Hyaluronic acid Dermal Fillers Patient Leaflet and Aftercare

What are hyaluronic acid dermal filler injections?

Dermal filler injections are administered using a small needle, a cannula or both. Dermal fillers usually come packaged in a box that contains sterile needles, product labels and a pre-loaded syringe that should be opened from its sterile packaging in front of you at the beginning of the treatment. The product label will include the name of the product, the batch number and expiry date. This will be documented on your treatment records and should be provided to you on request. The syringe will contain a clear gel like substance, which consists of a water-based carrier gel, hyaluronic acid, and may contain lidocaine, which is a local anaesthetic to make the treatment more comfortable. Hyaluronic acid is a naturally occurring substance, which is a major component of our skin and has a function in wound repair, hydration, and cell to cell communication. One of the main characteristics of hyaluronic acid is that it effectively binds water like a sponge, which is why it is an effective tissue filler.

There are over 60 different brands of filler available within the UK and many more worldwide, but some have better safety profiles than others. Individual brands differ in the properties of the filler, including particle size, concentration and cross-linking which affects their resistance to degradation (how long the filler will last), elasticity and volumising effect. Most brands will have several products in their range to enable treating different areas, ranging from softer fillers to treat fine lines and lips to firmer fillers to provide contour and shape.

Make sure you ask what brand of dermal filler your practitioner will be using and why.

What areas can be treated?

Dermal fillers can be used in most areas of the face and some areas of the body, including the neck, décolletage, back of the hands and genital areas. Technique is important and practitioners generally classify treatments as basic, intermediate or advanced. Ensure your practitioner is appropriately trained and experienced in the area you would like treating.

Commonly treated areas include:

· Nasolabial folds (nose to mouth lines)

· Upper and lower cheeks

· Oral commissures (corners of the mouth)

· Marionette lines (lines below the mouth corners)

· Lips

· Tear trough (hollowness beneath the eyes)

· Smoker’s lines (area above and below the lip)

· Jaw line

· Jowls

· Chin

· Nose reshaping

· Temples

Ensure your practitioner is trained and experienced in treating the area of concern.

How does it work?

During normal ageing, the fat compartments of the face lose volume and the ligaments holding them in place become weaker leading to a sagging appearance. Hyaluronic acid dermal fillers are extremely ‘hydrophilic’ or water loving. When they are injected, they boost the skins volume, so the area becomes revitalised and volumised. By placing the dermal filler in specific anatomical positions, this can also create a lifting effect. Adding volume helps to address issues such as volume loss, laxity and sagging of the skin, having a positive effect on lines and wrinkles. They can also be injected directly beneath lines to help soften and improve them.

Hyaluronic acid dermal fillers are injected using a small needle, a cannula or both and creates an instant filling out effect. Your practitioner should discuss what areas you would like treating and specific risks based on the treatment area, product used and your medical history. Most syringes contain 1ml of hyaluronic acid and often more than one syringe will be required to produce the desired result. This may be performed at the same time or at a later treatment session which should be discussed during your consultation.

Is it painful?

Most dermal filler injections contain a small amount of lidocaine, which is a local anaesthetic to help reduce any pain experienced during the procedure. Even with the addition of local anaesthetic, it is not a pain free treatment and it will depend on the injection technique, whether a cannula or needle is used and the individual’s pain tolerance.

In some circumstances, a topical anaesthetic, such as LMX4 or Emla™, may be used to provide additional pain relief, particularly when treating more sensitive areas, such as the lips. This will be applied to the skin and left on the surface for 20-40 minutes to take effect.

Once the anaesthetic has worn off, there may be some tenderness which is expected, but you should not experience a significant degree of pain. If you are experiencing considerable pain after the treatment, you must contact your practitioner as this could indicate that you are developing a complication.

Is it safe?

Hyaluronic acid is a naturally occurring substance present in the skin and the product itself is considered very safe, when it is has been purchased from a reputable pharmacy or supplier. Counterfeit products have been found in general circulation which do carry a much higher risk of adverse events, so it is important to seek a practitioner who can verify the source of the product.

