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FILL HARMONICS Dr. Cohen and others are encouraged by early findings of Voluma in peer-reviewed data. or possibly from injecting too much product around a blood vessel, causing compression that pinches off the blood flow. The risk of vascular compromise is higher in the glabella and the alar groove, he adds. Extra caution should be used in these areas. "The glabella is the injection site commonly believed to be at greater risk, as small-caliber vessels branch from the supratrochlear arteries to supply this watershed region with minimal collateral circulation," Dr. Cohen reported in "Understanding, Avoiding, and Managing Dermal Filler Complications," published in the June 2008 issue of Dermatologic Surgery. Precautions can help avoid tissue necrosis. "In the glabella, I tend to inject quite shallow and use small volumes of product in two or more sessions," Dr. Cohen says. "You need to have a high degree of suspicion; if you suspect there's a vascular issue, you need to see that patient immediately," says Dr. Applebaum. Dr. Cohen stresses that distinguishing between bruising and vascular compromise is very important. In the case of a vascular issue, cold compresses can be one of the worst responses. Instead, encouraging blood flow to the area with several steps may help prevent necrosis. Dr. Cohen has written about using nitropaste to try to facilitate vasodilation, as well as utilizing hyaluronidase to try to dissolve some of the HA—if the product is an HA filler—that is seemingly impinging on a vessel. A 2012 review article in Dermatologic Surgery co-authored by Cohen ("Systematic review of clinical trials of small- and large-gel-particle hyaluronic acid injectable fillers for aesthetic soft tissue augmentation", February 2013) reported that mean blood flow readings were 365% higher at transdermal nitroglycerin patch sites vs. placebo. Taking swift action can make all the difference in saving the skin tissue. "You can have tissue dying within minutes, hours or days," says Dr. Applebaum. Massaging the area, especially if an HA filler was used, can potentially dislodge a blocked vessel. Another helpful aid may be hyperbaric oxygen treatment sessions for vascular compromise, he adds. These consequences are less indicative of the materials used than the injection techniques. "Most complications have to do with technicalities of injecting through the skin into the deeper layers," says Dr. Fitzgerald, who adds that paying close attention to the patient's anatomy will go far in preventing such adverse events. The pressure and speed of the injection may also be a factor in another rare complication that can result in 32 NOVEMBER/DECEMBER 2013 | MedEsthetics blindness in certain higher risk areas, such as the glabella, alar groove or periorbital region. "Anything you inject rapidly with a good deal of force into an artery is going to flow upstream against the systolic pressure, possibly reaching the central retinal artery to result in blindness," says Dr. Fitzgerald. A slower injection technique will also help decrease bruising and swelling, she notes. It is hoped that using blunt-tipped cannulas instead of needles may help decrease the risk as well as result in less bleeding and bruising. In a small observational study, published in the April 2010 issue of Orbit, Berros, et al, reported that using cannulas for periorbital injections with Restylane led to fewer irregularities, inflammatory reactions and hematomas. The Future Of Fillers Though dermal fillers have been part of cosmetic medicine for almost 30 years now, there are still some truly innovative materials entering the market. Voluma (Allergan, allergan.com), an HA filler that has been approved for use in Canada and Europe for years, may soon offer U.S. patients effects that last 18 months or more and a high G prime for more lift and fill with less product. If approved as submitted to the FDA, Voluma will be the first filler to carry an FDA approval for the indication of mid-face volumizing related to aging. Another plus: like all HA fillers, Voluma is reversible with hyaluronidase. Dr. Cohen and others are encouraged by early findings of Voluma in peer-reviewed data demonstrating optimal lifting capacity and flow characteristics. Also look for Expression (Enhancement Medical, enhancementmedical.com), an HA filler that is currently approved for treatment of nasal airway obstruction. Used off-label as a filler, this injectable offers several potential benefits, including less observed Tyndall effect, less swelling, and homogenous sized and shaped molecules, says Dr. Applebaum. As new fillers continue to come to market, the trend toward specialized products that treat specific concerns and regions of the face continues to grow. In the future, physicians can look forward to a growing variety of materials that smooth, volumize and fill the skin with fewer complications and longer results than ever before. Andrea Sercu is a freelance writer based in the San Francisco Bay Area.