Guest Blog: Azza Halim, MD talks injectables, fillers & answers the questions you want to ask!
Updated: Sep 28, 2020
I'm really excited to host my first guest blog! There are so many knowledgeable and talented clinicians practicing today and I love being able to share their perspective with my clients, friends, and readers!
For this blog, Azza Halim, MD was gracious enough to jump on board and address some important questions about the safety of injectables and fillers. The "must knows " for providers and anyone seeking out this type of treatment!
PLEASE WELCOME AZZA HALIM, MD.
Dr. Halim is a Board certified Anesthesiologist as well as Aesthetic Medicine, Anti-aging and Regenerative Medicine Physician. Dr. Halim’s medical training began at Northwestern University in Chicago.
First Dr. Halim did a research fellowship in pharmacokinetics and pharmacodynamics, she then went on to do her internship in internal medicine. Dr. Halim did residency in anesthesiology, along with subspecialty training in critical care/trauma and pediatrics at Northwestern University.
She pursued her interests in Aesthetics, Lasers, PDO Threads thereby continued to build her expertise in various areas such as facial rejuvenation, integrative/functional medicine, nutrition, and hyperbaric medicine so that she may combine this knowledge to achieve beauty from inside out with the focus being on each patient’s skincare, diet, fitness as well as lifestyle.
For this blog, Dr. Halim addresses questions about injectables / fillers and provides an important perspective on what you should know before seeking out this treatment.
Thinking of getting injectables, does it matter who injects?
It's critical your provider understands facial anatomy which is fundamental to performing any aesthetic procedure just as it is for any aesthetic/plastic surgery. If a provider lacks understanding of the intricate details of facial muscles, nerves, arteries, etc. then a relatively simple injection can become a serious complication such as blindness.
All injectors should have thorough knowledge of facial anatomy, including the subcutaneous planes of anatomy: different nerves, muscles, and blood vessels. It is imperative to understand which areas have collateral circulation as well as those that do not as there are vessels that do not have valves thereby fillers will travel along path of least resistance resulting in obstruction of the retinal artery = Blindness.
Some complications can be mild yet others can be catastrophic such as if you accidentally inject a neurotoxin into a blood vessel, the neurotoxin just will not work and the worst thing that can happen will be a bruise yet if you inject a filler into a vessel this results in skin necrosis or even blindness, as vessels connect with the central retinal and ophthalmic retinal arteries and veins.
What are the risks or complications?
As with anything, there is always risk but in order to avoid or minimize bad outcomes there are few things that can be done as an injector:
Always know your anatomical landmarks. Mark them.
Always aspirate for 6-10 seconds before injecting any filler (does not apply to Botox).
Use appropriate size needle ( for example, a 30g needle is very small therefore even with a negative aspiration doesn’t guarantee not being in a vessel hence false sense of safety).
Don't prime the needle before aspiration. For example in the pyriform aperture use a new needle on each side.
Always inject small aliquots to avoid compression occlusion as well as vascular occlusion.
Never apply strong force on plunger when injecting.
Learn to use a cannula for high risk areas.
Never use too much product. It can cause compression occlusion. I.e. Lips: add only one vial in one setting.
Always give the patient specific instructions as to risks, complications whether immediate. or delayed, as well as when to call for immediate help vs routine follow up.
Never inject filler in an area in which you have not had formal training and experience.
Choose reversible products in higher risk areas and if you are a novice injector.
Always have a vascular occlusion crash cart. Always!
13. Have resources to treat complications if you cannot. Always have a way the client can contact your service 24/7. Sometimes a problem can occur days later.
14. Have patients stay local 48 hours after high risk area injections.
15. Provider should properly sanitize area prior to injections and ask client to not touch face/lick lips etc.
16. Learn to say no if you think clients expectations exceed what realistic results will be.
Understanding how to rescue the situation is equally important in order to salvage the catastrophe and minimize/prevent any permanent complication. But first, one must be proficient in recognizing the complication and diagnosing quickly to remedy the situation appropriately as well as understanding the crosslinking properties/rheology of each product which is why everyone should be properly trained and staying up to date with continuing education.
Are complications reversible?
The human body is very intricate as we can see in (Fig. 1 and Fig. 2). The facial muscles plus the vascular supply which are the “danger zones” that a provider must know and avoid.
Hyaluronidase is an enzyme that dissolves hyaluronic acid fillers. Usually the area of impending necrosis is flooded with anywhere from 200-400 units and some experts have suggested diluting the enzyme with saline for greater spread and lidocaine for vasodilation effect. Yet many will continue to flood the area till circulation resumes. Warm compress, massage, aspirin, and nitroglycerin have been used simultaneously with emphasis on hydrolysis of product with Hyaluronidase. Prompt treatment will determine outcome. Having an “aesthetic crash cart” is not an option but a necessity, when doing any injectables or even laser treatment, the provider must be well versed in Anatomy, procedure protocol, risks, and remedy options. A provider should have 8-12 bottles of hyaluronidase in their refrigerator at all times.
As a provider, in order to help us distinguish between a bruise versus vascular compromise, we should explain to the patient that if the area is purple, dusky gray with a patchy appearance and atypical pain then that suggests vascular compromise, whereas purple discoloration in a specific spot is more likely a bruise. If they have any questions, they must contact their provider immediately. Vascular complications are best resolved/rescued within first 24 hours. This is why having a skilled provider with experience, not just in the procedure but also experience as a clinician who has continued medical education (CME) in aesthetics, anatomy and is always available (or has someone available) to respond to any emergency if it should arise is a necessity! Experience from a one day training does not suffice as expertise. I recommend all injectors take a cadaver course to get intimate knowledge of facial structures. We all must start somewhere but must continue learning daily, for once we stop learning is when we will have complications. Healthcare, Beauty, and Wellness are forever evolving therefore we too need to constantly evolve and stay updated which why I enjoy sharing knowledge and learning from others along with various review courses.
Special thanks to Dr. Halim for writing this informative post! I contributed some content to the avoiding complications section. If you have additional tips please comment! If you have questions about what should be in your vascular code cart, please DM or email me. I strongly believe continuing education and training is the backbone to being a safe provider and helps us deliver optimal results. Never stop learning!
I hope you find these guest series helpful and I have many more to come! If you are a provider and would like to write a guest blog post, please direct message me through Instagram or leave a comment below. I'd love to hear from you.
If this topic interests you, I encourage you to follow Dr. Halim on Instagram @azzamdbeauty and visit her website www.azzamdbeauty.com. Until my next blog, I hope everyone stays happy, healthy, and safe!