Side-effects may be more likely due to the following factors:

· Patient factors: Condition of the skin, age, certain medical conditions, certain medications.

· Practitioner factors: Training, years of experience, number of procedures performed.

· Premises factors: Suitability of the premises.

There are certain risks from dermal filler treatments which should be discussed during your consultation.

We recommend that treatments are performed in a suitable clinical environment.

Possible adverse effects include:

· Pain: You may experience some minor tenderness or discomfort post-treatment. If you do have more pain than expected, it is important to contact your treating practitioner immediately as this may indicate a complication, such as a vascular occlusion.

· Redness: This is normal and usually resolves quickly. If the treatment area becomes red a few days after treatment, particularly if heat is also present, this may indicate an infection and you need to contact your practitioner straight away.

· Swelling: Some swelling or oedema is normal after treatment and may be worse the following morning after the procedure. However, persistent swelling should be reported to your practitioner as there may be treatment to help relieve this.

· Bruising: As the procedure involves injections in the skin, bruising is a common finding. This can be anything from a small mark on the skin to extensive bruising which extends beyond the area treated and can take up to two weeks to resolve. Rarely, bruising can lead to permanent staining of the skin.

· Infection: Your treatment should be conducted in an appropriate clinical environment, your practitioner should adhere to infection control protocols and you should receive appropriate aftercare advice to lessen this risk. Infection often develops as a warm, red, swollen area over the area that has been injected a few days after your treatment. If this occurs, make sure you contact your practitioner for a review as soon as possible.

· Herpes (Cold sores): Treatment around the lip area can exacerbate an outbreak of herpes, which may be worse than a normal outbreak and may require treatment from your practitioner. The ACE Group World recommends that preventative medication may be required for certain treatments in people who are prone to cold sores. It is important that this is discussed as part of your medical history.

· Lumps: Lumps may be present immediately after treatment due to product misplacement or migration or a lump may appear several weeks or months later in some cases. Lumps may appear as soft swellings or as hard nodules. They sometimes occur following an acute illness, such as a dental or sinus infection, or with exposure to excessive sunlight. If you develop a lump, it is recommended to arrange a face to face review with your treating practitioner.

· Vascular Occlusion: This is a rare, but serious, complication from dermal filler injections. In this situation, your blood supply may have been compromised by filler that has caused a blockage or obstruction of normal blood flow. If this is not correctly managed, the skin and tissue supplied by the blood vessel does not receive sufficient oxygen and can result in tissue loss, scarring and secondary infection. A vascular occlusion will normally cause severe pain, an irregular change in colour of the area treated and poor capillary refill (a test performed by your practitioner to see if the blood supply has been compromised). It will often appear immediately during treatment or soon afterwards and once this has been identified, your practitioner should have the necessary products at hand to effectively manage this.

· Blindness: This is an extremely rare and devastating complication that can occur with dermal filler treatments. There are certain areas of the face that pose a higher risk if they are injected, although it can occur from any facial dermal filler procedure. This should be discussed during your consultation with your practitioner, because if blindness occurs, it is likely to be permanent.

· Stroke: Another extremely rare, but documented complication of dermal fillers.

If you develop any unexpected side-effects after treatment, it is important to contact your practitioner for a review as soon as possible, as they may be able to offer some corrective treatment. Although your practitioner may contact you by telephone or video call initially or you may send your own photographs, this is no substitute for a face to face review to provide an accurate diagnosis.

Your practitioner should provide you with an out of hours emergency number.

What does the procedure involve?

Prior to your treatment you should be given a full consultation, complete a medical questionnaire and be offered a cooling off period to enable you to make an informed decision with full disclosure of the possible risks and side effects specific to you. You should also be given an indication of the cost of the treatment. Before you receive any treatment, you will be required to sign a consent form, this may be on paper or electronic, and be given the opportunity to ask any further questions. Photographs should be taken and kept as part of your medical record. These should not be used for any other purpose without your explicit permission.

