Part 3: Complications with Botox & Filler Injections
In this three part series we're discussing Botox and fillers with Marc Scheiner MD who trains clinicians through 14 credit CME two-day hand's on seminars with the American Society of Aesthetic Medical Professionals and Botox Training MD, an online botox training site for clinicians.
So Dr. Scheiner, tell me about some of the typical complications you've seen and how you deal with them?
In general, the complications are separated with regard to what product we're using. There are different complications with each filler within the filler class. We're going to see different complications from one filler to the next, but in general all the fillers are going to... Well, let me rephrase that. All the nonpermanent fillers are going to result in similar complications. That is to say that I believe you may experience a different set of complications with the permanent filler. So if we're talking about the nonpermanent fillers, they have their own set of complications and the Botulinum toxins which includes Dysport and Botox have their own complications. (It's not as if Botox has its certain set of complications and Dysport has a different set. Botox and Dysport have pretty much exactly the same potential issues.)
So what do I commonly see? Commonly with the fillers, I see some bruising. Not everybody has bruising but if I'm going to see a complication, that's what I'm going to see. Especially below on the bottom lips and the marionettes, so the chin, in that area. I commonly would see an extensive amount of bruising.
There are a couple of things we can do to prevent that or lessen that. I will talk about that in a moment but that's what I'm going to see, bruising and persistent swelling, especially with the augmentation of the lips. So after you're done augmenting the lips, oftentimes they start to swell immediately. So you have to explain to your client that that's not what their lips are going to look like in the next couple of days, it's going to decrease in size. So bruising and persistent swelling, perhaps some under correction meaning the client comes back in a week to 10 days and says you know, "My right smile line is better looking than my left smile line". So, under correction's the third thing I see.
I have not experienced any adverse reactions, any anaphylaxis or anything like that. As far as the Botulinum toxins, which again includes Botox and Dysport, the most common complication we're going to see is some bruising, some persistent redness and perhaps some droopiness of the eyebrow or eyelid. I believe that if you are injecting Botox long enough and treat enough patients you're going to see eyelid and eyebrow ptosis at some point so be prepared. I've certainly seen them both. You tend to see eyebrow ptosis a little.. not a little, definitely, you see eyebrow ptosis more commonly than eyelid ptosis. So if you have some droopiness of the eyebrow or eyelid, that certainly can be a result of both Botulinum products.
As far as injecting other areas of the face with Botox, specifically the periorbital area, you can result in asymmetrical smile or perhaps even some drooling from one side of the mouth. You want to be especially careful whenever you inject below the eye-line. You may see this if you're trying to correct a smile by injecting the levator labii. You may experience this if you're injecting the depressor labii or the depressor anguli oris with an attempt to target the corners of the mouth upward. With ageing, we notice that the corners of the mouth turn downward. The DAO is the depressor. It pulls the lips down so if you paralyze that with a little bit of Botox, you can let the levator overcome that pull and elevate the side of the lips. Too much Botox in that area can result in a little drooling or a little asymmetrical smile which is again, not a pleasant experience with the potential for some very unhappy patients so you want to be very careful and get some training before you ever attempt this... but that's a typical issue that I have seen.
Also, as I was discussing injecting the glabella, in combination treatment with filler and the Botox, one again must be very cognizant of the issue of injecting the blood vessel and resulting in some necrosis of the overlying skin.
The other complication that one may see if you're not careful with the tear troughs is visibility of product. Again, if you're too superficial, you will see the product is visible there. You can also see that in the nasolabial folds if you're too superficial. That can be improved by taking a small # 11 scalpel and very small nick? Right where that visibility is and expressing that product and in some cases, it may be necessary to use Hyalurodinase, which is an enzyme used to dissolve some of the hyaluronic acids fillers which are Perlane, Restylane and Juvederm. Radiesse is a separate chemical composition so that is not affected by Hyalurodinase.
So that's..those are, you know, an overview of the complications that we're going to see.
So if you're a brand new injector and you have not done this before, where are the land mines that you are going to want to avoid right to start?
Right off the bat, know you're crows feet, because one of the most common areas you're going to be asked to correct is the crows feet area without question. People are asking for the crow's area, the frown lines on the forehead.
We are going to be very careful in the crow's feet area for veins. Now, the veins, if they are inadvertently punctured with your injecting needle, are going to result in bruising, in bleeding, and in swelling. That's very aggravating for a lot of clients because the bruising, quite frankly, can last for 7 to 10 days. So it's an area that's a little difficult to explain bruising under your eye and beside your eye. So we're going to want to watch for veins in that area.
We're also going to be very careful with our injections in the glabella area to stay above the brow, the superorbital ridge, the bony portion of our orbit, 1 cm above that. That's important so that we make sure none of our Botulinum toxin is able to diffuse into the upper eyelids which would effectively paralyze a portion of the levator and result in eyelid ptosis. For the beginner, those are the kind of areas that we would be very, very careful about.
Is there anything in the filler side that you would express concern about starting out as a clinician just getting started?
Yes, the issue with fillers right out of the box is visibility of the product in the skin. So it's important to understand where the product is injected.
The most common..commonly used products for fillers, at least in where I live is usually Juvederm or Restylane which are hyaluronic acid fillers. Now those are placed in the dermis. The dermis is appreciated by a resistance that you feel as you introduce the needle into the skin. What I mean by that is if that you're too deep, the needle will move very easily into the tissue. If you are in the dermis, it takes a little bit of pressure for you to move that needle. It's also, as you're injecting, important to look at the area you're injecting and if you notice that you are able to visualize the product, then you need to reposition your product. So right out of the box, with the injection and the fillers, you need to be very cognizant of the ability of the product to be visible if you're at the wrong level of injection.That's really important and you should make sure that you're very comfortable with this before treating patients.
