1. Purpose

This SOP defines an evidence-based framework for the selection, handling, and clinical application of dermal fillers in cosmetic medicine. It standardises understanding of filler rheology, anatomy, and technique selection to improve safety and outcomes. It integrates national regulations and clinical governance expectations for cosmetic practice, including AHPRA cosmetic procedure guidance, TGA scheduling and device rules, and the NSQHS Standards for Clinical Governance and Partnering with Consumers. ^{1 2 3}

2. Scope

Applies to medical practitioners, nurses, and authorised staff who assess, prescribe, prepare, or inject dermal fillers across facial and cervical indications. It covers patient assessment, product classification, technique selection (needle vs cannula), injection planes, contraindications, anatomical danger zones, documentation, and escalation to emergency protocols where indicated. ^{2 4}

3. Dermal Filler Composition & Physiology

Most contemporary fillers are cross‑linked hyaluronic acid (HA), a glycosaminoglycan distributed throughout the extracellular matrix. Cross‑linkers such as BDDE stabilise HA chains, modifying viscoelastic behaviour (elastic modulus G′, viscosity) and cohesivity to influence lift, projection, spread, and persistence. HA’s hydrophilicity supports volumisation via reversible water binding, while enzymatic catabolism by hyaluronidases underpins reversibility. Non‑HA options include calcium hydroxylapatite (CaHA), poly‑L‑lactic acid (PLLA), and PMMA microspheres, which act primarily via collagen biostimulation and have different longevity and risk profiles. ^{3 5 6}

4. Rheology & Clinical Classification (G′, Viscosity, Cohesivity)

Rheological properties guide product selection and injection plane. High G′, cohesive fillers are suited for deep structural support and projection; medium G′, balanced viscosity gels support contouring and fold effacement; low G′, low viscosity products distribute superficially for fine‑line correction and hydration. Product choice must consider diffusion, tissue integration, shear deformation under animation, and vascular risk in each zone. Document the target outcome (lift vs blend vs hydrate) and match the rheology and plane accordingly. ^{5 6 7}

5. Injection Planes & Delivery Method (Needle vs Cannula)

Injection depth is determined by indication and risk. Supraperiosteal bolus or small depot placement supports skeletal projection (chin, jaw, malar eminence). Sub‑SMAS or subdermal threads blend contours in the midface and perioral regions. Superficial dermal micro‑aliquots treat etched lines. Cannulas may reduce intravascular penetration in high‑risk territories (tear trough, nasolabial fold, medial cheek) and allow smooth fanning; needles provide precision for small boluses or when periosteal contact is required. Selection should be justified in the record with local anatomy, risk, and outcome rationale. ^{5 8 9}

6. Anatomical Application (Selected Regions)

Midface and zygomatic arch: high G′ fillers for malar projection on bone or deep fat; avoid infraorbital foramen and angular vessels. Nasolabial region: mid‑G′ products with conservative aliquots and cannula fanning lateral to alar base to respect the facial artery course. Lips: low to medium G′ HA for definition and volume using linear threading or micro‑aliquots; avoid intravascular injection by respecting labial artery depth variability. Chin and jawline: high G′, supraperiosteal support for contour; be mindful of mental foramen and marginal mandibular nerve. Tear trough: cohesive, low G′ HA in minimal volumes via cannula, deep to orbicularis retaining ligament with careful patient selection. Document plane, approach, aspiration practices, and real‑time endpoint assessment. ^{7 9 10}

7. Longevity, Metabolism & Reversibility

HA fillers typically persist 6–18 months depending on cross‑link density, volume, placement plane, regional mechanics, and patient metabolism. Biostimulatory fillers may persist longer due to collagen neogenesis. Reversal of HA complications employs hyaluronidase, using evidence‑based dosing and repeated assessment when vascular compromise is suspected. Counsel patients on variability, potential for earlier resorption in dynamic areas, and the benefits and risks of reversibility. ^{6 9 11}

