Efficacy and Safety of Fillers, Chemical Peels, and Laser Skin Resurfacing

The third most common cosmetic procedures in the U.S., each done nearly a million times a year, are chemical peels and laser skin “resurfacings” to create a “controlled injury to the face.” The reasoning is that the regeneration, repair, and remodeling of the damage can result in a more tightened appearance, but may or may not actually help with wrinkles. The inflammation caused by these types of facials causes edema (fluid retention) in the face that, because of the swelling, can cause a transient improvement in the appearance of fine wrinkles, but in the end, may do more harm than good. Short-term side effects include bruising, swelling, itching, crusting, redness, infection, acne, and milia (little white cysts). Long-lasting side effects can include persistent redness, pigmentation changes, and scarring.

The second most common cosmetic procedure, after Botox, is volumizing injections of soft tissue fillers, carried out about three million times a year in the U.S. alone. Studies show subjective patient satisfaction is often high, though long-term efficacy data are lacking because people tend to undergo subsequent procedures. Adverse outcomes occur in about 1 in 40 procedures, most commonly bruising, discoloration, or unsightly lumps and bumps. Lumps are the most frequently reported adverse event reported to the FDA, followed by infection. It’s important to not apply makeup or otherwise touch the injection sites for at least four hours to prevent introducing bacteria into the needle tracks.

The most devastating filler complication is permanent blindness due to an accidental injection into an artery, which can cause skin necrosis, but most seriously can cause an embolus that lodges into the ophthalmic artery and cuts off blood flow to your retina. This is exceedingly rare, on the order of 1 in 1,000 nose injections, for example, and in nearly all the cases the vision loss was only in one eye.

There are some factors that mediate the blindness risk. Autologous fat injections—when they inject your own liposuctioned fat—seem to be the riskiest, since they use a larger volume and needle, though other facial injections, including platelet-rich plasma, have also resulted in irreversible vision loss. To prevent this, medical personnel are always taught to aspirate a bit first, pull the plunger on the syringe back to look for that red flash of blood that would indicate you’re in an artery. Unfortunately, this can give a false sense of security, as tiny movements of the needle can change its position.

The highest risk area is the glabella region, the skin between the eyebrows and over the nose. Unfortunately, there does not appear to be a safe zone since there’s a rich web of connections among arteries throughout the face. Though blindness from filler injections have been said to occur in any location on the face, there do not appear to be any cases arising solely from lip augmentation.

Like with Botox, these days a large fraction of filler injections are done by non-healthcare professionals in a medical spa-type setting. This raises concerns about illegal (non-FDA approved) fillers. There are reports of injections with everything from rubber cement to fix-a-flat, resulting in disfigurement and even death.