EMERGENCY CARE IN AESTHETIC

MEDICINE PRACTICE

MOHD SHAKIR BATHUSHA

PLASTIC SURGEON
 Appreciation

Dr Nur Abdul Karim

Emergency Physician, UiTM

Disclaimer - None
 OBJECTIVES

1. Basic Life Support

2. List And Manage Common Aesthetic Emergencies

With Regard To Procedures

3. Management Of Minor Emergency Situation

 Outline

* Part 1 * Part 2
* BLS - CPR * Management of Aesthetic
Procedure Complications
* General
* Specific
CARDIOPULMONARY
RESUSCITATION
BLS ( BASIC LIFE SUPPORT)
 Appreciation

Dr Nur Abdul Karim

Emergency Physician, UiTM

Disclaimer - None
* BLS – Foundation for saving life

* Aims :

* Providing high quality and effective chest

compression

* Manually supply oxygenated blood to brain,

other vital organ including the heart

* CPR – provide 10-30% of normal cardiac output

 Chain of Survival
(Out of Hospital Chain of Survival)

Advance Cardiac Care

•The 5 links in the adult out-of-hospital Chain of Survival are

Recognition of cardiac arrest and activation of the emergency

response system

Early cardiopulmonary resuscitation (CPR) with an emphasis on

chest compressions

Rapid defibrillation

•Basic and advanced emergency medical services

•Advanced life support and post-cardiac arrest care

•American Heart Association

Activating EMS ( Emergency Response
System)

* If emergency happens outside health care

facilities

* Call 999

* Clear description of situation, location, inform

contact number

* Follow all instructions

* Don’t hang up the phone till instructed by

dispatcher
 Recognition of Cardiac
Arrest
* Victim :
* Not responsive ( Tap Shoulder- Hello Are You OK?)
* Absent breathing or abnormal breathing

* Pulse detection alone is unreliable

* Immediately start CPR

2010 vs 2015 guidelines

A B C. Vs. CAB
High Quality Chest Compression

* Rate 100-120 per minute

* Depth – 5cm to <6cm deep
* Minimal interruption <10 sec between each
compression
* Allow spontaneous recoil between compression
Location : Adult : central chest , lower ½ sternum
Infant : Just below nipple
Pulseless Vent
Tachycardia
Vent Fibrillation
 VT

R-R intervals are usually, but not

REGULARITY
always, regular. RATE

The atrial rate cannot be

determined. Ventricular rate is
RATE
usually between 150 and 250 beats
per minute.

QRS complexes are not preceded by

P waves. There are occasionally P
P WAVE waves in the strip, but they are not
associated with the ventricular
rhythm.

PR interval is not measured since

PR INTERVAL
this is a ventricular rhythm.

QRS complex measures more than

0.12 seconds. The QRS will usually be
QRS COMPLEX wide and bizarre. It is usually
difficult to see a separation between
the QRS complex and the T wave.
 VF

There is no regularity shape of the

REGULARITY QRS complex because all electrical
activity is disorganized.

The rate appears rapid but the

RATE disorganized electrical activity
prevents the heart from pumping.

P WAVE There are no P waves present.

PR INTERVAL There are no PR Interval present.

QRS COMPLEX The ventricle complex varies

* Transfer to intensive care or cardiac care unit
 When to stop CPR

* No obvious sign of life

* Qualified help arrives / takes over

* Rescuer becomes exhausted

Management of Aesthetic Procedure
Complication
 Complications

* General * Specific
* Anaphylaxis * Injection site reaction
* Botulinum toxin
* Fillers
* Laser/RF/ Light devices
* Chemical peels
Global Scenario
 Managing expectation in aesthetic
intervention

* Expectation “ Seeking to prevent disappointment by establishing in

advance what can realistically be achieved” The Oxford English Dictionary

* Current era - exponential increase in the population seeking for

perfection in appearance

* Non surgical vs Surgical treatment (5x commoner)

* High patient expectation

* It’s ain’t what you don’t know that gets you in
trouble. It’s what you know for sure that just ain’t so
Mark Twain
What happens when expectation not
met ?

