Discharge Instructions and the Next-Day Photo

Most filler complications do not declare themselves while the patient is still in your chair. They declare themselves at home, to someone who is not sure whether what they are looking at is normal.

Which means the quality of your discharge process determines whether you hear about a problem at hour four or at hour forty.

Written instructions, not a verbal summary

Patients retain very little of what is said at the end of an appointment. They are relieved, slightly adrenalised, looking at their own face, and thinking about the journey home.

Dr. Jennifer Thomas-Goering treats written discharge instructions as a clinical pearl rather than an administrative courtesy: all her patients get written discharge instructions covering what to look for over the next several days.

The written version does three things a conversation cannot. It survives the drive home. It can be shown to a partner who will be the one to notice a colour change. And it exists in the record, which matters if the case is ever reviewed.

What the instructions should name specifically

Vague instructions produce vague calls. The goal is a patient who can tell you something useful at speed, which means naming the findings rather than describing a feeling.

The red flags that belong in writing:

• Pain outside the area that was treated. Michelle Langston's instruction is explicit on this — an ache in an area away from the injection is the call she wants.
• Any discoloration, particularly where nothing was injected. Her example is direct: treat the lips, and if there is discoloration up in the nose or higher, that is something she wants to know about.
• Increasing rather than settling pain. Discomfort should trend down.
• Numbness or tingling, which can indicate compression without an intravascular event and is easy for a patient to dismiss.
• Skin changes of any kind, including anything the patient would describe as a sudden acne breakout — early ischemic change is frequently reported that way.

Note what these have in common: each is framed as an observation the patient can make without judgement. “Call if something seems wrong” asks a layperson to trlage. “Call if you see colour change anywhere I did not inject” asks them to look.

The next-day photograph

The most useful addition to a discharge process costs nothing.

Thomas-Goering texts her patients the following day and asks them to send a picture. Her patients read it as attentiveness — as she describes it, they feel she is right there for them — and clinically it lets her look immediately and confirm there is nothing requiring intervention.

The value is in who initiates. A patient deciding whether to bother you will frequently decide not to. A clinician asking for a photograph at twenty-four hours removes that decision entirely, and catches the patient who would have waited.

Others use a follow-up phone call, which works but returns less information. Melissa Pulcini-Buttine adds video where there is any doubt, having patients FaceTime her when she is out of the office.

Where a photograph stops being enough

A remote image is a triage tool, not an assessment, and it fails in both directions.

Colour reproduction varies enormously with lighting and handset. Angle exaggerates asymmetry and swelling. As Pulcini-Buttine notes, sometimes the pictures look considerably worse than the reality — and the converse is also true, which is the dangerous half.

Most importantly, a photograph cannot give you capillary refill, temperature or tenderness. If the image raises a question, the answer is to see the patient, not to request a better photograph. We cover this fully in the limits of post-filler photo assessment.

The patient who will not come in

Langston describes a call from a patient reporting odd pain. She asked her to come in. The patient replied that she could not — they were out at the lake.

It turned out to be a bruise. It might not have been.

This is the argument for setting the expectation at the time of treatment rather than at the moment of concern. A patient told in advance that certain findings mean same-day review has already agreed to the inconvenience. A patient hearing it for the first time while on holiday is being asked to abandon their day on your say-so.

Building it into the workflow

1. Written instructions issued to every injectable patient, naming the specific findings.
2. The instructions in the record, ideally signed electronically before the appointment so the patient has read them in advance.
3. A scheduled next-day contact with a photograph requested, initiated by the practice.
4. A stated rule that certain findings mean being seen, agreed at the time of treatment.
5. A route to reach you outside office hours that a patient will actually use.
6. Staff briefed to escalate rather than reassure — the front desk is frequently the first to hear.

Langston uses an electronic medical record requiring patients to sign documents before attending, specifically so they read them. She notes that patients sometimes call having read the list and asking whether they should proceed — which she treats as the system working, not as a problem. The aim is not to frighten people. It is to recruit them as observers.

Related guides in this cluster

Part of Vascular Occlusion: Recognition and Response.

Clinical GuideThe Expected Filler Injection Response — Building the Baseline That Lets You Recognize IschemiaThe expected filler injection response — erythema, edema, ecchymosis — and how a trained normal baseline makes early ischemia recogniza Clinical GuideThe Golden Triangle — Why the Filler Deposit Site Isn't Where You Put the Needle InThe filler deposit site sits at the needle tip, not the entry point — about half an inch away, further with a cannula. Why that gap dec Clinical GuideImmediate, Early and Late — The Three Windows of Vascular Occlusion OnsetVascular occlusion onset is not one moment. Organize the picture into immediate, early and late windows — detection runs days past the