Recommendations for cosmetologists: Dublin protocol for the treatment of complications

Today, practicing cosmetologists are forced to admit that not only the number of fillers offered for the correction of appearance is growing, but also the number of complications associated with their introduction. The development of protocols for the treatment of such complications with the introduction of a filler would greatly facilitate the work of doctors. We offer our readers an interview with Patrick Tracy.

Patrick Tracy – chairman  Association of Cosmetic Physicians of Ireland and the Irish Regional Office of the British Cosmetic Medicine Association, which provided practitioners with a list of recommendations (the "Dublin protocol") for dealing with conditions where there is a risk of complications from the introduction of a filler in a patient.

 

What are the actions of the doctor in case of a threat of complications after the introduction of the filler

Of course, you need to understand and find answers to two main questions:

1. Why did this happen?
2. How can this be fixed as soon as possible?

First, you need to calm down. In order to act correctly in this situation, one must understand that this has already happened. Filler injections are the most common manipulations in aesthetic medicine. Serious complications from these injections are rare. But remember that it is these complications that seriously demoralize both patients and doctors.

It is important to understand what caused this complication. The reason may be a low-quality preparation or an error on the part of the doctor.

What are the most serious complications you have encountered

In aesthetic medicine, the appearance of each patient is very important for the doctor who performs the correction. Currently, there is still little literature that correctly and seriously describes all the complications that may occur in practice. That is why there are not enough protocols that doctors can use in their daily practice. For me personally, the most unfavorable is the necrosis of the skin of the nasal region. It is this area that is well vascularized, and problems in this area will carry frightening and serious complications.

What adverse reactions can be expected?

To my great relief, most of the reactions that occur from the introduction of hyaluronic acid fillers are not serious and correctable. These reactions can be grouped into the consequences expected from the introduction of fillers, and sudden, which the doctor cannot foresee.

Complications to be expected are injection site tenderness, erythema, volume expansion, and possible bruising.

Unforeseen complications we include those that result from the wrong technique of drug administration: this is the occurrence of nodular formations in the skin or the formation of a granuloma, as a reaction to the drug.

What symptoms should I look out for immediately?

It is very important in the practice of a cosmetologist to give a correct assessment of what is happening at the moment with the patient, and to understand the long-term consequences of the complication. It is this approach that will make it possible to apply adequate therapy, taking into account the anamnesis and the development of the clinical picture.

1. Paleness of the skin. Usually, blanching of the skin at the injection site is visible immediately at the time of the procedure.
2. Suddenly arising pain and hyperemia. Such symptoms will be observed if the artery is blocked at the time of administration or within 10 minutes after the administration of the drug.
3. Whitish gray discoloration of the skin around the insertion site. This symptom will last from 10 minutes to several hours.
4. Tissue thickening, hyperemia,  the formation of bubbles and blisters. These symptoms will occur from the first hours and continue for several days.
5. Fissures, ulcerations, delamination and eschar formation. Such a severe picture will be observed with incorrect or untimely treatment within days and weeks.

What is the mechanism of development of complications with the introduction of hyaluronic acid?

The development of complications that occur when small boluses of the drug enter the vessel. Typically, small boluses move down from the injection site along the flow of blood. This may cause slight obstruction or complete blockage in the collateral vessels. In this case, the localization of the problem will be limited to collaterals, and the area in which the microcirculation is disturbed will suffer.

Complications that arise from the ingestion of a large bolus of the drug in vessels of medium and large caliber carry more severe consequences. This is due to the fact that the material can be carried by the bloodstream and block the distal sections from the place where it was introduced, because. the drug simply has nowhere to go from the bloodstream. It is in this case that irreversible complications arise, for example, such as blindness.

What to do if the doctor suspects that the drug has entered the vessel, but is not sure about it

1. It is necessary to stop the administration of the drug immediately.
2. At the same time, you should start massaging the injection site.
3. Start applying warm compresses to the site of the suspected complication as soon as possible.
4. If you suspect that you have hit an artery, then you need to inject dexamethasone. It is best to inject as 3 boluses of 10mg.

After taking these precautions, you must under no circumstances allow the patient to go home. It is important to observe the development of the clinical picture during the first two hours. One of the most common mistakes is applying ice to the injection site. This is a completely natural reaction, but it is erroneous. Cold in this situation will narrow the blood vessels. Remember, if the patient complains of a sharp, severe pain, heat should be applied.

What is the further tactics if the complication has begun to develop

In this case, the next step is to start injecting hyaluronidase (Hyalase). It is important to properly prepare the hyaluronidase solution for administration in this case. My recommendation is to take a bottle of Hyalase 1500 IU and dilute with 1ml of saline. Then we collect 0.2 ml (300 IU) of the solution and mix it with 0.2 ml of 2% lidocaine. For therapy, we use 0.1 ml of this mixture, which is 75 units for each point that needs to be treated. We usually use 5 points around the injection site.

Remember to treat directly at the site of the complication.

Initiate topical therapy with nitroglycerin ointment immediately. It makes no sense to prescribe nitroglycerin inside. Its action should be targeted precisely at the zone in which the complication develops.

Contraindications to the use of nitroglycerin ointment are:

• allergic reactions to the components of the ointment;
• anemia of high severity:
• taking phosphodiesterase inhibitor drugs (sindenafil, talafil, vardenafil);
• severe headaches.

Are there any reports that Viagra is prescribed for complications associated with the introduction of hyaluronic acid fillers?

Indeed, drugs such as Viagra (Sildenafil), Cialis (Talafil), Levitra (Lardenafil) can be used for complications caused by circulatory disorders due to blockage or occlusion of blood vessels. 

  In addition to the muscle tissue of the cavernous bodies, phosphodiesterase is found in the smooth muscle tissue of the vessels of the skeletal muscles and internal organs. An important feature is that it is also contained in platelets. Suppression by Viagra, a selective inhibitor of cyclic GMP, of a specific type of PDE enzyme in these tissues can lead to peripheral vasodilation. Clinically, this manifests itself in the appearance of blush on the cheeks — a fairly common effect, as well as a decrease in blood clotting. 

When prescribing these drugs, one must be extremely attentive to contraindications.

Let's summarize.

Steps of the Dublin Complications Protocol

1. Stop injections immediately.
2. Massage of the area where the injection was made.
3. Hot compress applications.
4. Dexamethasone bolus.
5. Administration of a Hyalase cocktail with lidocaine.
6. Introduction into the complication zone of HLA at a dose of 75 units 
7. Using nitroglycerin ointment (for 12 hours).
8. Viagra-Cialis-Levitra.

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