* Dissatisfied patient
* Complaint
* Bad publicity through social media
* Claim for damage

Establish expectation in first consultation

Documentation
 Understanding your patient
* Set expectation right at the first consult
* Establish realistic outcome
* Young pt – judgement clouded by social media / peer
* - in such pt address truly unattractive features
* Media – patronizing celebrity, try to look alike
* TRO - Body dysmorphic disorder

* Knowing the limitation of practitioner

* Adequate knowledge and appropriate skills

* Upto-date
 Anaphylaxis
* A serious life threatening hypersensitivity (allergic)
reaction that is rapid in onset and may cause death

* Anaphylaxis is an acute, life-threatening, multisystem

syndrome resulting from the sudden release of
mediators by mast cells and basophils.

* Common agents : food, insect, medication and latex

* IgE mediated mechanism

* American Academy Of Allergy, Asthma & Immunolog Epidemiology, Mechanisms, and Diagnosis of Drug-
Induced Anaphylaxis, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5446992/#
 Common Allergens Found in Cosmetic
Products

* Classified into :
* Latex
* Fragrance
* Preservatives
* Dye
* Chemical
* Metals
US Pharmacist July 2013
Drug-induced anaphylactic reactions in Indian population: A systematic review
1 1
Tejas K. Patel, Parvati B. Patel, Manish J. Barvaliya, and C. B. Tripathi
Commonest symptoms

* Respiratory difficulties or Low BP

* Angioedema / Mucosal involvement
* GI symptoms
* 5 – 30 min within contact to allergen
( sometimes > 1 hr or biphasic)
Symptoms
 Differential Diagnosis

* Life-threatening * Non Life-threatening

condition

* Asthma * Vasovagal / Faint

* Low BP + Petechial rash = * Panic attack
Septic Shock * Idiopathic non-allergic
urticaria or angioedema
Management
Transfer to ED
Adrenaline @ Epinephrine

* Alpha and Beta Adrenergic receptor

agonist
* Mechanism :
* Systemic vasoconstriction
* GI relaxation
* Stimulates the heart
* Dilates bronchi
* Dilates cerebral vessel
* Reverse peripheral vasodilatation and reduce oedema.
( alpha component)

* Route : IM or IV ( IM is preferred – margin of safety)

* IM injection site : middle third, anterolateral thigh

* # sufficiently long needle to ensure injection into muscle

 Dosage

* Adult. : 0.5 mg ( =500 µgm)– 1:1000

* Repeat dose at 5 min interval
* Failure of treatment due to
* Delay in institution of treatment
* Pt on beta blocker
Delivery device
 Others

* Bronchodilators ( Salbotamol, Ipratropium,

Aminophylline, Mg )
* Cardiac drugs ( Atropine for bradycardia)
* Inotrope – Noradrenaline, Vasopressin

* Better to be given in an acute bay / icu setting

Specific complications
Management
 Fillers

* Gel like substance used to :

* restore lost volume
* Smooth lines
* Soften creases
* Enhance facial contour

* Made of : Hyaluronic acid, Calcium hydroxyapatite, Poly L-

Lactic Acid, PMMA, Autologous fat
American Board of Cosmetic Surgery
 Example

* Component :
* HA : Brand names include: Juvederm, Restylane, Belotero
* Calcium hydroxylapetite : Brand name: Radiesse
* Poly-L-Lactic Acid : Brand name: Sculptra
 Complication with fillers

* Complications with filler can be best categorized based on :

1. The time of onset: Early (<14/7), late (>14/7 to 1 year) and

delayed reaction (>1 year)

2. Aesthetic relevance: minor versus major.

Lafaille P, Benedetto A. Fillers: contraindications, side effects and precautions. J Cutan

