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Critical Thinking – Beyond the Paradigm: Surgical vs. Nonsurgical Facial Adverse Events

Nonsurgical facial rejuvenation encompasses a variety of options including skin care, laser treatments, chemical peels and injectables. These categories are subdivided. Skin care includes, but not limited to,  growth factors, anti-oxidants, retinoids, and sunscreens including variations of chemical, human, and plant based products. The term “lasers” often refers not only to erbium, YAG and light-based lasers, but radiofrequency (RF) devices. RF devices may be monopolar, bipolar, tripolar, microneedling/RF combo, and treated either externally or internally. Chemical peels range from deep dermis to superficial epidermal peels.  Injectables include botulinum toxins, hyaluronic acids (HA), Radiesse, Sculptra, as well as, Bellafill.  The options are abundant. Clients depend on their provider to recommend the best treatment, usually based on a budget, with optimal outcome of aesthetic improvement.  Consideration is also given of risk factors for complications and downtime.

Surgical facial rejuvenation offers numerous avenues for “natural” restoration. Facelifts include the upper, middle, and lower face combined with neck rejuvenation, upper/lower blepharoplasty and facial implants. Surgeons offer a variety of techniques for each of these procedures. Fat injections are frequently integrated with facelifts, although many times fat transfer to the face is a sole procedure recommended for volumization. Hyaluronic acids and profractional laser procedures have been combined with facelifts. The surgeon advises on treating facial skin laxity, loss of volume and textural issues.

nonsurgical proceduresEvaluate the following case:

A 65 y/o female underwent a lower facelift, fat transfer to the cheeks combined with fractionated laser. Post-operatively, the right facial nerve was compromised demonstrating facial paralysis.  The nerve regenerated after a few months with minimal residual weakness.  A portion of the fat transfer gradually absorbed as expected. At 18 months post-op, the client underwent injection of “a filler” to the high lateral cheek, zygoma and anterior cheek for additional volume. Client was happy with the results post-injection. Approximately 4 months later, a “bump” was noted in the right inferior cheek which  casted a shadow in photos.

The client sought advice by a different provider than who had previously performed surgery or injected the filler. Upon assessment, slight contour convexity in the right inferior cheek was visualized. Palpation of the area was described as pea-size, round, firm, mobile, and without redness or discomfort. She denied change in size of the lesion since she noted onset.

Questions a provider may ask themselves include:

  • How long has the lesion been present?
  • Has the size changed?
  • Any history of previous injectables, if so had there been complications?
  • What product was injected post-operatively?
  • Was the product injected too superficially?
  • Has the product migrated inferiorly?
  • What was used as skin prep prior to injection?
  • If it is an HA, should I inject Hylenex?
  • Should I utilize radiofrequency to “break down” HA?
  • Could this be a biofilm?
  • Has the patient had recent dental work?
  • Could this be a tooth abscess?
  • Has the patient been under stress?
  • Is the patient immunocompromised?
  • Has the patient had adjunct aesthetic procedures such as chemical peels, lasers or radiofrequency treatments since injection?
  • Any recent systemic infections or signs/symptoms of infection?
  • Why does this late onset nodule feel firm, round, mobile yet without discomfort or signs of irritation or infection?
  • Could this possibly be fat necrosis secondary to fat injections?
  • Would this nodule be associated with the facial nerve paralysis, which has since resolved?
  • Lastly, should I inject with Hylenex, or should I refer for another opinion since I am not quite sure the etiology of this lesion/nodule?

In this case:

  • An HA had been injected
  • Skin was prepped with Hibiclens
  • No signs/symptoms of systemic or localized infection
  • No recent dental procedures
  • Stress level is normal status for client
  • Not immunocompromised
  • Unlikely due to nerve injury
  • Denied additional injectables, laser, radiofrequency, skinpen or chemical peels since injected in high lateral cheek

Seasoned injectors utilizing critical thinking skills research “beyond the paradigm.” The provider assessing thought the fact the nodule was late onset fat, as well as, HA injections, palpable, round, firm and mobile was unusual.  In this case, a second opinion was sought by a plastic surgeon. Ultrasound demonstrated a fluid filled cyst diagnosed as fat necrosis secondary to fat transfer two years earlier. One cc of clear yellowish colored, oily fluid was aspirated. The nodule resolved while contour irregularity smoothed. The client was very happy with the positive outcome to an unexpected adverse event.

Complications attributed to aesthetic procedures occur in the hands of the highly educated, skilled, experienced physicians, nurse practitioners, physician assistants and registered nurses. It is the due diligence of the licensed professional to utilize critical thinking skills. Treatment plans are founded upon the provider’s knowledge and experience in combination with the most recent evidence-based research. Safety is priority. Researching above and beyond the paradigm will provide the best outcome. Going this extra step, aids in building a trusting relationship and the happy clients. Pleased clients refer their friends, which is essential for business growth.

Suzanne Ramsey, RN, BSN, CPSN, CANS

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