Scope: Botulinum toxin type A/B, hyaluronic-acid fillers, biostimulators, threads (contextual), and local anaesthetics used adjunctively.

This SOP sets out the immediate recognition, treatment algorithms, escalation thresholds, and reporting duties for complications arising from cosmetic injectables. It operationalises AHPRA cosmetic procedure guidance, ACSQHC NSQHS Standards, Australian Resuscitation Council (ARC) emergency care algorithms, NSW Health clinical governance requirements, and TGA pharmacovigilance/DAEN reporting for medicines and devices. Follow this SOP in conjunction with clinic Anaphylaxis, Vascular Occlusion, Infection Control, and Incident Management SOPs. ^{1 2 3 4 5}

Readiness & Setup

• Emergency tray: adrenaline 1 mg/mL (1:1000), chlorphenamine/antihistamine, corticosteroid, salbutamol spacer, oxygen with masks, bag-valve mask, pulse oximeter, sphygmomanometer, glucometer, IV access kit.
• Filler rescue kit: hyaluronidase (multiple 1500 IU vials), warm compress supplies, nitroglycerin 2% paste (if used locally), aspirin (if not contraindicated), sterile saline, small-gauge needles/cannulas.
• Documentation: batch/lot labels, time-zero clock, complication forms, incident register access.
• Team roles: caller, airway/ABCs, drug preparation, scribe; drill quarterly with ARC algorithms. ^{2 3}

Triage & Global Algorithm (First 2 Minutes)

1. Stop injection immediately.
2. Call for help.
3. ABC approach: airway, breathing, circulation.
4. Assess red flags:

• Sudden severe pain, livedo/reticular blanching, coolness, or colour change → suspect vascular occlusion (VO).
• Wheeze, stridor, hypotension, urticaria, GI symptoms → suspect anaphylaxis.
• Ptosis, diplopia, dysphagia/voice change days to weeks later (toxin diffusion) → urgent review pathway.
• Nodules, swelling, erythema, delayed tenderness → consider biofilm/delayed inflammatory nodule (DIN). ^{2 5}

Acute Vascular Occlusion (Hyaluronic-Acid Fillers)

Recognition: immediate severe pain; blanching or dusky discoloration; livedo/reticular pattern; delayed capillary refill; coolness. High-risk zones include glabella, nasal dorsum/sidewall, nasolabial fold, and lip arterial arcades.

Immediate Actions:

• Stop injection; keep patient; call senior clinician.
• Warm the area; gentle massage to disperse filler (avoid aggressive pressure). Consider applying nitroglycerin paste sparingly to enhance perfusion if within local protocol.
• Hyaluronidase: Reconstitute (e.g., 150–300 IU/mL) and perform high-dose, multi-point flooding across the ischemic territory; typical initial dose 1500 IU (entire vial) distributed; re-assess every 15–30 minutes; repeat up to several vials guided by skin reperfusion and pain relief.
• Consider aspirin (e.g., 300 mg PO) if not contraindicated; maintain patient warmth and hydration.
• Assess for ocular symptoms (vision change, ocular pain, diplopia). Any visual symptom = emergency transfer. ⁵

Ocular Emergency Pathway (suspicion of retinal artery involvement):

• Call emergency services and ophthalmology immediately; aim for transfer within minutes.
• While awaiting transfer: gentle ocular massage may be considered; maintain normocapnia and head positioning per ophthalmology advice. Do not delay transfer for ancillary measures.

Post-event Care & Documentation:

• Photograph before and after hyaluronidase; record total IU, time stamps, and response.
• Daily review for 72 hours; consider prophylactic antibiotics if skin breakdown occurs.
• Log incident in register; consider TGA DAEN report if device/medicine failure suspected.

Anaphylaxis (Any Injectable / Topical Exposure)

Recognition: acute airway/breathing/circulation compromise with skin/mucosal changes or GI symptoms after exposure.

Immediate Actions (ARC-aligned):

• Lie patient flat; do not sit or stand; pregnant patients in left lateral position.
• Adrenaline IM 1:1000 to mid-outer thigh, 0.5 mg (0.5 mL) adults; repeat every 5 minutes as needed.
• High-flow oxygen; IV fluids (normal saline) for hypotension; salbutamol for bronchospasm.
• Call ambulance; monitor SpO2, BP, pulse; prepare for airway support.
• Antihistamines and corticosteroids are adjuncts only after adrenaline.
• Observe minimum 4–6 h after resolution; longer if severe or biphasic risk. ³

Follow-up: provide written action plan; advise avoidance and referral for allergy investigation. Report serious medicine/device reactions to TGA (DAEN).

Infection & Cellulitis

Presentation: progressive erythema, warmth, pain, purulence, fever. Distinguish acute cellulitis from inflammatory nodules. Consider HSV in perioral region after trauma.

Management:

• Mark borders; photograph; swab if purulent; initiate empiric antibiotics per local guidance (e.g., anti-staphylococcal coverage). Escalate if systemic signs or failure to respond in 24–48 h.
• For suspected abscess, imaging and drainage as indicated.
• For HSV reactivation: start antivirals promptly per guidelines.
• Document batch/lot; consider TGA reporting if product-related. ^{4 6}

Delayed Inflammatory Nodules (DIN) / Biofilm

Presentation: tender nodules weeks–months post-filler; may fluctuate; minimal surface erythema; may follow infection or immunologic trigger.

Management (stepwise):

• Stage 1: Empirical oral antibiotics covering biofilm-formers (per local antimicrobial guidance) 2–4 weeks.
• Stage 2: Intralesional hyaluronidase for HA-based products; repeat as needed with ultrasound guidance if available.
• Stage 3: Consider oral corticosteroid taper for significant inflammatory component if infection excluded.
• Stage 4: Refractory cases → specialist referral; consider culture/biopsy and targeted therapy. ^{4 6}

Eyelid Ptosis / Unintended Botulinum Toxin Effect

Presentation: unilateral/bilateral eyelid droop 2–10 days post anti-wrinkle treatment; may include brow heaviness or diplopia. Management:

• Reassure: typically self-limiting (2–8 weeks).
• Apraclonidine 0.5% or oxymetazoline ophthalmic drops can stimulate Müller’s muscle for temporary lift (if suitable).
• Avoid further toxin to affected region until resolution; schedule review; document units, dilution, sites.
• Escalate if visual disturbance, atypical neuromuscular signs, or systemic symptoms. ^{1 5}

Suspected Vascular Compromise without Classic Ischemia

If pain and pallor are equivocal but risk is high (e.g., nose/glabella injections), err on the side of treatment: low threshold for hyaluronidase flooding, warm compress, and observation with serial capillary refill checks.

Bruising, Hematoma & Swelling

Apply immediate pressure and cold packs. Consider ultrasound if expanding hematoma or suspected arterial injury. Review anticoagulants/antiplatelets; counsel on expected course; provide written aftercare.

Product Migration & Tyndall Effect

Presentation: bluish hue or contour irregularity from superficial HA placement or migration along planes. Management: hyaluronidase microdosing to affected plane; avoid overcorrection; reassess after edema resolution.

Neuropraxia / Nerve Irritation

May present as paresthesia or neuropathic pain. Reassure; NSAIDs if appropriate; review within 1–2 weeks; image if progressive or atypical.

Documentation, Escalation & Reporting

• Record: timeline, symptoms/signs, products with batch/lot and expiry, volumes/units, anatomical maps, asepsis, and interventions.
• Photography: baseline and serial images.
• Escalation: Major/critical events → notify Medical Director immediately; consider HCCC if unresolved complaint; AHPRA if practitioner concern.
• TGA DAEN: report serious medicine/device reactions or device malfunctions.
• Follow-up: schedule clinical reviews; close the loop in CQI with root cause analysis and CAPA actions. ^{1 2 4 5}

Prevention, Consent & Patient Communication

Use cannula where appropriate; aspirate selectively; inject slowly in small aliquots; remain mobile with low plunger pressure; avoid high-risk planes; adhere to asepsis and no-tap water rule; stop if pain is out of proportion. Obtain AHPRA-compliant informed consent including risks, alternatives, and emergency contact pathways; provide written aftercare. ^{1 2}

Sources

1. Ahpra/Medical Board of Australia, Guidelines for non‑surgical cosmetic procedures (2025)., viewed 27 October 2025, https://www.ahpra.gov.au/News/2025-01-31-Guidelines.aspx ↩
2. ACSQHC, National Safety and Quality Health Service (NSQHS) Standards (2nd ed.)., viewed 27 October 2025, https://www.safetyandquality.gov.au/standards ↩
3. Australian Resuscitation Council, Anaphylaxis and Basic Life Support Guidelines., viewed 27 October 2025, https://resus.org.au/guidelines/ ↩
4. Therapeutic Goods Administration (TGA), Reporting adverse events & DAEN., viewed 27 October 2025, https://www.tga.gov.au/reporting-issues ↩
5. HCCC NSW, Complaints and consumer protection in health services., viewed 27 October 2025, https://www.hccc.nsw.gov.au/ ↩
6. NSW Health, Infection Prevention & Control and Clinical Governance resources., viewed 27 October 2025, https://www.health.nsw.gov.au/ ↩