Editorial Board Forum: Spotting and Avoiding Complications

Do you have any suggestions or lessons learned regarding the management of intra-operative or intra-procedural complications?

Jason N. Pozner, MD: In a solo practice it's easier. In a larger practice SOPs need to be in place so all issues are reported to the medical director. Also provide close care; We bring people back very frequently for follow up to catch things early.

Gregory Buford, MD: For our fillers, we have a treatment policy in place for suspected vascular occlusion. Otherwise, we see very few issues with injectables. We are currently not using any energy-based devices in-office but will be bringing in ThermiRF in the next few weeks. Prior to that, we will be designing safety protocols and other protocols aimed at identifying and treating potential complications.  

Jeanine B. Downie, MD: With intra-procedural complications, it depends. For example, if I am injecting a hyaluronic acid and notice a flash of white, I immediately withdraw the needle and go get Hylenex to inject into the area. Unfortunately, this happened to me two years ago but I was able to rescue the day with hyaluronidase. We also used Nitropaste and had the patient return the next day and two days after as well. She had no occlusion, and wound up asking me to reinject the area, as she was slightly sunken underneath. She is fine and continues to do filler.

Additionally, I will call colleagues with questions when I see an odd complication I have not seen before, like nodules in the lips from something I did not inject. The bottom line is that in many cases I ask the patients to go back to the doctor who injected them with the substance that caused the nodules.

Paul J. Carniol, MD: Early identification and management of complications is obviously important to all of us and can be challenging.  If/as possible early recognition as described by Dr. Downie in her clinical example is important. We will all probably agree in general it is best to be prepared for complications in advance.

Renato Saltz, MD: I am completely paranoid (read the book “Only the Paranoid Survive” by Andrew Grove, fantastic!) and bring patients back very often and document visits with photographs. Our five master aestheticians have been with us for a long time (three since we opened in 2002) and have the same policy. Catch problems early with proper patient reassurance, patient safety, and ultimate patient satisfaction.

Joel Schlessinger, MD: Complications are best avoided and this takes restraint and a very careful approach to which patients you want to care for, especially when dealing with cosmetic issues. I decline about 50 percent of my tumescent liposuction patients for health reasons or concerns about potential complications or dissatisfaction. While some might think that is a bad idea, it lets me sleep at night.  

Over time I have referred more closures to plastics or ENT/oculoplastics as well and that likely avoids complications. When I do have a complication I am very quick to involve colleagues if necessary rather than trying to handle it myself. Most importantly, approaching complications in a positive and proactive manner rather than sweeping them under the rug is perhaps the best thing to do as that trains your team and encourages them to share situations with you rather than trying to handle them alone.

Dr. Saltz: We have team communication with bi-weekly staff meetings (including the surgeon!) to discuss “the good and the bad.” This prevents mistakes or misinformation!

Do you have a policy for dealing with patient-reported complications post-procedure?

Dr. Buford: We handle any concerns as quickly and as efficiently as possible. I have found that it's much easier to bring someone in for a quick look than to try to ignore the issue at hand. We also use email photography as a great way to screen out concerns. We simply have the patient take a picture of the area (e.g., incision) and then email this to us. We can then review the concern and generally get a good idea of whether this is something of urgency. My staff are excellent about weeding out issues vs. non-issues but always err on telling me what is going on.  

Dr. Downie: After chemical peels many times patients will call up and say they have irritation. If it is minor irritation we get them topical cortisone and they follow up in the office several weeks later. If it is significant irritation we may see them as soon as the date that they have called. It depends on that what they are reporting. With other patient complications, it depends on what it is. Laser burns must be seen immediately, filler complications must be seen immediately. Botox complications can be seen within a couple of days. My staff is instructed to tell me about every complication. Sometimes they minimize complications and I need to know about them.

Dr. Carniol: First, we do not define minor bruising as a complication after a minimally invasive procedure. It is our goal to see all patients who report complications beyond minor bruising. Frequently a patient will be concerned about an issue and when we see them it is only minor. For those patients we just reassure them. However, for those who are having a complication this enables us to initiate treatment earlier.

Dr. Schlessinger: I insist on knowing about all of these. The other day we had a person who was concerned about whether she was asymmetric after a filler placement.  The call came in about 20 minutes before I was supposed to leave for a flight and I asked her to come in so I could see her immediately. She arrived and it was clear that the pictures showed asymmetry prior to the procedure, which was reassuring to her. I ended up just making my flight but it was worth it even if I hadn't to make sure she was happy and I didn't worry about it while I was gone.

When a patient experiences a significant side effect—even if it is anticipated and the patient is educated about it in advance—do you do anything beyond medical management of it?

Dr. Buford: Our goal is to provide top notch customer service. To do this, we evaluate each issue on a case-by-case basis and proceed accordingly. I would rather keep a breast augmentation patient happy with a complimentary Botox treatment if that means that they then go on to rave about me to their friends. In the long-run, I simply ask myself what I would want done in that circumstance. I find that a majority of our patients are very realistic and get far less angry because we identify and treat any complications early. They just care that we care!

Dr. Downie: When patients experience significant complications that are expected I call them a lot and I hold their hand through all of it. I definitely offer my time, which they appreciate for the money they spent. Sometimes a free chemical peel/ cosmeceutical product is very helpful.

Dr. Carniol: With any procedure there is a risk of side effects. We discuss this with all of our patients in advance.  If a patient is having a complication we work with them through their complication. We give them TLC if/as needed. However, as side effects, can occur and we discuss this in advance in general we do not give them a free service.

Fill in the blank and explain: The most easily avoided “complication” in aesthetic medicine today is…

Dr. Buford: “Unrealistic Expectations!”

Dr. Schlessinger: Overfilling. I always tell my patients that fillers are like a game of ‘21'.  Once you go over 21 you lose and if you are at 18 it's best to hold!

Dr. Saltz: Avoid false expectations. Use complete detailed informed consent for everything. Have well informed and well trained staff—the entire clinic should have one single message.

Dr. Pozner: Managing expectations; underpromise and overdeliver.

Dr. Carniol: Many times this is an aesthetic complication. Aesthetic trends/styles seem to vary by the geography and demographics of your practice(s). It is important to aim for an aesthetic result that fits the patient demographic and geography. 

Dr. Downie: Overfilling our patients' faces. Despite what patients want, we have to use our cosmetic judgment and make sure their face is balanced. It is very important that our patients look natural and not artificial, and they are relying on us to give them the results that they both want and need.