“Peu, rarement au bon endroit” Michel Pistor
“Мало редко и в нужное место” Мишель Пистор

Mesotherapy complications

Mesotherapy complications and undesirable effects

This chapter is not aimed at frightening or turning doctors and patients away from mesotherapy.

Quite the contrary, a person that is well informed, is well equipped.

For doctors - it is another reason to think about the level of their professional grounding in the sphere of mesotherapy.

For patients - it is another reason to think about confidence to a doctor.

Unfortunately, both doctors and patients fall for the bait of advertising, not taking into account possible consequences.  

As a result, distributors (not always honest) are the winners, and trustful doctors and their patients loose in this situation.

That’s why we wish doctors and their patients to be wise and reasonable in choice of each other, as well as of methods and drugs for mesotherapy. 

Often in order to attract patients, managers of beauty shops announce mesotherapy to be a very efficient method of treatment (rejuvenation) that is absolutely painless and doesn’t have any side effects or complications.

We pity if anybody believes in it. Any efficient method of treatment or drug has side effects and complications. Moreover, the more active a drug/method of treatment, the more expressed the side effect can be.

Doctor’s art is to choose the most efficient method and drug with minimum harm to the patient’s health. And the result must be active for a long time.

Mesotherapy complications occur rarer when the qualification and intellectual level of a mesotherapist are higher. 

As a rule, complications appear when a doctor has low professional training; disregard antiseptic and aseptic rules, uses illegal or non-examined drugs.

Also it’s necessary to not confuse such concepts as complications and undesirable effects!

 

 

 

Often the following effects are ascribed to the complications:    

- painful sensations;

- hemorrhages and hematomas;

- vascular reactions (erythema and leukoderma);

- dotted or linear skin injury;

- detachment of epidermis, etc.

In mesotherapy practice – these are undesirable side effects, pay for the advantages that mesotherapy gives in treatment and prevention of diseases, in correction of aesthetical defects.   

 

Painful sensations

Physiological pain (short-term and moderate painful influence) has physiological importance, because it stimulates emissions of catecholamines and somatotropin, working out of collagen, lipolysis, improvement of perfusion and many others).

Factors, influencing on the painfulness of the procedures:


1. Individual characteristics of a patient:

- threshold of pain;

- biorhythms (season, day, menstruation, etc.);

- stress situation (because often people need medical help exactly during stress);

- psycho-emotional condition and mood for the result.

A course of mesotherapy must be planned taking into account these factors.

2. Mistakes in technique, or necessity to use definite techniques. 

The first problem can be solved by acquiring practical skills, using of needles and regimes of mesoinjector with little traumatic effect.

In second case anesthesia and analgesic methods are more actual.

3. Local stimulation of nociceptors with drugs.

In order to avoid all these effects, it’s necessary to have good knowledge of pharmacology, to use correct local anesthetics in the composition of mesotherapeutic mixtures, or to practice preliminary anesthesia (analgesia) to make the procedure less painful.

 

 

Bleeding, hemorrhages,  hematomas.

 

Local bleeding and hemorrhage are unavoidable reality of injection way of drugs’ introduction (with penetration through basal membrane of skin, where vessels are located). 

Intensity of bleeding and hemorrhages depends on: 

- diameter of a needle or  properties of a vessel (the more diameter a needle has or the more lumen a vessel has, or the more blood pressure is inside it, the bigger area a hematoma has);

- condition of coagulant and anti- coagulant  system of blood of a patient; 

- condition of vascular walls (vessels’  permeability, capillary fragility, for women the period of menstruation has high importance).

Mesotherapy can cause single and multiple hemorrhages or hematomas, which appear to be:

- cosmetological defects, if they are located on the open areas of skin; 

- strong  stimuli for  coagulant and anti-coagulant  systems of blood, immunity, local enzymic processes, reparation processes, synthesis of skin proteins, etc.  

The following measure can help to minimize hemorrhages: 

- correct performance of techniques and methods of mesotherapy;

- usage of atraumatic thin needles, 0,26-0,3 mm in diameter;

- pressing of perforated vessels till full stop of bleeding;

- correct selection of drugs;

- correction of the condition of coagulant system (repeal of  anti-coagulant and anti-aggregant drugs a day before and 2-3 hours after the mesotherapy session);

- improvement of vascular wall and reduction of its permeability (angioprotectors in mesotherapeutic and system way);

- correction of general and local blood pressure (arterial and venous);

- avoidance of penetration of a needle in superficial vessels, etc.

 

 

 

 

 

Change in microcirculation – erythema, leukoderma

 

Even simple mechanical impact to skin usually causes change of  cutaneous covering («white» or «red» dermographism), depending on the predominance of influence of sympathetic or parasympathetic nervous system of a patient.

Mesotherapeutic stimulating of skin receptors is much stronger stimulus that’s why almost all patients can have vascular reactions. 

Often mesotherapy provokes the inversion of vascular tonus (skin paling is against the background of erythema and skin redness is against the background of paleness). This indicates  regulating mechanic influence of meso needle on the receptors of nervous and vascular systems, located in skin, and  influence on nervous system is primary.

Use of vasoactive drugs allows to reach the required result – vasodilatation or vasoconstriction.

Physiological erythema appearing during mesotherapy session usually passes after 20-40 minutes except the cases (under indications or by ignorance) of usage of  vasoactive or stimulating drugs.

Vasoconstrictors are used in mesotherapy only under the strict indications because persistent vasoconstriction can lead to local dystrophy and even skin necrosis.  

Pathological changes of microcirculation must be treated because they can lead to pathology of skin and subcutaneous fat.

 

Mesotherapy complications

Mesotherapy complications can be as follows:

- iatrogenic  (provoked by the actions of medical personnel, for example, a doctor without necessary qualification, not following the rules of antiseptics, not possessing enough knowledge and practical skills in mesotherapy and mesopharmacology, not knowing the peculiarities of mesotherapeutic usage of drugs, at the worst, provoked by the actions of paramedical personnel or cosmetologists not having medical education at all);

  -technogenic (provoked by incorrect use of equipment and techniques of introduction);

- pharmacogenic (provoked by activity of drugs);

- mixed.

Complications can be predictable and unpredictable:

- unpredictable complications are those that can be hardly predicted and that’s why are hardy prevented and treated, appear at the use of mesodrugs of doubtful origin, with unknown composition, not registered as drugs, not accepted officially, not having detailed description and instruction; 

- unpredictable complications are the side effects of drugs in cases of idiosyncrasy, overdosage or unreasonable use, but under the condition of knowledge their full composition (not only active components) because additional components can provoke undesirable reactions from local irritation to  anaphylactic shock.


The most dangerous complications from all possible are allergic reactions of immediate type, which threaten the patient’s life.

There are infectious or infectious-toxic, as well as histotoxic (necrotic) complications that placed on the second position. First local inflammatory reaction (infiltrate, lymphangitis, lymphadenitis, abscesses, and gangrene) can appear, and without adequate help general reactions (sepsis, infectious-toxic shock) can appear after it. 

Complications connected with side effects of drugs are less dangerous for patients. At a good knowledge of clinical pharmacology in general and mesopharmacology in particular, they can be predicted, prevented and in case of their appearance – efficiently treated.

Examples of predictable complications:

Iatrogenias of incompetence:

Use of triiodothyronine:
 
- monopreparations or ready cocktails containing thyroid hormones (triiodothyronine,
triac) are often used at treatment of cellulopathy (cellulite, hudrplipodystrophy, obesity), without preliminary endocrinological examination and indications.

Possible consequences:
 
- thyrotoxicosis;
- manifestation or progression of pathology of a thyroid gland (hyperthyroidism thyroiditis);
- depression of the production of native hormones;
- producing of antibodies which block introduced and native hormones;
- reciprocal inhibition of secretion of thyrotrophic hormone and intensifying of secretion of thyreostatin (triac is used right to suppress  thyrotrophic hormone);
- withdrawal syndrome.

What results does such therapy can have? (Let’s remember bio additive Li Da)

Use of proteins: 

Some therapists introduce collagen, elastin aimed at improving skin turgor. What it can be fraught with?

- allergic reactions are mostly provoked by the proteins, to which class these substances belong;
- protein redundancy (for example, collagen) provokes increase of producing of proteolytic enzyme, in this case –collagenase, which destroys both exogenous and endogenous collagen (this causes primary apparent cosmetic effect, which is changed later for the following dermodystrophia leading to dependence from the introduction of proteine from outside);

- dotted introduction of collagen doesn’t create conditions for its «correct» spreading in connective tissue, because it has high molecular weight that limits its diffusion;

The next example concerns use of a drug phosphatidylcholine which is ascribed to have steatolytic activity. In truth it provokes necrosis of tissues.

Local use of phosphatidylcholine is prohibited al over the world, even in the USA, where it is widely promoted. It is used only for the decrease of local lipopexia (steatoma, lipoma).

