Nowadays, according to statistics of International Aesthetic and Plastic Surgery associations, the most popular cosmetic mini-invasive procedure is soft dermal filler injection and volume enhancers. Soft tissue fillers are increasingly used for aesthetic purposes for the rejuvenation of the face and selected areas of the body. Various materials are now available that may have different side effect profiles. The goals of aesthetic medicine are to maintain a natural and healthy appearance and to assist patients in looking their best. Another very important aspect is to provide such procedures safely and effectively what need to be certified, experienced and skilled aesthetic medical provider. The clinician must be aware of such risks, to recognize them and treat them properly, and also to be able to prevent them with the use of proper techniques.

Typical associated symptoms of imminent necrosis

The immediate appearance of discoloration postinjection is the typical presentation of vascular ischemia after a filler injection. The "tell-tale" signs of arterial/venous occlusion that could lead to skin necrosis include the following:
• Skin blanching
• Dusky (i.e., grayish blue) skin
• Ecchymosis
• Reticulated erythema
• Intense pain in the treated area

What to do with occlusion and obstacle necrosis

In the event of arterial/venous occlusion and impending necrosis, the goal is to quickly promote increased blood flow to the affected area. Treatment options include the following:
• No ice
• Warm compresses (immediately)
• Massage or tap the area to facilitate vasodilation and dispersion of material
• Aspirin
• Hyaluronidase (only if using HA)
• Corticosteroids
• If ischemia is not reversed and necrosis is unresponsive, contact a plastic or reconstructive surgeon - Subcutaneous injections of low molecular weight heparin may be helpful
• Antibiotics
• Antivirals (if impending necrosis is around the mouth)
• Multiple laser treatments at 3-month postinjection intervals may be necessary

Tips for Injecting Near the ''Danger Zones''

While rare, vascular occlusion and subsequent necrosis and/or vision loss can occur after injecting a dermal filler or volume enhancer; when it does, prompt medical attention is critical to prevent the potential of scarring. Sudden pain and/or blanching are warning signs of vascular occlusion, ischemia, and impending necrosis. It can also present as painless, patchy erythema. Actions that decrease the potential of complications of this nature from occurring include the following:
• Aspirate before injecting
• Inject in a retrograde fashion
• Inject small aliquots of filler/volumizer at a time (too fast, too much, or too deep = trouble); a good rate to consider is less than 0.3 ml/min
• Avoid using anesthesia near a vascular bundle that may induce vascular spasm, such as those containing epinephrine; also avoid using epinephrine so that the cause of blanching can be determined quickly
• Use the smallest gauge needle possible to slow the flow of product
• Pinch/tent the skin to provide more space between superficial branches of main arteries and to move away from underlying vasculature
• Use a reversible product—HA (i.e., hyaluronidase will quickly break down HA fillers)
• Manually occlude the origin of important vessels with the nondominant finger
• If using a nonreversible product (e.g., calcium hydroxylapatite, poly- L -lactic acid, and polymethylmethacrylate), be mindful of the viscosity as one will have fewer options should the product increase pressure around a vessel; this can be mitigated by using smaller aliquots of nonreversible product, and the viscosity can be lowered by premixing with lidocaine solution or extruding through a small-gauge needle
• Inject in a more medial and superficial plane
• Assess pain during the injection
• Keep a watchful eye on.

Conclusion

Because of filler efficacy and safety, and the increase the number of procedures has been accompanied a lot of complications as well. The complication management knowledge is crucial in the field of esthetic medicine, minimizing their incidence by means of appropriate patient, product, and injection technique selection, as well as a sound understanding of facial anatomy, is probably the best approach. Clinicians should be fully aware of the signs and symptoms related to complications and be prepared to confidently treat them.