Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers

Focus on the Upper Face

Maurício de Maio, M.D.; Arthur Swift, M.D.; Massimo Signorini, M.D.; Steven Fagien, M.D.


Plast Reconstr Surg. 2017;140(2):265e-276e. 

In This Article

Minimizing Complications With Injectables

Common early and self-limited complications that may occur include erythema, edema, pain, and bruising. Lumps and bumps or bluish-gray discoloration under the skin caused by the Tyndall effect may occur with injection of fillers when injected too superficially. Allergic reactions (very rare with hyaluronic acid fillers) typically occur within several hours and can be avoided, in most cases, by careful pretreatment interview of patients. Late complications such as chronic inflammation, infection, granuloma, and hypertrophic scars are also rare.[3,4] Treatment should be guided by the particular circumstances of each case and best practices of appropriate medical management.

Avoiding complications is the highest priority and must begin with a thorough understanding of the target regional anatomy followed by careful, precise injection technique. Continuous review of the relevant anatomy is essential so that one is aware of the cautions and hazards presented by the arteries, veins, and nerve bundles in the treatment area. The use of a slow, smooth, and careful injection technique is imperative in all treatment settings. Aspiration, although not a guarantee of extravascular location, is advisable in many situations to ensure proper placement of the needle/cannula whenever the needle penetrates beneath the skin. The use of an optimal injection volume is critical for obtaining the desired treatment effect. More is not always better, because overvolumization can lead to undesirable aesthetics and/or complications.

Several general precautions should be taken to minimize the risk of local complications. Makeup and other contaminants on the face should be removed before the injection,[5] and patients should be instructed to avoid use of makeup for at least 12 hours after the procedure. Aseptic technique should always be used, which includes thoroughly washing hands and wearing gloves, and preparing the skin site for injection with chlorhexidine, povidone-iodine, or alcohol.[5] The skin should be visibly assessed for local dermatologic disorders (e.g., active acne), active bacterial or viral infections, or inflammatory disease processes (e.g., cutaneous lupus erythematosus); treatment through irritated or inflamed skin should be avoided.[6] The injection needle should be changed regularly to minimize the risk of infection and increased discomfort caused by the use of a blunt needle. Although smaller gauge needles may carry a risk of penetrating smaller vessels inaccessible to larger bore needles, the slower injection speed with smaller needles is essential for avoidance of product spread when the needle is inadvertently placed intravascularly. Smaller needles also tend to cause fewer infections and local adverse events. In treatment areas with challenging anatomy or a higher risk of complications, it may be advisable to use blunt cannulas instead of needles. Blunt cannulas may help avoid inadvertent intravascular injection.[7] If vascular compromise or compression caused by hyaluronic acid fillers occurs, it will typically be evident by blanching and can be treated with injection of hyaluronidase into the area; aggressive massage and warm compresses may also be helpful.[3,4] Again, it is important to emphasize that the anatomy of the treatment area and depth of the underlying vital structures should be constantly reviewed.