absolutely no risk involved in these “nonsurgical” procedures? I have written before about “acceptable risk.” ¹⁰ It is something that is difficult to define and even more difficult when the risk cannot be accurately quantified. As I said in that previous editorial, “What is acceptable risk for one may not be acceptable to another, yet each is entitled to a clear and direct statement of what is known and unknown about a given procedure.” I believe that most plastic surgeons are careful to provide exactly that. Forthrightness about potential complications, particularly when the risk is small, should not significantly dampen a patient’s enthusiasm for undergoing a procedure. If it does, then that individual is not a good candidate, and it is best to know sooner rather than later.

I urge anyone reading this editorial to re-review the articles listed as references below and to search ASJ online as well for additional articles on the topic of filler injection techniques and safety. As in any surgical or nonsurgical procedure, there are 2 aspects to consider with respect to complications: prevention and management. Though risks associated with injectable fillers cannot be completely eliminated, most experts agree that key elements of prevention include knowing the anatomy and its common variations; injecting slowly, with minimal pressure, and in small increments; and moving the needle tip so as not to deposit large amounts of filler in one spot. Other precautions may apply to specific facial regions.

During or after a procedure, if vascular compromise is suspected, action should be taken without delay. Although there currently is no evidence-based, accepted standard of care for treating visual compromise resulting from soft-tissue filler injection, there are a number of vision loss treatments that have been implemented with varying success. Experts suggest having a current supply of hyaluronidase readily available and also establishing a relationship with an ophthalmologic colleague with whom you have discussed, in advance, the possibility of requiring emergency assistance.³

I entitled this editorial “The Last Word on Fillers,” but my intention was to make the point that, in fact, we have not yet arrived at the “last word.” Our “rules” for prevention are imperfect and subject to variance. Our treatment protocol for complications is far from well established, and we have no certainty that negative outcomes such as blindness can be reversed. What we do have, however, is an aesthetic treatment with an excellent safety record that offers many options for patients. Through ongoing clinical research, we must continue refining techniques to reduce risk, including ultrasound and 3D imaging, while we ensure that patients have access to all the available information to make a fully informed decision.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes