Understanding complications: Scalp necrosis and temporal lifting
Do you perform temporal lifting procedures with dermal fillers? Have you ever considered scalp necrosis as a complication? If the answer is no, then you do not want to miss this, keep reading.In this blog, Dr Tim Pearce recounts his experience at a recent complications conference where he met a European aesthetic clinician who showed him one of the worst complications he has ever seen, scalp necrosis. He shares more about how this awful result happened, the risks involved when performing a temporal lift procedure, and if we could achieve a similar result with less risk.
Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>
Temporal lifting is not for the faint hearted
Dr Tim first saw this specific temporal lifting procedure discussed a couple of years ago when the published paper was posted on Professor Sebastian Cotofana’s Instagram page. He makes the caveat that in this blog, we are talking about the effectiveness of the temporal lifting procedure and not discussing safety as that was not the intent of the clinical publication.
However, upon seeing this technique demonstrated, Dr Tim’s first thought was that the entry point of the injection is in the exact place you would put a cannula if you were trying to cannulate the superficial temporal artery. He remembers that he did note this in the comments on the post itself, but now wishes that he had made more of it at the time. This is because once he saw the scalp necrosis complication, shown to him at a recent conference, he realised how important it is that we alert other aesthetic injectors around the world that this is not just a case of inject here, achieve a result, and carry on – temporal lifting procedures require much more thought, and this is a particularly dangerous way to inject.
Therefore, there is the argument whether the results that can be achieved warrant the risk of performing this procedure, obviously that is for each clinician and patient to determine themselves.
What is the temporal lifting technique using dermal fillers?
The technique is called the temporal lifting technique and is performed using a cannula. The entry point of the cannula, as demonstrated in the published clinical paper – Clinical validation of the temporal lifting technique using soft tissue fillers – is just pre-auricularly going up towards the scalp. The problem with this entry point, notes Dr Tim, is that it is parallel with the large, superficial temporal artery which makes it extremely risky, especially for less experienced aesthetic clinicians and injectors.
He believes that it is also important to discuss if there is a safer way of achieving the same result for the patient; (if you think the result is worth pursuing for your patient).
It is also vital that we delve into the psychology of a clinician who might see such a post on social media from a world-class, reputable source, and be thinking that it is probably something they should incorporate into their aesthetic practice to keep up with current trends. Dr Tim urges caution and hopes that clinicians will think beyond jumping on any bandwagons and consider the potential risks of new techniques, technologies, and concepts. He warns that new ideas are often not well tested, and with experience you learn that something new comes along, that seems amazing, and everyone wants to try it, but then they find out later that it does not work or is very risky – remember hyaluron pens anyone? His advice is to wait and think things through before you implement something new into your practice and skill set.
In this case, as it is a published technique, Dr Tim surmises that clinicians may feel much more confident to try it themselves, when in fact they should err on the side of caution. Remember, the study was not an assessment of risk, but an assessment of effectiveness of the technique.
Can the temporal lifting technique be performed safely?
To answer that question, we need to think probabilistically about the risk. It is likely that you could perform the procedure today and not cause a vascular occlusion (VO). You could carry out ten of them, very carefully, and still not cause a VO.
Vascular occlusion is a rare event, no matter how terrible the injector’s skills may be – it is quite difficult to get a blood vessel full of filler. However, if you take a particular aesthetic procedure and let a hundred thousand practitioners perform it, they are all going to have different risk profiles in terms of frequency of complication and different risk profiles for severity of complication – these two factors are often confused.
When it comes to the temporal lifting technique, Dr Tim dislikes the procedure as it is a high-volume injection, in a small area, and in a place where it is very difficult to check for capillary refill because it is in the scalp, therefore diagnosis of a VO will be delayed.
The technique uses a long cannula to get to the location for filler deposition, thus aspiration will be less effective, and the mobility of the cannula will be less natural, even if you are not in a vessel. You will be required to push, relatively hard, to get the cannula into place and this experience will be different with each case because every patient is different.
All these considerations line up for the worst possible outcome to be more frequent – that being a large bolus of filler entering into the superficial temporal arteries, blocking blood supply to the scalp, and permanently scarring the pat
The case study shown to Dr Tim at the complications conference highlighted the shocking nature of such an injury; the woman had a deep necrotic wound that destroyed her ability to grow hair, with no opportunity for hair replacement surgery to benefit the patient post healing. She will be scarred for life, and such an injury, with complete loss of approximately a third of the hair growth on her scalp is quite damaging for an individual and their quality of life.
This is not to say that there is no place for this procedure, however; Dr Tim is of the opinion that we should be weighing up this potential downside as a significant reason to consider not carrying out the procedure or being very selective with the patients chosen. It should not be recommended to every patient who wants a 1–2-millimetre lift at the
Think before you jump on the bandwagon with a new procedure or technique
Dr Tim provides his take home message after reviewing the clinical paper on the temporal lifting technique and seeing a case of a scalp necrosis as a complication.
- Just because something can be done does not mean that you should try it.
- Just because it has been validated in terms of efficacy or results does not mean it has been validated in terms of risk – we must thoroughly think through the likelihood of injury with any procedure, especially where evidence is lacking.
- Just because it is effective does not mean it is a good idea for every or any patient.
- Just because it is performed a certain way does not mean there is not a safer way to do it – in this case, anything that is not parallel with the arteries is likely to be safer than this described entry point.
- Do no rush into doing something just because it looks deceptively simple in an online post, take things slowly, think them through, and get expert training before you try a new procedure.
What did you think when you first saw the temporal lifting technique? Were you excited to try it or were you thinking that it looks too dangerous? Let Dr Tim know your experience and opinions, you can find Dr Tim Pearce on Instagram.
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Aesthetics Mastery Show
The worst complication I’ve ever seen | Scalp Necrosis
In this episode, Dr Tim talks about one of the worst complications from a temporal lift he’s ever seen. Dr Tim shares more about how this awful result happened, the risks involved when performing a temporal lift procedure and if we could achieve a similar result with less risk. Watch the full Aesthetics Mastery Show here.
Jessica Nunez is among the many practitioners who commented on the video. She said:
“Hi Dr Pearce, I’ve seen this procedure performed for temporal filler. It’s not something I’ve done because I’m always concerned about the safety of the patient. Thanks for posting this video:)”
Read more and join in the debate on our YouTube channel.
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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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