By Madilyn Moeller

Just like with all medical procedures, aesthetic treatments come with a chance of adverse outcomes, even when providers follow all the proper procedures. The safest med spas are the ones most prepared for complications to occur and ready to resolve them.

Veterans of the profession shared their insight to explain how med spas avoid complications and manage them when they happen to keep patients safe. Below, find their answers to the following questions:

1. What are the most common complications that can arise from popular aesthetic treatments (dermal filler, Botox, laser treatments) and how can these complications be prevented?
2. How do practitioners assess a patient’s medical history and overall suitability to ensure the best outcomes and avoid complications?
3. What safety protocols and best practices do aesthetic providers follow to prevent complications and ensure patient safety during treatments?
4. How important is proper training and medical experience in reducing risk?

Understanding Aesthetic Complications in Med Spas

What are the complications you might see in a med spa?

During a consultation, med spa providers explain to the patient any possible risks associated with the aesthetic treatments they recommend. Usually these start with expected side effects, which might include minor discomforts such as redness, bruising, pain at the treatment site, and swelling. Once an unwanted after-effect slides further on the scale of severity, health care professionals use a different term to describe what the patient is experiencing.

You might be familiar with the term “adverse reactions” from prescription drug warning labels. These are unwanted responses directly caused by that treatment. The adverse reactions listed on the prescribing information for a popular botulinum toxin product include eyelid ptosis, eyelid edema, headache and brow ptosis. Complications, in scientific research, are referred to as adverse events or AEs, with naming adjusted according to severity. So, drooping of the brow after a neuromodulator injection would be considered an adverse event, but vascular occlusion after a filler injection would be considered a complication, and an infrequent one at that.

Why do complications sometimes happen?

Even the most experienced, highly trained injectors will encounter complications over the course of their careers. Facial anatomy is variable, which is why a deep understanding of the underlying structures and vasculature of the face is a critical starting point for aesthetic injectors. That clinical foundation helps them avoid the mistakes that can turn into serious mishaps in the hands of inexperienced providers, and it provides them with the know-how to quickly and effectively manage any complications that do arise in patients under their care.

Patients going to a med spa should be aware of the possibility of complications before receiving aesthetic treatment. This discussion is not meant to discourage anyone from seeking services, but rather to encourage patients to have these conversations with their providers.

“No procedure is without any risks,” says Steven F. Weiner, MD, of Aesthetic Clinique. “So, you have to understand the risk before you start the procedure and the chances of them happening.”

Common Complications from Popular Aesthetic Treatments and How They Can Be Prevented

What are the most common complications from neuromodulator (Botox) injections?

Minor adverse events: drooping of the brow, uneven forehead treatments, crooked smiles

Moderate complications: eyelid ptosis

Complications from an injection of botulinum toxin are short-lived. The medication, when injected properly, is expected to last only three to four months, depending on the product used (Botox Cosmetic, Dysport, Xeomin, Daxxify, Jeuveau). While a patient may have to wait for the toxin’s effects to lighten, the severity of common adverse events from these treatments is low. If one brow is left higher than the other, the aesthetic injector can make adjustments after the fact to help correct any unevenness.

How do injectors prevent these complications when targeting wrinkles?

Prevention starts with knowing the anatomy and performing a thorough patient assessment. For a neuromodulator appointment, providers often take photos of the patients making various facial expressions to track their muscle movement and fine-tune their approach to treatment.

There are a few strategies and techniques during treatment that can help aesthetic practitioners manage the risk of complications. Injectors can more easily prevent drooping when they stay away from the lower forehead when injecting neurotoxin, to avoid being too close to the brow. Injectors also avoid the orbital rim when treating crow’s feet and inject superficially when treating the lateral corrugators (muscle above the brow bone, starting at the inner end of the eyebrow).

What are the most common complications from dermal filler injections?

Minor adverse events: swelling, malar edema, overfilling, migration, poor cosmetic result

Moderate complications: nodules, inflammatory nodules

Uncommon but major complications: vascular occlusion

The most common complications health care providers see after filler injections, after swelling, are affectionately called “lumps and bumps.” A skilled medical professional can determine whether a lump is inflammatory and follow the appropriate treatment protocol. Sometimes this means a course of steroid injections or antibiotics.

Vascular occlusion after filler injection is a serious complication that is estimated to have a likelihood of around 1 in 6,000 treatments. Vascular occlusion, or vascular obstruction, can happen when filler is injected into a blood vessel, blocking the flow of blood and oxygen to the area. Depending on which vessels are affected and how much time passes before the blockage is cleared, a vascular occlusion can lead to tissue death (necrosis) or even heart attack, vision loss or stroke. Medical spas maintain connections with ophthalmologist practices to quickly seek their assistance in the event of filler blocking blood flow to the eye.

Many of the most popular dermal fillers are primarily composed of hyaluronic acid (HA), a naturally-occurring molecule that binds water and helps the skin retain moisture. If one of these fillers is the culprit of an aesthetic complication, providers often use an enzyme called hyaluronidase to break down the hyaluronic acid into smaller particles, partially or fully dissolving the problematic filler. The practitioner injects this dissolver every fifteen minutes or so until the complication has resolved, monitoring the patient throughout this process.

How do med spa providers prevent complications when injecting filler?

Experience and training with the product, understanding the rheology of the product and where to inject it all come into play. With filler injections, practitioners use structures of the face as a guide for proper placement of the product. That product varies greatly in thickness and viscosity, which is something that your med spa provider has taken into account. Lip filler is more fluid, for example, while filler in the jawline or cheeks is sturdier to provide structural support. Those fillers are also placed in deeper layers of the skin, closer to the bone. An injector’s understanding of the planes of the face and the properties of that specific filler help them develop a treatment plan of where to inject.

Depending on the filler used, preferred technique and the risk level of the injection site, med spa providers can also make safety considerations when choosing to inject with a needle or cannula. So many factors go into patient safety when injecting dermal filler, and even the best of injectors can have complications. The important thing is having the skill, experience and training to manage adverse reactions if they arise.

What are the most common complications from aesthetic laser treatments?

Mild adverse events: prolonged recovery periods, results not meeting expectations

Moderate complications: post-inflammatory hyperpigmentation (PIH), hypopigmentation

Redness, swelling, discomfort, itchiness, peeling, and sensitivity are some of the side effects patients can expect after a med spa laser treatment. Pigmentation complications after laser treatment are primarily a concern for patients with darker skin types. The higher concentrations of melanin in darker skin tones absorb more of the energy and become damaged, which leads to lightening or darkening of treated areas.

How do med spa providers prevent complications from laser or energy device treatments?

Conscientious med spa laser specialists know how to use the device and apply the appropriate settings for each patient’s needs. They choose fractional and Nd:YAG lasers for patients with darker skin tones to minimize the risk of damage and PIH, or refer them to other aesthetic practices that have those devices if their med spa is not equipped with that technology. They also select the right candidates for laser treatment and suggest alternative treatment plans when a potential patient is not suited for energy device procedures.

Part of prevention is careful administration of the laser energy. Concentrating the heat in one area for too long, overlapping too much with each pass of the laser device, or “bulk heating” an area of tissue hotter than its ability to handle the heat, can all lead to potential adverse events.

How Med Spas Minimize Complications

Med spas are medical facilities. Medical spas are medical practices staffed with licensed, trained health care practitioners. A physician provides supervision for the practice or, in states that allow independent practice for experienced advanced practice registered nurses or physician assistants, prescribing practitioners take responsibility for developing protocols and delegating treatment. Even for non-medical aesthetician treatments, those providers are licensed, the products are thoroughly vetted and all peels, facials, microdermabrasion and more are performed according to a set procedure. Each of the treatments in a med spa takes a skilled provider to perform, and the training those providers undergo is, of course, based first in patient safety.

As you would find in any proper health care facility, the treatment rooms in a med spa are maintained with the highest standards of cleanliness. A sterile environment is important for infection control during aesthetic procedures, so this effort to minimize complications is healthy for both patients and the med spa’s compliance record with state and federal regulations for medical facilities.

