How to read a filler consultation

Hyaluronic acid fillers can be dissolved with hyaluronidase. That is the single largest safety advantage they have over every other category of injectable, and it is only an advantage if the clinic keeps the drug on the premises, in date, in usable quantity, with someone trained to use it.

So ask directly: do you keep hyaluronidase here, how much, and have you used it? A clinic that has never needed it is either very lucky or not counting.

The complication that matters is vascular occlusion — product entering or compressing an artery and cutting off the blood supply to the tissue it feeds. It is uncommon. It is not rare enough to be theoretical, and it is time-critical: the window in which flooding the area with hyaluronidase can save the tissue is measured in hours, not days.

So: what are the signs I should watch for, who do I call at nine in the evening, and what happens then? You want an answer that includes a number reaching a human being, not a voicemail and an appointment on Tuesday. Ask what the protocol is for a change in vision. The correct answer involves an emergency department and an ophthalmologist immediately, and a clinic that has thought about this will say so without hesitating.

Find out who is performing the treatment, what their registration is, who supervises them, and whether that supervisor is contactable on the day. If the person consulting you is not the person injecting you, the assessment you have just had is worth considerably less than it appeared.

• A price before a plan. If the first substantive number is a per-syringe price or a package that expires on Friday, a product is being sold rather than a decision being made.
• We will do a syringe and see. One millilitre spread vaguely across a face achieves very little and teaches you nothing. A plan can be staged; it should not be aimless.
• Permanent filler offered lightly. Polymethyl methacrylate and silicone cannot be dissolved. Complications from them can appear years later and are managed surgically. A first cosmetic appointment is not the setting for that decision.
• Certainty about longevity. Nobody can promise a gel will be entirely gone in six months. Imaging keeps finding hyaluronic acid in place years after treatment, particularly in areas that move very little.
• Reluctance to photograph. Standardised photographs protect you more than they protect us. An injector who does not want a record is telling you something.
• No mention of what can go wrong. Bruising, swelling, asymmetry, nodules, delayed inflammatory reactions, the bluish Tyndall effect from superficial placement, migration, vascular occlusion and, very rarely, blindness. If none of that was said aloud, the form you signed was paperwork rather than consent.
• Same-day treatment as the default. We will treat on the day when someone has the information and wants to proceed. Being moved smoothly from consultation to chair without a pause is a technique, and it is worth noticing that it is being used.
• No examination in movement. A face assessed only straight on and at rest has been assessed on a third of the available information. You should be asked to smile, frown and purse, and to be looked at from the side.

The reassuring consultation is usually the less exciting one. It involves being examined for longer than you expected, being told which of your concerns is not a filler problem, and quite often being told to do something else first — a retinoid, a laser course, weight stability, sleep — before anything is injected.

Being refused is the strongest signal of all. Every practitioner here has declined treatments this month: faces that had enough product in them already, requests that would not have achieved what the person actually wanted, and people who would be better served by a surgeon than by us. A clinic that never says no has removed the only real quality control it has.

If you leave a consultation with a written plan, a staged sequence, your risks in writing and a review date, the appointment did its job — whether or not anything was injected.