TABLE 2.

Good Practice Guidelines

KNOWLEDGE OF INJECTION ANATOMY

Understand depth, distribution, and common variations of major vessels to guide safe injection plane. Extreme caution should be taken when injecting those with previous facial surgery, as this may have altered the anatomy. Caution should be applied when injecting areas where there is scar tissue or previous surgery.

Technique

Inject slowly at a low pressure (this will limit how much may inadvertently enter a vessel, limit retrograde flow, and limit extent of ischemia). Consider using a cannula of 25 gauge or larger.1 Inject in small increments per site to limit potential occlusion size. If aspirating, understand that this is not failsafe and even when done correctly, it is unreliable.14 Consider using targeted digital pressure to compress arterial pathways, particularly preventing retrograde filler movement. Do not use adrenaline with lidocaine as this may mask the blanching produced by occlusion.4

OBSERVE

Carefully observe the tissue for any color changes and ask the patient to alert to altered sensations including pain and visual disturbance as injecting.

^*Adapted from Consensus on Minimizing the Risk of Hyaluronic Acid Embolic Visual Loss and Suggestions for Immediate Bedside Management Greg J Goodman, FACD, Aesthet Surg J, 20196