Post-Procedural Adverse Events
Common, mild immediate adverse events, such as swelling and tenderness at the treatment site, or redness, bruising, and pain are transitory in most patients. Swelling and bruising are most common around the eyes and the neck. Use of ice packs or cold air to the affected areas is effective for edema.9 Bruising or hematoma formation is usually mild and will fade without intervention in 7-10 days. Use of pain medication is dependent on the patient and is at the discretion of the physician. Persistent pain can be an important marker of an evolving vascular occlusion event and should be followed-up.9
In the weeks following laser treatment, PIH can develop in dark skinned individuals. Few studies show whether PIH can be prevented or minimized. In a split face study of 40 patients of Asian descent with SPT IV, short-term use of post-operative topical corticosteroids reduced the risk of PIH following fractional CO2 laser for acne scars. Both sides of the face were treated with petrolatum while one side also received 7 days of post-operative 0.05% clobetasol ointment. Assessments at 2 and 3 months showed significant reduction in PIH in the side of the face treated with the steroid ointment.47
Delayed adverse effects after filler injections include pigment change, nodule formation, and infection. Different patterns of pigment change provide clues for etiology and treatment. The most common type of pigment change, PIH, is brown in hue and is the result of skin trauma. Although this often resolves in several months, strict sunscreen use with hydroquinone treatment and facial peels can hasten improvement.45 Although uncommon, reticulated brown-red discoloration can occur a couple months later at the site of hyaluronic acid fillers. This represents a hypersensitivity reaction to the hyaluronic acid filler.48 Pigment changes are unresponsive to hydroquinone and to laser treatments with Nd:YAG 1064 nm. The brownred hyperpigmentation will respond to hyaluronidase treatment, which dissolves the hyaluronic acid.48 This type of hypersensitivity reaction has not been seen with fillers composed of hydroxyapatite or poly-L-lactic acid.4
A different pigment change, consisting of a slate gray appearance, can occur due to hemosiderin deposition in the skin.4 The hemosiderin comes from extravasated red blood cells. Hemosiderin associated pigment does not respond to bleaching agents. It will respond to Q-switched Nd:YAG laser treatments over several months. If laser therapy is not helpful, hyaluronidase can be tried.4,48
Operator skill and experience, literature-backed choice of treatment, and careful pre-procedural patient education and periprocedural management will reduce the risk of adverse outcomes following aesthetic procedures in people with SOC. The current algorithm aims to use available evidence to underscore nuances in SOC that should be considered to optimize outcomes of medical aesthetic treatments.
Common, mild immediate adverse events, such as swelling and tenderness at the treatment site, or redness, bruising, and pain are transitory in most patients. Swelling and bruising are most common around the eyes and the neck. Use of ice packs or cold air to the affected areas is effective for edema.9 Bruising or hematoma formation is usually mild and will fade without intervention in 7-10 days. Use of pain medication is dependent on the patient and is at the discretion of the physician. Persistent pain can be an important marker of an evolving vascular occlusion event and should be followed-up.9
In the weeks following laser treatment, PIH can develop in dark skinned individuals. Few studies show whether PIH can be prevented or minimized. In a split face study of 40 patients of Asian descent with SPT IV, short-term use of post-operative topical corticosteroids reduced the risk of PIH following fractional CO2 laser for acne scars. Both sides of the face were treated with petrolatum while one side also received 7 days of post-operative 0.05% clobetasol ointment. Assessments at 2 and 3 months showed significant reduction in PIH in the side of the face treated with the steroid ointment.47
Delayed adverse effects after filler injections include pigment change, nodule formation, and infection. Different patterns of pigment change provide clues for etiology and treatment. The most common type of pigment change, PIH, is brown in hue and is the result of skin trauma. Although this often resolves in several months, strict sunscreen use with hydroquinone treatment and facial peels can hasten improvement.45 Although uncommon, reticulated brown-red discoloration can occur a couple months later at the site of hyaluronic acid fillers. This represents a hypersensitivity reaction to the hyaluronic acid filler.48 Pigment changes are unresponsive to hydroquinone and to laser treatments with Nd:YAG 1064 nm. The brownred hyperpigmentation will respond to hyaluronidase treatment, which dissolves the hyaluronic acid.48 This type of hypersensitivity reaction has not been seen with fillers composed of hydroxyapatite or poly-L-lactic acid.4
A different pigment change, consisting of a slate gray appearance, can occur due to hemosiderin deposition in the skin.4 The hemosiderin comes from extravasated red blood cells. Hemosiderin associated pigment does not respond to bleaching agents. It will respond to Q-switched Nd:YAG laser treatments over several months. If laser therapy is not helpful, hyaluronidase can be tried.4,48
Operator skill and experience, literature-backed choice of treatment, and careful pre-procedural patient education and periprocedural management will reduce the risk of adverse outcomes following aesthetic procedures in people with SOC. The current algorithm aims to use available evidence to underscore nuances in SOC that should be considered to optimize outcomes of medical aesthetic treatments.