Med spas use FDA-approved medical devices. Med spas, as health care facilities, protect the license of their medical director or supervising physician by using and prescribing only FDA-approved products, technologies and medications. The process of FDA approval is a multi-stage endeavor, with rounds of discovery, research and review to ensure the medical device is safe for the public. Med spas are committed (and obligated!) to make decisions in the best interest of their patients, and that means training providers in the safe use of FDA-approved products.

Med spa practitioners educate patients. While training reduces risk by teaching providers all about the safety of top med spa treatments, responsible practitioners translate all of this into plain language as part of their patient education. A patient’s first appointment before receiving treatment at a med spa is for a consultation with a prescribing practitioner (MD, NP, PA). During that consultation, which in compliance circles is called the good faith exam, the practitioner decides if a patient is suitable for treatment and defines the treatment plan. The patient leaves with an appointment on the books and a leaflet explaining what to avoid in the days before treatment, along with proper care post-treatment.

“There really is no ironclad way to say a hundred percent, ‘You will never have X,’ because what I usually feel about occlusive events, as an example, is that it's like driving a car,” says Hermine Warren, DNP, APRN, CANS, in advice to fellow injectors. “The more road miles you acquire, the more likely it is. It's a when, not an if. You will get an occlusion at one point in your life. But the best thing that an injector can do is to be confident and not dive into a procedure they're not comfortable with. To be slow, to know when they are gonna be getting into trouble, to use all the tools available to help them navigate away from trouble. And to really make sure that your patient is totally in sync with what's going on and what you're doing, and that you set them up appropriately. But there is no ironclad way to say you will never have an adverse complication.”

Assessing a Patient’s Medical History and Suitability for Treatment

What might increase the chances of complications from an aesthetic treatment? Med spa practitioners are trained to spot red flags in a patient’s medical history that would prohibit them from receiving treatment or that could increase the likelihood of an adverse event. The time to ask these questions is during the initial consultation, not when the syringe is in hand.

Cautions in the patient’s medical history

Contraindications for neuromodulator injections: Patients with neurologic disorders are typically excluded from receiving botulinum toxin injections because it may interact with medications they take.

“For instance, say, somebody has a history of epilepsy,” says Warren. “They can certainly get neurotoxin. However, you need to make sure that it's not going to be contraindicated with the medications they're taking. But certain medications for epilepsy would be potentiated with Botox or with Dysport. And so, you have to really understand what their medical history is, and I would say that every patient without exception, before your visit should have a good faith exam performed.”

Contraindications for dermal filler injections: Patients with an autoimmune disease, patients taking blood thinners, and patients taking certain medications will need to be carefully considered for filler treatment.

Contraindications for laser treatment: People with darker skin types will not be suited for treatment with specific wavelength lasers. People who have healing problems, or who have poor protoplasm (are in poor overall health) may not be candidates for laser treatment due to the likelihood of prolonged healing time.

"I always do modifications on my good faith exams, meaning I'll do an initial one, and then every time a patient comes in, I do an update of it to see if their health history is the same, or if it's changed now,” says Warren. “If I know, for instance, the patient's been put on blood thinners, then they need to be informed that yes, they can be injected, but the likelihood of bruising is more likely, because it's a blood thinner. You need to be able to understand what medical conditions will potentiate what you're doing, will disrupt what you're doing, will enhance what you're doing.”

Educating patients on risks and complications

 Patients consenting to receive an elective aesthetic treatment must first be informed of the side effects, expected results and adverse reactions. Without this, they can hardly claim to understand the treatment they agree to sit for.

Med spa practitioners go over all of the crucial details during the consultation. Once the provider has assessed the patient and explained the treatment options, they go into the specifics of what that procedure will entail from the lead-up pre-procedure to post-treatment recovery. Patients should ask any and all questions they have not only about the procedure but about the practitioner’s training and experience in performing the treatment.

