In recent years, the aesthetic medicine field has seen a rapid increase in the use of intradermal injections of hyaluronic acid and botulinum toxin. Sadly, this boom has been accompanied by an increase in side effects, especially because these injections aren't always administered by people who are trained and accredited in this practice. Martine Baspeyras, MD, dermatologist in Bordeaux who specializes in cosmetic dermatology and cosmetology, and chair of Vigilance Esthétique, France's society for the regulation of cosmetic dermatology procedures, reviewed the situation at a press conference held before the Journées Dermatologiques de Paris dermatology conference.
Hyaluronic Acid Injections
Aesthetic medicine has seen a meteoric rise in recent years in Western countries, with a growing market in botulinum toxin and hyaluronic acid injections to fill wrinkles and loss of facial volume. Hyaluronic acid acts differently, depending on its concentration and cross-linking. Its volumizing effect remodels the face and reduces wrinkles. It stimulates fibroblasts, the production of collagen, and elastic fibers: It induces tissue regeneration. It also has a long-term hydrating effect. These are temporary benefits requiring frequent injections to maintain the aesthetic effect achieved. "Injections are minimally invasive medical procedures that should only be administered in a medical environment compliant with good practice," said Baspeyras.
The most common and least serious side effects of cosmetic injections are hematoma or redness, which are linked to the fact that a needle has crossed a small blood vessel that has consequently bled. These side effects are temporary and will disappear in around 10 days or so. "They are less common than they were 10 years ago, thanks to the use of new methods to administer these injections, such as through cannulas," said Baspeyras.
Sometimes, cosmetic procedures go wrong, leading to asymmetry and excessive swelling. Another nonserious risk is that correction attempts may fail, resulting in an unsightly outcome (the opposite of what was intended) because the hyaluronic acid was not injected in the right place or has migrated. "Medicines can be given to correct injection errors," said Baspeyras.
Other complications, such as when the product is injected into a small arteriole, are thankfully very rare — just one case has been reported in France. This complication can trigger a hyaluronic acid embolism that affects the circulation of blood to one area of the face, causing tissue necrosis. The doctor will then enact a treatment protocol involving an enzyme to break down the hyaluronic acid, combined with a blood thinner.
Likewise, swelling or nodules can appear after the injection. If they persist, the doctor can take a sample for histology testing to determine the cause. When bacteria are identified, following poor unhygienic conditions, antibiotic therapy must be prescribed.
Patients must be informed before receiving a cosmetic injection. This disclosure is intended to prevent risks both common and rare. "But one of the major challenges in the cosmetic dermatology field is misuse of these injections by nondoctors, like beauty therapists, hairdressers, and manicurists, who believe themselves to be qualified to administer hyaluronic acid or Botox injections after watching an online tutorial showing them how to do it," said Baspeyras. Patients visiting dermatologists to fix complications from beauty injections tell them, "The woman who does my nails said to me, I've learnt how to give injections and I can do them on you!" "Having an injection in a hair salon, outside of a medical setting is wrong, not to mention illegal! You might pay a bit less than you would with a doctor, but the risk of complications is much greater," warned Baspeyras, who is also a legal expert.
Before having an injection, make sure that certain rules have been followed. The person giving the injection must be a doctor, he or she must know about hygienic practices, and he or she must have studied facial anatomy in full and be trained. "But a side effect may be down to the product itself, the person who injected it, or even the patient," said Baspeyras. This is why practitioners of these cosmetic injections must take a full patient history before the procedure to make sure that the patient isn't experiencing an outbreak of herpes, psoriasis, or eczema, and that he or she doesn't have chronic inflammation.
Injections mustn't be given to patients experiencing an autoimmune flare-up, and in any case, injections must only be administered to people whose health condition is stable and whose medication history is known.
Practitioners should also ask about any dental problems their patients may have before giving an injection. Examining the teeth and gums allows a practitioner to check for abscesses that could promote infection post injection. "A doctor will rarely inject more than three syringes per session to let the hyaluronic acid settle into place, for good absorption, and to ensure that both sides of the face are symmetrical," said Baspeyras, who also advises patients "to learn to say no, by justifying why an injection shouldn't be carried out" when the conditions required for the cosmetic procedure have not been met, from the doctor's point of view. She issued another warning: Don't inject someone on the same day they come to see you. Wait a while. "Beauty procedures are never urgent," said Baspeyras.
Experts to the Rescue
Faced with an injection-related complication, a group of French Cosmetovigilance experts (Vigipil/Vigidec) has established itself within France's Dermatology Society. "Any doctor presented with a patient suffering from an injection-related complication can contact the group, and it will set out the course of action that he or she must take, explained Baspeyras. We offer virtual treatment advice once the doctor contacting us has completed the form for reporting complications." The creation of this group is all the more important because from a legal standpoint, this is what affects the patient who is responsible if there are any after-effects. The expert group also encourages reporting all side effects.
This article was translated from the Medscape French edition.