 Using of this drug for big areas causes necrosis of tissues similar to necrosis at introduction of calcium chloride to tissues. What happens in the focus of necrosis? Destruction of tissues, i.e. alteration is the first stage of inflammation which is followed by the stages of exudation and proliferation. The result of such process is creation of connective tissue – fibrosis and sclerosis.

What this means for a patient? First he will have pain and edema, then they will be less or even disappear at all, but the process in subcutaneous fat will be continued.

As a result, cellulite will progress later, but in the fibrosing stage,  and later it will be necessary to treat edema, fibro-sclerosis, steatomata.

 Necrotic complications of cellulite treatment with phosphatidylcholine (photo materials from the open foreign resources).

МЕЗОТЕРАПИЯ УКРАИНЫ Курсы, обучение врачей мезотерапии. Осложнение - некроз кожи и ПЖК после мезотерапии с фосфатидилхолином.









Infectious complications

Infect2







The most dangerous for life and health of patients are immediate allergic reactions, including anaphylactic shock, Quincke's edema and  asthmatic status.


Symptoms of anaphylactic shock


The first symptom or even the precursor of development of anaphylactic shock is sharply apparent local reaction in the place of allergen’s introduction in organism – unusually sharp pain, strong edema, swelling and reddening in the place of a drug injection, strong itch spreading fast all over the skin (pruritus generalisatus). At the introduction of allergen orally the first symptoms can be sharp pain in stomach, nausea, vomiting, edema of larynx and oral cavity.

In short time these symptoms are followed with apparent edema, bronchiospasm laryngospasm, leading to harsh heavy breathing. It will lead to tachypnoe, asthmatic breathing. Hypoxia starts. A patient pales, lips and visible mucous tunics, as well as outlimb (fingers) can become cyanotic (blueish). Blood pressure of a patient will goes down quickly and a collapse progresses. A patient can faint. 

Anaphylactic shock progresses very fast and can lead to the death in some minutes or hours after the introduction of allergen into the organism.

Clinical presentation:

At less heavy processing of the shock symptomatology can include the following effects:

 

- felling of fever with sharp hyperemia of skin,

- general excitement or contrary, depression, flabbiness

- anxiety, fear of death,

- pulsing headache,

- noise or ringing in  ears,

- compressing pain behind breast bone,

- skin itch, urticaria, confluent rash,  

- angioneurotic edema (Quincke's type),

- hyperemia of sclera,

- lacrimation,

- stuffiness in nose, rhinorrhea

- itch and tickling in throat,

- spastic dry cough, etc.

 


After prodromic effects there is a fast (from some minutes to an hour) processing of symptoms and syndromes that condition the following clinical presentation.


Pruritus generalisatus and urticaria take place not in all cases. At the heavy cases skin manifestations (urticaria, Quincke's edema) are absent. They can appear 30-40 min later from the beginning of reaction and finish it. It appears that in such case arterial hypotension brakes progressing of  urticaria and reactions in the place of sting. They appear later when blood pressure becomes normal (at going out of anaphylactic shock).

The following symptoms are usual for it: spasm of unstriated musculature of viscera with the clinical manifestations of bronchiospasm (cough, expiratory dyspnea), spasm of musculature of gastrointestinal tract (crampy abdominal pains, nausea, vomiting, and diarrhea), women can also have spasm of uterus (pains in down part of stomach with blood-tinged discharge from vagina).  

Spastic effects are aggravated by edema of mucous tunic of viscera (respiratory and gastrointestinal tract).

 Presentation of asphyxia can progress at the apparent edematic syndrome and the localization of pathological process at mucous tunic of larynx. Phenomena of dysphagia can take place at edema of larynx.  

At systematic allergic reactions heart appears to be the organ-target (direct influence of mediators to myocardium). Patients have compressing pains in heart, tachycardia. Electrocardiogram made during anaphylactic shock and one week after it registers derangements of heart rate, diffusive disorder of trophism of myocardium with it’s further normalization in dynamics.

Hypoxemia and hypocapnia appear at non-heavy anaphylactic reactions.
At the heavy anaphylactic shock hypoxemia as well as  hypercapnia and andacidosis become more apparent,.

Hemodynamic disorders at anaphylactic reaction can have different levels of  severity – from the moderate lowering of arterial blood pressure with subjective feeling of near-unconscious condition to the heavy hypotension with loss of consciousness (for an hour and more).

Such patients have the typical appearance: sharp paleness (sometimes, cyanosis) of skin, sharpened face, cold clammy sweat, sometimes foam from the mouth.