Do not feel pressurised or coerced into having treatment at the same time as your consultation.

The practitioner will perform an examination of the area to determine the most appropriate treatment plan. They will advise on what product and how much will be required to perform the treatment as well as whether they will be using a needle, a cannula or both. It is important to have realistic expectations about what dermal fillers can achieve.

If a topical anaesthetic cream is to be used, this will be applied and removed after 20-40 minutes to allow it to take effect. The area to be treated will be cleaned, makeup removed if worn, and then disinfected. If a needle is used, you will experience several pin pricks or a scratching sensation and possibly a mild burning sensation as the product is injected. If a cannula is used, the practitioner may first inject a local anaesthetic to numb the insertion site, this itself can cause a burning or stinging sensation. Cannulas can create an odd pulling or tugging sensation as they are moved into place beneath the skin.

Depending on the treatment area(s) and the amount of hyaluronic acid used, treatment time will often be between 15 to 30 minutes. Following your procedure, the practitioner may massage the area and then clean the skin. Some practitioners might apply a cream post-treatment. Once you and the practitioner are satisfied with the results of the treatment and you have been given sufficient recovery time, you should be given the opportunity to book a follow up appointment and receive aftercare information either in paper form or electronically.

Am I suitable for treatment?

You may not be suitable for treatment if any of the following apply:

· Dermal fillers cannot be given to pregnant or breast-feeding women and is not recommended if you are actively trying to get pregnant or undergoing IVF.

· If you suffer from keloid scarring or have active skin conditions, such as acne or psoriasis.

· If you have certain medical conditions, such as diabetes, rheumatoid arthritis, autoimmune conditions, blood clotting disorders, cancer, immunosuppression (either medical or drug-related).

· If you are suffering from any skin infection in or near the treatment area, including cold sores.

· If you are suffering from any other infection, including dental, throat, ear, chest or sinus infections.

· If you are unwell, including coughs and colds, on the day of treatment.

· If you are taking any medicines which affect bleeding, such as aspirin or warfarin.

· If you have had Roaccutane or isotretinoin in the past 6 months.

· Certain allergies, including lidocaine or bee sting allergy.

· Recent facial surgery or other dermal fillers in the same area.

· Permanent implants, such as silicone implants in the face or pins and plates.

· Previous rhinoplasty, if considering dermal fillers in the nose.

It is important to be honest about your medical history, previous surgery, previous or planned dental treatment and any medication taken so that you can have a safe and effective treatment.

Pre-treatment advice

· Avoid taking anti-inflammatories (such as aspirin, ibuprofen or naproxen) for 3 days prior to treatment (unless this has been prescribed by your doctor) as this increases the risk of bruising.

· Alcohol, fish oils, St. John’s Wort, Gingko Biloba and Vitamin E should also be avoided for 3 days prior to treatment to lessen the risk of bruising.

· If you are prone to bruising, taking arnica orally for a few days prior to treatment may lessen the risk.

· If you are unwell on the day of your appointment, contact the practitioner to reschedule.

· Avoid sunbeds and tanning for 1 week before and after treatment.

· Ensure your practitioner is informed if there are any changes in your medical history or medication taken before receiving any treatment.

Post-treatment advice

After treatment, most people can resume their normal daily activities. Immediately after treatment, there may be some redness, tenderness and swelling at the injection sites. Bruising may be obvious immediately after treatment and may be quite pronounced.

Although there is little evidence, many practitioners advise the following:

· Do not apply make-up for 12 hours after treatment to reduce the risk of infection.

· Avoid saunas, swimming pools and sunbeds until the initial swelling and redness has settled.

· Try to avoid touching or rubbing the treated area until the following day, as you may affect the results of treatment or cause infection, unless otherwise advised by your treating practitioner.

· Avoid extremes of hot or cold and vigorous exercise until the initial swelling has resolved.

· If swelling persists, you may be advised to apply a cool pad to help remedy this.

· Contact your practitioner if you experience any unwanted side-effects.