Kimberly J. Butterwick, MD, is a dermatologist in private practice in San Diego. Her blog will focus on issues related to cosmetic dermatology.

BLOG: ASDS discussions include Kybella injection techniques, potential blindness from fillers

The recent American Society for Dermatologic Surgery annual meeting had record attendance and a packed program featuring new technologies, videos, live demonstrations, and plenty of practical tips and pearls. 

There were several lectures about Kybella (deoxycholic acid, Allergan), which was recently FDA approved for submental fat; potential blindness from fillers; body contouring; and various combinations of technologies and fillers to optimize patient results. There was time for discussion at many sessions, during which some issues were debated.  

Some pearls and debated issues are included below.

Kybella injections:  Several people talked about ways to minimize post-operative swelling including oral prednisone 20 mg po x 2 days (Tina Alster, MD) or injecting triamcinolone to the treatment  area at the same time. 

There was debate about the use of steroids with Kybella, however, due to the possibility that inflammation may be part of the therapeutic response; it was argued one would not want to blunt that effect. 

Many have begun to taper the quantity of the recommended injection (0.2 cc) at the edges of the treatment areas and increasing the interval between treatments as inflammation may still be present at one month.  Many use intralesional lidocaine 0.1% or marcaine to reduce the pain or ache after injection and others feel this is unnecessary. 

Some speakers noted a side effect of alopecia in the beard area after Kybella treatment.  The effect was temporary in cases that were presented, but male patients need to be warned if they have a beard as it may last as long as 4 months. 

There was an overall positive buzz about Kybella with patients tolerating the side effects and being quite satisfied with the results. 

Many have seen impressive skin tightening as the fat is reduced, although there was caution about exposure of the platysma bands after the fat is removed.  Patient should be advised of this as well.

Blindness from fillers:  This potential rare but devastating adverse event was addressed throughout the meeting during several lectures and demonstrations. 

Because there are many communications between the external and internal carotid systems, the injector must always be on guard.  Slow injections with minimal pressure on the plunger, small injection quantities, and moving the needle in a retrograde manner was advised as well as thorough knowledge of the vascular anatomy and potential danger zones. 

Cannulas are often used in danger zones in the medial cheek, tear troughs, and upper nasolabial fold areas. 

The temple has a vulnerable vessel, the middle temporal vein which may communicate with the internal carotid system. Deep supraperiosteal injections are safest in this area. 

Should a patient experience sudden blindness or impending symptoms, various scenarios were discussed.  Injectors should have on hand a referral source to a retinal specialist and/or should learn how to flood the orbit with hyaluronidase.  

Some indicated there was a 90 minute window to treat these patients, but Ebby Elahi, MD, an ophthalmologist from New York, stated if the retinal artery is occluded, the damage happens immediately and is not reversible. 

The recent Dermatologic Surgery article by Beleznay et al (October 2015) was referenced many times and is an excellent resource and includes a reference on the technique for retrobulbar injections of hyaluronidase, 300-600 units. 

I will offer practical tips and pearls from the ASDS meeting lectures on body contouring and various combinations of technologies and fillers to optimize patient results in my next blog entry.

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