LIMITATIONS
Statements used in the algorithm are based on a combination
of data and expert opinion. While alternatives for periprocedural
measures for laser, nonenergy and injectable cosmetic
procedures in patients with SOC are possible, the algorithm
represents best practices developed from a panel of expert
clinicians supported by peer-reviewed literature. However, there
is a lack of literature for periprocedural measures for cosmetic
procedures specifically for people with SOC.
CONCLUSIONS
Patients who desire aesthetic procedures deserve high-quality
care administered by an experienced provider. The aim of the
new algorithm presented here is to develop a clinical pathway
that establishes an informed decision-making, stepwise process
for optimal periprocedural care in patients with SOC who
undergo laser, nonenergy, and injection aesthetic procedures.
Prevention includes sun avoidance and use of sunscreen with
an SPF of at least 30. Oral viral prophylaxis is recommended for
those with a history of HSV-1 and should be considered in those
who undergo ablative procedures. Longer laser wavelengths
and techniques to avoid excessive skin injury are recommended.
Fewer injections and slower injection speeds will reduce risks
with aesthetic fillers. Pre- and post-procedure topical agents
such as topical corticosteroids, hydroquinone/other bleaching
agents, photoprotection, or adjunctive stabilized HOCl, may
help improve treatment outcomes in patients with SOC.
DISCLOSURES
The authors disclose receipt of an unrestricted educational
grant from Swiss American LLC for support with the research of
this work and also received consultancy fees for their work on
this project. Komel V. Grover is an employee of Swiss American
CDMO All the authors developed the manuscript, reviewed it,
and agreed with its content.
REFERENCES
1. 2021 Plastic Surgery Statistics Report. American Society of Plastic Surgeons. Accessed [DATE]. plasticsurgery.org/documents/news/ statistics/2021/plastic-surgery-statistics-full-report-2021.pdf.
2. Taylor SC. Skin of color: biology, structure, function, and implications for dermatologic disease. J Am Acad Dermatol. 2002 Feb;46(2 Suppl Understanding):S41-62. doi:10.1067/mjd.2002.120790. PMID: 11807469.
3. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol. 2016;74(3):584-587. doi: 10.1016/j.jaad.2015.10.044.
4. Quiñonez RL, Agbai ON, Burgess CM, Taylor SC. An update on cosmetic procedures in people of color. Part 1: Scientific background, assessment, preprocedure preparation. J Am Acad Dermatol. 2022 Apr;86(4):715-725. doi:10.1016/j.jaad.2021.07.081.
5. Gold MH, Andriessen A, Cohen JL, et. al. Pre-/postprocedure measures for laser/energy treatments: A survey. J Cosmet Dermatol. 2020;19(2):289-295. doi:10.1111/jocd.13259.
6. Gold MH, Andriessen A, Goldberg DJ, et. al. Pre-/postprocedure measures for minimally invasive, nonenergy aesthetic treatments:
2. Taylor SC. Skin of color: biology, structure, function, and implications for dermatologic disease. J Am Acad Dermatol. 2002 Feb;46(2 Suppl Understanding):S41-62. doi:10.1067/mjd.2002.120790. PMID: 11807469.
3. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol. 2016;74(3):584-587. doi: 10.1016/j.jaad.2015.10.044.
4. Quiñonez RL, Agbai ON, Burgess CM, Taylor SC. An update on cosmetic procedures in people of color. Part 1: Scientific background, assessment, preprocedure preparation. J Am Acad Dermatol. 2022 Apr;86(4):715-725. doi:10.1016/j.jaad.2021.07.081.
5. Gold MH, Andriessen A, Cohen JL, et. al. Pre-/postprocedure measures for laser/energy treatments: A survey. J Cosmet Dermatol. 2020;19(2):289-295. doi:10.1111/jocd.13259.
6. Gold MH, Andriessen A, Goldberg DJ, et. al. Pre-/postprocedure measures for minimally invasive, nonenergy aesthetic treatments:
