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Filler: everything we thought we knew is only halfway true

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Safety is one of your top priorities when it comes to getting treatments like Botox and fillers. But how do you evaluate whether your provider and their techniques are, in fact, safe?

I saw a patient recently who had been treated by the same provider with Botox for years. She’d felt comfortable and safe. More recently, she began to dip her toe into treatment with filler.

Following her treatment, the patient was not entirely satisfied with her result, and sought evaluation at another clinic that had access to ultrasound. She was informed that everything looked fine, and there was no need to dissolve.

Finally, she came to me. Having just been at a cadaver dissection workshop literally the day before, I knew from across the couch that the filler was not placed appropriately. I looked with my ultrasound, and sure enough it’s in the wrong spot.

She looked at me imploringly and said, “tell me the truth. Did this happen because she didn’t have the right training?” You might be surprised to hear that my answer was no.

The field of medical aesthetics is only about 30 years old. When compared to fields like general surgery and orthopedics, that is a blip in time. Research is constantly being done to determine what is safe, what gives the best results, and to define best practices in the field.

Even just three years ago, I was taught things I now disagree with. I believe the patient’s provider had adequate standard training and did the injection as safely as she knew how. But the field has changed and that can no longer be the standard.

I began using ultrasound in my practice almost two years ago. I had experience using ultrasound as a nurse anesthetist, doing nerve blocks and central line placements, so I felt confident it was a skill I could apply to aesthetics, although I did not yet feel confident evaluating the structures of the face or aesthetic treatments.

In order to gain fluency, I began doing ultrasound assessment of every filler patient before and after treatment. I knew that with practice I would feel increasingly comfortable using the ultrasound as a tool, and assessing what I saw with it.

After about six months of practice, I took an ultrasound course for facial aesthetics to hone my skills. But I knew that daily practice would still be the most important thing I could do to gain expertise. So I continued scanning every filler patient.

What I saw during that time really surprised me. I found that most people’s blood vessels do not lie where the textbooks say they should. That most of the treatments I’d learned were “completely safe” were indeed only safe about half the time. I began adjusting my techniques accordingly.

This past weekend, I traveled to Oregon to learn from Julie Bass Kaplan, a world leader in aesthetics and its application of ultrasound. She confirmed what I had been sensing for over a year–almost everything we thought we knew about filler injections was only about halfway true.

When the patient above left my office, my heart ached for her. Her complication is mild and treatable, but my heart ached at the near impossibility of her being equipped to determine whether a provider is “safe” or not. Even the clinic she’d visited with ultrasound had lacked the ability to correctly identify her complication–and I know they have had training, but have they had regular practice?

Please don’t think that I’m arrogant. Complications can happen to every provider. That is why I feel compelled to be an early adopter of ultrasound, to use it frequently, and to seek ongoing education on how to use it better.

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