Aesthet Surg. 2010;3(1):16–19. doi:10.4103/0974-2077.63222
3. Causality of the adverse reaction:
a) injection site reactions;
b) adverse effects resulting from an improper
injection technique;
c) allergies and hypersensitivity reactions and
d) vascular mediated events

Lafaille P, Benedetto A. Fillers: contraindications, side effects and precautions. J

Cutan Aesthet Surg. 2010;3(1):16–19. doi:10.4103/0974-2077.63222
Filler

Lafaille P, Benedetto A. Fillers: contraindications, side effects and precautions. J Cutan

Aesthet Surg. 2010;3(1):16–19. doi:10.4103/0974-2077.63222
 Injection site Reaction

* Pain
* Oedema
* Erythema
* Bruising
* Immediate complication
* Caused by intra- vascular injection
* Leading for embolus impeding blood flow
* Clinical features :
* Arterial – immediate severe pain, whitish skin
discoloration
* Venous – dull pain
 Management

* Pain : Small needle

* Pre-procedure EMLA
* Cold compression
* Nerve/ Regional block
* Stop certain supplement : Gingko, Vit E, Omega-3, ginseng
* Avoid vascular area
Tyndall Effect
 Tyndall Effect

* Presentation : Bluish Hue on the skin as a result of light

refraction through the skin layers hitting the injected filler

* Blue light refracted 10X more than red light

* Cause :
* Fillers are injected too superficial
* Fillers are injected in tear troughs
* Skin is too thin (previous skin treatment, genetic etc)
 Complication associated with
improper technique

* Agent : HA
* Superficially injected HA leads to :
Nodule formation
Bruising appearance ( unresolving compared to
vascular bruise) @ Tyndall Effect
* Site : Areas with thin skin, tear trough, nasolabial fold
* Mx : Small - massage / Aspiration / I&D
Large - Hyaluronidase
 Other types of filler

* Artecoll TM ( PMMA microsphere in bovine collagen gel )

* Use : Deep facial static fold, depressed acne scar, lip
augmentation, post rhinoplasty dorsal irregularities
* Superficial injection - persistent redness, itchiness,
hypertrophic scarring , lumpy nodule
* Mx : Local corticosteroid injection, massage

* Others : Poly-L-Lactic Acid – Presents as skin nodule

 Lumps and Bumps

* Could be either :
* Non inflammatory
* Inflammatory
* Infectious
* Cause :
* Superficially injected fillers
* Excess fillers
* Incorrect product indication

* To mange - differentiate the type ( inflammatory vs non

inflammatory vs infectious )
 Management
* Early onset lumps – massage and observe

* If the non-inflammatory lump persists, treat the over

correction:
1. Needle aspiration or minimal stab wound incision with
evacuation
2. Hyaluronidase 150U/ml
3. PIH treatment with intense pulsed light/laser; photo-
protection; orTreatment
depigment cream.
of Soft Tissue Filler Complications: Expert Consensus Recommendations
Aesthetic Plast Surg. 2018; 42(2): 498–510.
Published online 2018 Jan 5. doi: 10.1007/s00266-017-1063-0
 Hyaluronidase

* HA – linear polysaccharide with alternating

monosaccharide and glucosamine
* Naturally an ECM component - function to hydrate
dermis
Region Hyaluronidase

Nasal and perioral 15 – 30 U

Periorbital 3-4U

Infraorbital 10 – 15 U

Lower lid 1.5 U

The Use of Hyaluronidase In Aesthetic Practice, Martyn King, Cormac Convery, Emma Davies; Journal Of Clinical And
Aesthetic Dermatology, June 2018, Vol 11, No 6
Storage - 2 -8º C, if at room temperature shelf life 1 year
Recommended reconstitution – with NS ( less painful )
Vascular compromise following fillers
 Blindness
* Caused by periocular
embolism of HA
* Excruciating pain
* Needs restoration of
circulation within 60-90
min to restore vision
* Treatment : Retrobulbar
injection 150-200 U in 2-4
ml diluent, inferolateral
orbit
 High risk area for vascular
compromise