So how can you tell, in both fillers and Botox or Dysport that a treatment is not going the way you want it to go and what are the actions that you take in that point to compensate?
Well, with Botox, you're not going to be able to know if it's going right or wrong other than if you have some bleeding, which would be the result of injecting into a blood vessel. So bleeding is pretty common actually with these injections, a small amount of bleeding. We just apply a little bit of pressure with the gauze and the bleeding will stop.
Now there are situations if you're in around the periorbital area, the crow's feet area where you could place your needle into a blood vessel and experience an immediate collection of blood under and it could, actually before your eyes, explode the skin to a marble or a size of a large marble or even a golf ball. Immediately if you notice that that crepe-like skin is bruising and swelling, you need to immediately apply pressure. I always use the 10 minute rule. I just sit there for 10 minutes and then push pressure and explain to the patient that "We're having a little bleeding and you're going to experience a little bruising. We're going to put some ice and do everything we can but right now it's important that we get this to clot." So that's one thing that can potentially happen.
As far as the filler, again, I mentioned that if you notice you're going to be able to see product, you need to readjust your syringe. Make sure you're a little deeper in the dermis. For the product that is already visible, hopefully you've been watching it and you don't have accumulation of product and simply take a # 11 blade and make a little nick over that visible portion of product and then gently express, just push it out through your thumb and index finger. You don't need to suture that opening, it will heal by itself. Those would be the common things you see.
Of course, we're all medical providers and we all must be ready to treat an allergic reaction regardless of what field we're in so I always have a little emergency kit available and I have not experienced this yet. I have experienced some phase of vagal reaction and everybody will experience that but a true anaphylaxis reaction, secondary to the injection I have not experienced. But of course if that happens, you need to have some Epinephrine available, some Benadryl, perhaps some steroids and understand that's going to require immediate and urgent treatment. As far as the phase of vagal reactions, I see those 2 usually after I do a dental block. The Lidocaine and the Epinephrine usually will cause that and they get a little bit sweaty and a little out of it. And I simply stop the procedure, put them in a Trendelenburg position, place a cool wrap over their forehead and I always talk to them. I always let them know that I'm there with them and this is a normal reaction, it's going to pass shortly and I just keep changing the cool compresses. And everybody resolves, in a few moments, and that's the end of that.
What do you think about injecting outside of a medical clinic? There are clinicians treating patients at Botox parties or going to another location, for example, a spa that might have patients there to be treated. What do you think of treating outside of a clinic?
I am of the belief that if the clinician, the practitioner has a firm understanding of the potential risks involved with the products and is in a situation where he or she will be able to address those risks then they're fine. I would imagine though that most people are not considering the issue of potential allergic reactions to the products when they do a Botox party or they go to a salon or days spa. If they were to inject at a salon or a Botox party and they were thinking of the issue of potential anaphylaxis or allergic reaction, and they were prepared to handle that, then I think it's fine. Of course, it's a rare, rare event that anything like that would happen, but it certainly can. So I think if one's prepared to do that, I don't think it's any different than doing it in your office and I don't have a problem with it if it's just for the injectables. Of course, there are some other potential complications like insurance and informed consent that might be impacted.
That's an interesting thought. I remeber reading a story about a physician who was offering "Botox parties" where wine and cheese were served and it seems that if somebody is imbibing wine or spirits there may be concerns about informed consent. Have you got any thoughts on that?
Well, I think, you know, there are other different scenarios that could be presented with regarding to the injection of Botox and fillers outside the office. I certainly wouldn't suggest injecting or performing any medical procedure when alcohol is involved in any situation so I would not even consider that. When you say Botox party, I'm thinking it's a party because of the Botox not a party because liquor's there, and certainly not on a salon, I wouldn't anticipate liquor. So obviously the consent forms need to be signed and no alcohol needs to be involved because I believe that alcohol would make any consent null and void, I would imagine.
Read the other parts of this interviw:
About: Dr. Marc S. Scheiner completed his undergraduate studies at the University of Delaware, and received his medical degree at the University of Texas. Following his residency at the University of Florida, he practiced family medicine in the small town of Elkton, Maryland.
Dr. Scheiner was accepted at the Nassau University Medical Center in 1999, where he entered the General Surgery Program. Following the completion of his general surgery residency, he began training with the oldest and largest plastic surgical group in the United States, the Long Island Plastic Surgical Group in New York. Dr. Scheiner completed his plastic surgical training and moved back to Cecil County to open the O’Leigh Aesthetic Surgery Center, filling a much needed gap in locally provided plastic surgical care.
In 2006, Dr. Scheiner, along with several other local physicians, began construction of a new medical facility in Elkton, Maryland. This building, in addition to being Dr. Scheiner’s new office, houses Cecil County’s first ambulatory surgery center, the Upper Bay Surgery Center. Upper Bay Surgery Center offers ambulatory surgical procedures in a private, comfortable, and safe environment.
About Botox Training MD
Botox Training MD is an online course for clinicians that teaches you everything you need to know to begin offering Botox and filler injections inside your medical practice. It's exactly the same course and content that is taught in Dr. Marc Scheiner's two day course but comes packed with extra information and bonuses. Best of all, better than trying to remember everything you saw and learned during an in-person course, this course is taught via video and delivered online so you can review each module as many times as you want or need to.
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Here's a welcome message from Marc Scheiner MD, the Botox Training MD online course instructor.