Australasian Dentist Issue 92

CATEGORY AUSTRALASIAN DENTIST 79 LINICAL Stage 4: Clotting and coagulation The blood that has pooled will clot and the tissues will try to repair the necrotic tissues. Scar tissue will result due to the impaired vessels and blood flow. Once the vascular occlusion reaches this stage, a surgeon will need to be involved to rectify the skin necrosis, removing necrotic tissue. The patient will also be left with a permanent aesthetic injury. The patient is now in real trouble, and will need surgical intervention to debride the tissues to control the tissue healing. only provides a great aesthetic outcome, but also a safer experience for both the practitioner and the patient. This is especially important when injecting anywhere near the facial, nasal, temporal and ophthalmic arteries, as well as other areas of the face that are connected to these vessels, such as the nasolabial fold. A detailed history for the patient, including previous facial injuries and trauma is also very important to consider. Stage 5 Complete necrosis and tissue loss. Due to the end stage of tissue necrosis and loss, the tissues will be lost. Scar tissue is profound and re-establishing the blood flow will require a multi-disciplinary team. How to prevent a vascular complication As we all know, prevention of a problem is better than dealing with it. Recognising a VO and what stage it is at is also important and intervening early. So let’s look at the possible strategies for prevention. Having a deep understanding of the anatomy is fundamental to cosmetic injecting. Knowing what layer to place dermal filler not The technique is the foundation to safer cosmetic injecting. The cosmetic practitioner should use very small aliquots of dermal filler in any area, and also inject using very light pressure. This is important so that the blood pressure is not overcome with the filler material, should it be inadvertently injected intravascularly. Another important point is to constantly move the tip of your needle or cannula. This ensures that the filler is distributed in an area, rather than a bolus being injected into or over the vessel in one place. Finally the injection method is also really important. A global consensus group determined in 2016, that an important strategy to minimise and avoid complications was to use a cannula, and this should be part of your cosmetic ‘tool kit’. When injecting my patients, and when educating practitioners through Dermal Distinction Training Academy, I use a cannula to deliver dermal filler 99% of the time. The cannula should have a blunt round end, with a side port. I prefer a cannula no longer than 50mm so that I can control the cannula depth and direction. It is also important to select a cannula that is 25 gauge or larger. For thicker dermal filler, I will use a 22 or 23 gauge cannula. If using a cannula that is 27 gauge or smaller, the cannula acts just like a needle, and offers little safety over a needle. When using a cannula, it is also important for the cosmetic practitioner to know where the cannula is at all time (depth and direction), move the cannula whilst injecting 100% of the time, and to gain consent from your patient. A cannula is considered an ‘off- label’ delivery of dermal filler, and the patient must consent to the use. I include this in my consenting protocol and my consent forms when I am consulting with a patient. If you are not using a cannula to deliver dermal filler, you must consider training in this treatment protocol as a medical and dental safety minimum. Finally, every clinic must have Hyalase on-site. It is recommended that you have a minimum of 5 vials available. If you are not sure if the area is bruised or has a Vascular Occlusion (VO), assume it is a VO and Hyalase the area immediately. The cannula design The word ‘cannula’ comes from Latin, meaning ‘little reed.’ Essentially, a cannula is a flexible tube that can be inserted into a bodily cavity, duct, or vessel to administer or remove fluid. The