* High risk sites :

* Endartery – ala triangle,
nasal tip
* Poor collateral – glabellar
region
 Management

* Stop treatment
* Massage, warm pack
* Hyaluronidase
* Referral to plastic surgeon – wound and
reconstruction
* Referral to ophthalmologist – treat blindness
Strategies to reduce skin necrosis risk
with HA

a. Aspirating prior to injection

b. Utilizing lower volumes and serial injections in high-
risk areas
c. Treating one side at a time
d. Pinching/tenting the skin to provide more space
superficial to the branches of the main arteries
e. Manual occlusion of the origin of the supratrochlear
vessels with the non-dominant finger
f. Blunt cannulas may reduce, but does not eliminate, the
risk
Rohrich RJ, Bartlett EL, Dayan E. Practical Approach and Safety of
Hyaluronic Acid Fillers. Plastic and Reconstructive surgery. Global
Open. 2019 Jun;7(6):e2172. DOI: 10.1097/gox.0000000000002172.
 Botulinum Toxin

* Types available in market:

* Onabotulinum @ Botox
* Abobotulinum @ Dysport
* Incobotulinum @ Xeomin

* Common indication in aesthetic medicine:

* glabellar lines, forehead wrinkles,
* periorbital and perioral lines, platysmal bands
* horizontal neck lines, masseter lines
Contraindications of the use of Botox

* Myasthenia gravis
* Amyotrophic lateral sclerosis
* Multiple sclerosis
* Eaton Lambert syndrome,
* Pregnant and breastfeeding
* Neonate and children
* Focal and systemic infections
* Hypersensitive or allergic to Botox and
* Patients who had previously undergone lower eyelid
surgery
Complications
 Other complications

* Injection site reactions

* Muscle weakness – Mastication ( masseter region
injection)
* Short term hyperesthesia

* NON- INJECTION SITE COMPLICATION

* Improper placement, or diffusion to unintended adjacent

muscle
3 – 6 months
 Management

* Appropriate technique
* Anatomical knowledge
* Adequate volume ( care in dosage and dilution)
* Avoid local diffusion – DON’T lie down after
procedure, don’t massage
 Energy device
Laser, IPL, USG, RF device

* Very safe. BUT

* CAN PRODUCE BURN OF VARYING DEPTH

* POST INFLAMMATORY HYPERPIGMENTATION

* Hazard to operator
* Smoke ( carcinogenic property, viral particle)
* Cutaneous injury ( ablative laser)
PIH
 PIH

* Sun screen
* Hydroquinone, tretinoin cream 0.1%
* Lightening of hyperpigmentation– topical gel,
chemical peel
* Klingman formula ( hydroquinone 2%, tretinoin 0.05%,
hydrocortisone 1% ) - PIH in dark skinned
* Camouflage makeup
 General Management of
Complications

* Choice of laser – targeted chromophore

* Assessment of skin type
* Test dosing
* Appropriate energy delivery
* Cooling
* Post laser advice and care
* Sun screen
 Chemical Peel

* Chemexfoliation – chemical agent with defined strength

applied to skin to produce controlled destruction of
layers of skin followed by regeneration and remodeling
 Complications

* Immediate (Within minutes to hours after peeling):

* Pruritus, burning, irritation
* Persistent erythema, and edema
* Ocular complications
* Delayed (Within a few days to weeks):
* Loss of cutaneous barrier and tissue injury: Infections
(bacterial, herpetic, candidal)
* Abnormal wound healing: Scarring, delayed healing,
milia and textural changes
* Pigmentary changes: Hyperpigmentation,
hypopigmentation, demarcation lines
* Adverse reaction to chemical agent: Acneiform
eruptions, allergic reactions, toxicities
THANK YOU