“All of those are usually covered by me in my consent forms every time that a patient's going to have either neuromodulators or fillers, because I think it's really important for them to understand what the downsides are,” says Warren. “The, as we call it, BRAs, the benefits, the risks, and the alternative. And I think that you're not being diligent unless you really cover that every time with a patient, and they understand what's going to happen to them and what they're going to get, or what they could possibly get.”

How Med Spas Manage Aesthetic Complications When They Occur

Three main factors influence the likelihood of a complication: The patient, technology and technician. Whether the patient was the wrong candidate, the filler was injected in the wrong plane, the injector was inexperienced, or a combination of these, when a complication happens, blame is not top of mind. In the moment, med spa providers stay calm because they have a plan in place to address this adverse reaction. They communicate with the patient and act quickly to start correcting the problem, conferring with colleagues or specialists in their network as necessary. By following the protocols outlined in the med spa’s standard procedures designed by highly qualified medical professionals, the med spa practitioner steps back into their health care background.

“The complication rate in toxins and fillers and even lasers is very low, but [patients] have to be aware that they occur, and seeking out providers that have the most experience, and not necessarily the least expensive cost is recommended,” says Dr. Weiner. “People with good reputations, and that train other providers and teach courses, are going to be the highest level of care.”

Handling complications during or after treatment

During treatment, med spa providers will observe the skin’s reaction. For filler injections in particular, practitioners repeatedly use the capillary refill test to make sure that blood continues to flow everywhere it is supposed to and that no vessels have been blocked with filler product.

Suppose a nodule pops up after filler injections. The aesthetic practitioner will assess the skin condition and determine whether the lump is inflammatory. Sometimes filler can be massaged to smooth lumps and bumps away, and non-inflammatory nodules can be resolved with minimal fuss. If the nodule is identified to be inflammatory, the practitioner will initiate treatment in line with the protocols that the med spa has in place specifically for that complication. After the complication has been resolved, the practitioner will meet again during follow-up appointments to monitor the patient’s healing. Throughout the situation, the med spa will be in constant communication with the patient.

“In areas that are high risk, I will evaluate with ultrasound prior to assess the vascular anatomy and structures,” says Dr. Weiner. “I will evaluate prior filler using the ultrasound, so that I have an idea of what has already been injected. There are certain times where you don't want to inject when they have certain types of fillers, particularly silicone. If you see that on ultrasound, you don't want to be injecting these patients.”

Safety protocols that med spa practitioners follow

Med spas prepare for aesthetic emergencies by following facility safety protocols and the standard procedures outlined by the practice’s supervising practitioner. This complication prep is simply part of the standard of care expected in any safe med spa.

Med spas retain a list of current contact information for local emergency centers and other aesthetic practices in the region, along with specialists who have agreed to provide assistance in an emergency. A medical spa’s crash cart, or emergency kit, is routinely stocked and checked to make sure it includes all the necessary equipment to respond to a medical emergency.

Proper protocol also involves thorough documentation of everything that is discussed, any photographs taken, signed forms and waivers, written records of dosage and treatment areas, and any other details involved in the patient’s treatment. These details are standard in medical practice, and they can also serve as a reference if a patient seeks care elsewhere in the future.

“I have a whole list of protocols for everything that I do,” says Warren. “And it's been collaborated with me and the physician I work with. And it basically starts from the very beginning where you're talking to the patient about the product, and it goes all through how you would inject; what you would inject with; what type of needle you would use; would you use a cannula, or a needle, or both; what you would do if there's a complication. And I follow those protocols and they're constantly updated on a yearly basis because things change in our business all the time.”

Best practices to avoid complications from popular aesthetic treatments

Warren has been injecting for over almost 21 years and says she is still learning, still becoming the best injector she can be.

"What creates, for me, the best outcomes,” says Warren, “is really being very cautious, taking my time. Making sure that the skin is extremely clean and just, being slow. Slow and steady wins the race. Aggressive injectors usually will have a lot more adverse events.”

Dr. Weiner prefers to use cannulas when injecting filler due to their safety profile relative to needles. He constantly moves the cannula while injecting in small linear threads.