At examination: arterial blood pressure is low or not defined, rapid pulse, cardiac tones are indistinct, in some cases are not heard, accent of the second heart sound can appear above the pulmonary artery.  Rough breath sounds, dry rales are in lungs.   

Tonic and clonic convulsions can appear as a result of ischemia of central nervous system and edema of serous tunic of brain. Unintentional defecation and urination are not rare on this stage.

There is a high possibility of fatal outcome without timely intensive care. However and timely rapid care cant always prevent it.

Treatment of anaphylactic shock

The first measure at anaphylactic shock must be urgent injection of adrenaline - 0.2-0.5 ml of 0.1 % solution hypodermically or better intravenously. Injection of adrenaline can be repeated up to total general dose 1-2  ml of 0.1 % solution for the short time period (several minutes), but in any case it  must be injected with the divided dose.

In what follows adrenaline is introduced as needed, taking into account the short period of its semiejection, depending on arterial blood pressure, cardiac rhythm, overdose symptoms (tremor, tachycardia, muscular twitching). It is not allowed to overdose adrenaline, because its metabolites have the ability to worsen course of anaphylactic shock and to block adrenoreceptors.

Glucocorticoids must be injected after adrenaline. The doses of glucocorticoid necessary to stop the  anaphylactic shock are tens times more than «physiological» doses and many times more than doses used for the treatment of chronic inflammatory diseases. 

Typical dose of glucocorticoids at anaphylactic shock is a 1 «large» ampoule of methylprednisolone (as for pulse-therapy) with the volume of 500 mg (i.e. 500 mg of methylprednisolone), or 5 ampoules of dexamethasone, 4 mg each (20 mg), or 5 ampoules of prednisolone, 30 mg each (150 mg).

Fewer doses have little effect. The necessary dose is defined by the condition of a patient.

Effect of glucocorticoids as opposed to adrenaline, appears not immediately but tens of minutes or some hours later, but it lasts longer.

It is indicated to inject antihistaminic drugs which don’t lower arterial blood pressure and don’t have high own allergic potential: 1-2 ml of 1 % dimedrol or suprastin, tavegil.

Promethazine is contraindicated, because it has as well as all derivatives of phenothiazine the considerable own allergic potential, and besides that it lowers arterial blood pressure that is low enough as it is.

Injection of chloride or gluconate calcium is not only contraindicated but can also affect negatively on the patient’s condition.

There is an indication of the slow intravenous injection of 10-20 ml of 2.4 % solution of aminophylline aimed at taking the bronchiospasm away, decreasing the pulmonary edema and relieving the breath.

In case of need it is necessary to make artificial lung ventilation and external cardiac massage.

A patient with anaphylactic shock must be laid in horizontal position with the lowered or flat (not picked up!) head for better blood supply of brain (taking into account low arterial blood pressure and low perfusion of brain). Apply inhalation of oxygen, intravenous drop-by-drop introduction of physiologic saline or another water-salt solution for the restoration of hemodynamic indices and arterial blood pressure.

Antishock set:

2 tourniquets,

sterile syringes (2, 10, 20 ml),

disposable intravenous system,

5-6 ampoules of each preparation:

- 0,1 % adrenaline solution;
- 0,2 % noradrenaline solution;
- 1 % mesatonum solution; 
- antihistamine drugs;
- 5 % ephedrine solution;
- aminophylline solution;
- 40 % glucose; 
- 0,9 % sodium chlorides solution;
- 150 mg  prednisolone;
- 125 mg hydrocortisone solution;
- 20 mg dexamethasone;

Cordiamin,  caffeine,  corgliconum,  strophanthine in ampoules,  penicillinase  in ampoules,  tongue forceps, mouth-gag,  100 ml of ethanol, cotton,  gauze tampon, scalpel,  oxygenous pillow, tracheostomy or intubation set,  etc.


Mesotherapy tactics

It is necessary to collect the allergological anamnesis very carefully and to make allergic tests.

A patient must stay in clinic minimum 40-60 minutes after the introduction of drugs.

At the suspicion of any allergic reaction, it is necessary to stop the session, to provide dynamical medical supervision. At the confirmation of the suspicions of allergic reaction it is necessary to begin rendering medical aid and at the same time to call an emergency team.

It is necessary to prepare information about the introduced drugs (commercial name of drug/drugs, composition, active and additional components, injected doses, methods of introduction, results of allergic test, etc.).   

Though in mesotherapy heavy allergic reactions are very rare, every doctor must be ready to render emergency medical aid and a patient must be informed about the consequences of mesotherapy (not only about complications but also about possible hematomas and painfulness of the procedure, about behavior during the period of rehabilitation and so on).

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