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Optimizing Outcome from Facial Cosmetic Injections and Promoting Realistic Expectations
Leslie Baumann
Although the various injectable materials used to minimize the signs of aging facial skin are safe, adverse reactions can occur. Among them, bruising is by far the most common. Practitioners and patients alike can take several steps to reduce the risk of inducing such a response. While there are subtle but distinct differences in the techniques involved in injecting Botox and similar products such as Reloxin (also known as Dysport) and Myobloc as well as the various soft tissue augmentation
llers (including the collagen products Zyderm, Zyplast, Cosmoderm, and Cosmoplast and the hyaluronic acid [HA] products Restylane, Hylaform, Hylaform Plus, Captique, and Juvéderm), the approach to avoid bruising as a sequela of such procedures is the same. I have found that discussions of ways to avoid and treat bruising are part and parcel of promoting realistic expectations.
Preparations
1.Instruct patients to avoid, 10 days prior to the scheduled procedure, medications, herbal formulations, and other agents that confer a bloodthinning effect and, therefore, can facilitate bruising (Table 113.1).
Tylenol, which does not affect platelet function, can be taken.
2.Applying ice to the area to be treated prior to injection and after injections may decrease bruising.
3.Note that bruising is more likely to occur in very light skinned individuals and red heads.
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Posttreatment
1.Recommend that patients obtain a product containing arnica or vitamin K, and/or retinol, to apply after the procedure as a further preventive measure against bruising and/or to treat any bruises that develop.
2.Advise patients to avoid hot showers, saunas, or other exposure to heat for 6 hours after injection to reduce the risk of bruising. Also, suggest avoiding sun exposure and alcohol for 24 hours, since both have been associated with erythema.
Expectations
Tell Botox/Reloxin patients the following:
1.Treatment involves injections via a tiny needle smaller than the size of a pinhead.
2.Frown lines usually require three injections: crow’s feet receive three injections per side, and lines in the forehead usually get five to eight injections.
3.Following treatment, the skin will have a few raised bumps in the area of injection that look like insect bites. These typically last about
30 minutes.
4.Having already taken precautions against bruising, patients should be reminded which products to use at the first sign of bruising.
5.All skin care and makeup use can be resumed after treatment.
6.It takes about 10 days for the full treatment effects to be seen.
7.Treatment effects last 4–6 months (Myobloc injections last about 6 weeks).
Tell soft tissue augmentation patients the following:
1.Each wrinkle will require about three to five injections to treat.
2.HA llers are more painful than collagen injections because the collagen-containing fillers contain the anesthetic lidocaine.
3.Collagen fillers are associated with less swelling and bruising than HA llers. Injecting first with collagen and then HA will often reduce swelling and decrease the bruising risk as well as provide the benefits of both types of fillers.
4.Collagen fillers tend to last 4–6 months.
5.Most HA products last 4–6 months. Juvéderm may last up to 1
year.
6. Sculptra, a dermal stimulator rather than fi ller (it stimulates the production of collagen), may last as long as 2 years. Unlike the fillers, it does not provide instant results—it is injected every month for 3–5 months until the desired result is achieved. Epinephrine can be added to the product to decrease bruising.
7. Dermal stimulators can be combined with dermal fillers or Botox/ Reloxin (like dermal fillers) to achieve both immediate short-term correction and delayed long-term correction.
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8. A good skin care routine, including a retinoid such as Tazorac, Differin, or Retin-A to prevent future wrinkles, is recommended. Sunscreen should be used DAILY as well as an antioxidant supplement.
It is essential to be candid with patients regarding the results and potential side effects of cosmetic facial surgery. Specific expectations should be provided by the practitioner, who should underestimate or underpromise in terms of the finished result. These are not permanent procedures. Finally, good consent should be obtained so that patients are fully informed about potential complications.
Table 113.1. Drugs and Herbal Agents to Avoid for at Least 10 Days Prior to Scheduled Injections
ÆAlcohol
ÆCoumadin
ÆFish oil
Garlic Ginger Ginkgo Ginseng Green tea
Nonsteroidal antiinflammatory drugs (NSAIDs)
Aspirin
Advil
Motrin
Ibuprofen
ÆSt. John’s wort
ÆVitamin E
ÆWarfarin
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Filler Pearls: General Considerations
John R. Burroughs and Richard L. Anderson
Fillers are an outstanding adjunct to Botox and, in some situations, are superior to surgery. In our practice, we prefer the nonanimal-based synthetic llers (Restylane, Juvederm, Perlane, and Radiess). This is because skin and allergy testing is not required and there is no risk of animal-based disease transmission. In our practice, we have found that patients have a higher acceptance for the synthetic than for animal-based products. Patient acceptance is quite high, and both the physician and patient can immediately enjoy the rejuvenative effect just following injection. We recommend patients avoid any blood-thinning agents for approximately 2 weeks prior to injections.
Hyaluronic acid fillers can be reversed by injecting a small amount of hyaluronidase.1 The injection of 25–150 units of hyaluronidase will remove hyaluronate fillers in the event of asymmetry or overtreatment.
Nitropaste can also be kept on hand to apply to the skin in case of vascular compromise.
Reference
1.Soparkar, CN, Patrinely JR, Tschen J. Erasing restylane. Opthal Plast Reconstr Surg 2004;20:317–318.
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