8. Safety, Complications & Escalation

Expected post‑injection effects include tenderness, oedema, and ecchymosis. Complications include vascular occlusion (blanching, livedo, severe pain), visual symptoms (ophthalmic involvement), infection and biofilm, delayed nodules, and Tyndall effect. Immediate management follows local emergency SOPs: cease injection, massage/warmth for VO, prompt high‑dose hyaluronidase, consider aspirin if not contraindicated, urgent ophthalmology pathways if visual changes, and antimicrobial strategies for suspected infection. Serious adverse events warrant documentation, internal incident review, and where appropriate reporting to the TGA DAEN. ^{3 5 12 13}

9. Consent, Documentation & Traceability

Obtain written, procedure‑specific consent covering product type, reversibility, risks, recovery, and alternatives. Capture baseline and outcome photographs. Record brand, ARTG number (if applicable), batch/lot, expiry, reconstitution details, syringe/needle or cannula used, injection planes, total volume per zone, and immediate endpoints. Link batch labels to the EMR and retain for recall readiness. Provide written aftercare and red‑flag instructions. ^{1 2 12 14}

10. Training, Audit & Governance

Maintain practitioner credentialing for filler procedures, annual CPD with complication simulation (vascular occlusion and anaphylaxis), and periodic peer review of cases. Conduct audits of documentation completeness, tray setup, cold‑chain integrity for associated products (e.g., hyaluronidase), and adverse event follow‑up. Governance aligns with clinical risk management expectations and partnering with consumers standards to ensure a learning system. ^{1 3 9 15}

Sources

1. AHPRA, Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures (2025)., viewed 27 October 2025, https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Cosmetic-medical-and-surgical-procedures-guidelines.aspx ↩
2. ACSQHC, National Safety and Quality Health Service (NSQHS) Standards (Clinical Governance; Partnering with Consumers)., viewed 27 October 2025, https://www.safetyandquality.gov.au/standards ↩
3. Therapeutic Goods Administration (TGA), Regulation of therapeutic goods; DAEN adverse event reporting., viewed 27 October 2025, https://www.tga.gov.au/ ↩
4. NSW Health, Clinical Governance and Patient Safety Policy Framework., viewed 27 October 2025, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_043.pdf ↩
5. ACE Group World, Dermal filler complications and vascular occlusion guidance., viewed 27 October 2025, https://uk.acegroup.online/ ↩
6. RACGP, Cosmetic procedures and safe prescribing resources., viewed 27 October 2025, https://www.racgp.org.au/ ↩
7. NHMRC, Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019)., viewed 27 October 2025, https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019 ↩
8. WHO, Patient safety and procedures framework., viewed 27 October 2025, https://www.who.int/teams/integrated-health-services/patient-safety ↩
9. Australian Prescriber, Dermal fillers: clinical use and safety., viewed 27 October 2025, https://australianprescriber.tg.org.au/ ↩
10. Australasian College of Dermatologists (ACD), Clinical resources on fillers and anatomy safety., viewed 27 October 2025, https://www.dermcoll.edu.au/ ↩
11. TGA DAEN, Database of Adverse Event Notifications (medical devices and medicines)., viewed 27 October 2025, https://apps.tga.gov.au/Prod/DAEN/daen-entry.aspx ↩
12. OAIC, Australian Privacy Principles (health information, images)., viewed 27 October 2025, https://www.oaic.gov.au/privacy/australian-privacy-principles ↩
13. SafeWork NSW, Clinical waste and hazardous substances guidance., viewed 27 October 2025, https://www.safework.nsw.gov.au/ ↩
14. PBS, Pharmaceutical Benefits Scheme (reference for S4 substances and counselling context)., viewed 27 October 2025, https://www.pbs.gov.au/ ↩
15. ISO 13485, Medical device quality management systems (overview)., viewed 27 October 2025, https://www.iso.org/standard/59752.html ↩