“It's also knowing the layers of the face and the SMAS layer and determining whether you're going to be injecting above or below the SMAS for safety concerns,” says Dr. Weiner. “Also, knowing with the rheology of the filler to know which planes are best for which particular filler types. Putting the wrong filler in the right plane isn't necessarily appropriate. You don't have the optimal results when you do that.”

Importance of proper training and medical experience

A skilled aesthetic practitioner has a thorough understanding of facial anatomy, which is crucial for avoiding issues like vascular occlusion. Knowing the ins and outs of facial structures helps ensure the procedure is safe and effective, and in the rare case that complications do arise, a qualified medical provider will be prepared to recognize and address the issue quickly, preventing it from becoming a bigger problem. For that reason, med spas employ licensed, well-trained professionals and continually train their teams to enhance patient safety.

“I think every person should at least have a year minimum of nursing in either medical or surgical, that they even understand what it is to have a Vasovagal, which is a person passing out, a lack of oxygen, and what to do, that they know how to start an IV, that they're really competent injectors,” says Warren. “Now, people make fun of what we do. And they say, oh, it's so frou-frou. But it's actually, really probably one of the most important jobs anybody can have, because you're dealing with someone's most important commodity, which is their face.”

Ongoing training and staying up-to-date

Med spa professionals are committed to continued education and training to keep up with this fast-paced profession. Ongoing training ensures that providers are not only proficient in the latest techniques but are also well-versed in the latest safety guidelines and industry best practices.

“The number one important factor in determining results and safe treatments is experience and training, and that includes a thorough knowledge of anatomy, including cadaver anatomy as well as a training in complication management and proper and sterile technique when performing injections,” says Dr. Weiner.

Choosing the Right Med Spa to Avoid Complications

When selecting a med spa, thorough research is key to ensuring a safe and effective experience. Start by reading online reviews and testimonials to gauge patient satisfaction. Pay close attention to the qualifications and experience of the staff, particularly the medical professionals overseeing treatments. The facility itself should be clean, well-maintained and adhere to strict hygiene standards.

During your consultation, ask questions about safety protocols and training experience, then request to see before-and-after photos of past patients who are similar to you. A safe med spa will gladly provide this information and address any concerns.

“The reality of what I always say to all my patients is you want somebody who's not going to just hold your hand, sing Kumbaya, and applaud you when you've had a successful outcome,” says Warren. “You want somebody who knows what they're doing, if you have a poor outcome or an outcome that needs to be corrected.”

Selecting a reputable med spa is crucial for minimizing the risks associated with aesthetic treatments. A well-trained team, strict safety protocols, and thorough patient education can prevent many complications from arising in the first place. However, in the rare instance that an issue does occur, an experienced provider will have the knowledge and skills to address it quickly and effectively. It’s important to thoroughly research a med spa’s credentials and feel confident in asking about their safety measures, staff qualifications and post-treatment procedures. Find a trusted med spa to ensure that you not only achieve stunning, natural results but also feel supported and cared for throughout your aesthetic journey.

Hermine Warren, DNP, APRN, CANS, ISPAN-F

Hermine Warren, DNP, APRN, CANS, has been in nursing since 1974, with an advanced practice degree since 1980. She is an educational/clinical GAIN trainer for Galderma, is a PALETTE faculty member, is co-faculty for the Academy of Injection Anatomy with Chris Surek, DO, FACS, and has maintained a clinical practice in the non-surgical cosmetic subspecialty field since 2004. She is a member of Sigma Theta Tau since 1979 and a member of the Golden Key International Honour Society since 2013.

Steven F. Weiner, MD

Steven F. Weiner, MD, is a board-certified head, neck and facial plastic surgeon. He interned and spent his residency at The Johns Hopkins Hospital, where he became an instructor for two years. In mid-2005, he laid down his scalpel and began concentrating his efforts in non-invasive and minimally invasive cosmetic procedures, creating The Aesthetic Clinique. Dr. Weiner divides his time between his practice, physician trainings and lectures. He has served on multiple advisory boards, participated in FDA trials and authored several clinical papers. He is world-renowned for his filler techniques using cannulas and his reJAWvenation procedure, which he performed on The Doctors.