Cosmetic injectables are on the rise, we see them everywhere we go. In a recent blog post I summarised the FDA meeting from March 2021, noting that adverse effects from cosmetic injectables are on the rise, in part due to their rising availability, often by less experienced injectors and related to this, failure to recognise adverse events when they do occur. 

Nonetheless cosmetic injectables are a billion dollar industry, and the marketing is slick and everywhere. 

They're in every mall, on every corner, advertising with big signs "injector in clinic today, complimentary consult!"

So you go in, and your venture into the world with your first ml of dermal filler, most commonly, lip or cheek filler for most people.

You are sent home, and told bruising, swelling and some discomfort are normal and it'll all settle in a few days.

So when should you worry if it is just bruising or something more?

Some basics first:

• bruising is almost certainly guaranteed anytime skin is penetrated by a sharp object, usually needles 
• swelling as a side effect of the bruising is also likely, with some asymmetry that is usually temporary (unless it is pre-existing) 
• some parts of the face are more prone to bruising. Common areas include the delicate area around the eyes, and the lips, among the most common areas to treat with injectables, both anti-wrinkle treatments as well as dermal fillers. 

So how do you know what is normal and when to worry? 

Vascular Occlusion ie VO due to cosmetic injectables occurs when filler is inadvertantly injected into a blood vessel instead of in the surrounding tissue. This can lead to complete or partial blockage of the vessel.

• this is usually immediate if complete blockage, but may be delayed due to some other factors 

So what signs should you be looking for to indicate a VO bruising?

• Pain 

Severe pain is sometimes experienced at the time of injection, but it is not always a given. The use of numbing cream or injected local anaesthetic may mask this symptom if used, so may be less reliable until it wears off some hours later. Worsening severe pain during treatment or in the hours following treatment, especially if one sided eg one cheek or one side of a lip, is a possible sign of a VO versus just a bruise, requiring an urgent review. 

• Blanching

With compromised blood supply to areas downstream of the injected area, a change in colour of surrounding skin is common, and may vary from white, to pale, or dusky depending on what is happening. This colour will persist and not respond to massage or heat or warmth and with progression may look more like a lacey doiley. 

• Discolouration 

Discolouration of the skin is usually several hours following treatment if it is not picked up earlier as skin begins to accumulate blood that cannot flow and which does not have enough oxygen, leading to a dusky, purplish hue and eventually, blue-grey appearance of the skin. It may resemble bruising, but bruises do not discolour on pressure, while this will if your clinician has shown you how to look for this (I routinely do, especially if injecting high risk areas or new patients). 

• Coolness 

With compromised blood supply to an area of the skin, the skin begins to cool down over time, and this may be appreciated by comparing warmth in nearby skin versus compromised skin (hard to do if you are not trained). 

• Skin Death 

This occurs if the VO is not picked up, usually around 2-3 days post injury. The compromised skin has begun to die due to lack of nutrients and oxygen downstream from the blocked vessel. At this stage, it is still not too late, though some skin may not survive and repair may take weeks to months compared to if picked up sooner. 

So should you simply avoid all injectables? 

The aim of this educational blog is to illustrate the following points: 

• medical aesthetics is not just beauty, which works on the surface of unbroken skin. Once skin surface is broken, it is medical territory with attendant risks. 
• all medical procedures are a risk : benefit analysis and you should rely on your treating doctor or clinician to educate you on your options and risks, which must necessarily include doing nothing at all, and not proceeding if you are too worried/ afraid or want no risk. 
• your choice of clinician is your insurance in the event something does go wrong despite all due diligence, so choose based on qualifications and experience not on price. 
• your aim, as with any consultation you book with a doctor, should be to go in to be informed and to be educated, not to be sold to, and not to be treated irrespective of whether the treatment is right for you. Pay for the expertise and service of your clinician, so you can make the best and safest decision for you, not just on the day, but also longterm.