Biostimulatory Filler Procedure Note (Non-HA Fillers)

Date/Time: [Date and time of procedure]

Provider: [Clinician name and credentials]

Patient: [Patient name and identifier]

Procedure: Biostimulatory Filler Injection

Product: [Brand and material class: PLLA / CaHA / PMMA]

Session: [Single session / Session X of Y planned]

Pre-procedure photos: [Yes with consent / No]

Indication and Treatment Goals

[Clinical indication and anatomic areas. Patient-stated goals. Clinician treatment goals for this session. Staging rationale and criteria for continuation or modification across sessions.] (Compose a concise paragraph. Note that expected improvement is delayed with biostimulatory agents.)

Pre-Procedure Screening

(For each item, document Yes/No/Not assessed. If Yes, specify relevant details. Retain "Not assessed" rather than omitting.)

• Allergies (medications, lidocaine, prior filler reactions): [Yes / No / Not assessed] [Details if Yes]
• Bleeding risk (anticoagulants, antiplatelets, bleeding disorders): [Yes / No / Not assessed] [Details if Yes]
• Pregnancy or breastfeeding: [Yes / No / Not assessed]
• Active skin conditions at treatment sites: [Yes / No / Not assessed] [Location and description if Yes]
• Herpes simplex history: [Yes / No / Not assessed / Not applicable] [Prophylaxis plan if indicated] (Include if perioral treatment planned)
• Prior fillers/biostimulators in planned areas: [Yes / No / Not assessed / Unknown filler history] [Product, timing, plane if known]
• Recent procedures in area: [Yes / No / Not assessed] [Procedure type and timing if Yes]
• PMMA skin test: [Not applicable / Performed on (date): (result)] (Include if PMMA selected)

Product Selection and Consent

Product Selection Rationale

[Rationale for selecting biostimulatory class. Reason HA not selected if relevant. Alternatives discussed. On-label or off-label use status with patient acknowledgment if off-label.] (Keep concise; clearly state why this product/class is appropriate for goals and anatomy.)

Informed Consent Documentation

• Nature, purpose, and expected benefits of procedure discussed.
• Delayed onset of results discussed (weeks to months for biostimulatory effect).
• Staged treatment plan explained; number and spacing of sessions discussed.
• Immediate post-procedure appearance does not represent final outcome.
• Non-reversibility compared to HA emphasized (cannot be dissolved).
• Risks reviewed: bruising, swelling, pain, nodules, granuloma, infection, asymmetry, over/undercorrection.
• Serious risks reviewed: vascular occlusion, skin necrosis, vision loss, stroke.
• CaHA-specific: possible delayed inflammation following illness, vaccination, or dental procedures. (Include if CaHA selected)
• All questions answered; patient elected to proceed: [Yes / No]
• Written consent: [Signed consent on file / Not signed: (reason)]

Pre-Procedure Verification

Patient identity verified; procedure and sites confirmed; product verified (correct vials/syringes present); allergies reviewed. (If any element not verified, specify which and corrective action taken.)

Preparation

• Patient position: [Supine / Semi-recumbent / Seated / Other]
• Skin antisepsis: [Agent and method]
• Aseptic technique: [Standard aseptic technique used / Sterile field created]
• Anesthesia: [None / Topical (agent, duration) / Nerve block (agent, volume, sites)] Lidocaine within product: [Yes / No]

Product Reconstitution/Dilution

(Include only if product required reconstitution or dilution. Omit entirely if product used as supplied.)

• Diluent(s) and volumes: [Type(s) and mL]
• Hydration/standing time: [Duration]
• Prepared by: [Name/role, date/time]
• Mixing method: [Method if relevant]

Treatment Record

(Add one row per treated anatomic area/subunit. Complete all columns.)

Area/Subunit	Side	Plane	Device	Technique	Volume (mL)
[Anatomic area]	[R / L / Bilateral]	[Supraperiosteal / Deep subcutaneous / Subdermal / Other]	[Needle / Cannula, gauge]	[Linear threading / Fanning / Bolus / Micro-aliquots / Other]	[mL]
[Additional areas as needed]

Total volume injected: [Total mL]

Aspiration prior to injection: [Performed routinely / Selectively performed / Not performed]

Product Traceability

• Product name and material class: [Brand; PLLA / CaHA / PMMA]
• Vials/syringes used: [Count]
• Lot number(s): [Lot numbers] (Required; if unavailable, document reason)
• Expiration date(s): [Expiration dates] (Required; if unavailable, document reason)
• Total volume injected: [Total mL]
• Lidocaine in product: [Yes / No]
• Permanent material counseling: [Not applicable / Patient advised to inform future clinicians and radiologists of permanent filler placement] (Include if PMMA or other permanent material)

Procedure Tolerance and Immediate Outcome

[Patient tolerance during procedure. Vasovagal symptoms or need for breaks. Analgesia adequacy.]

Immediate outcome: [No immediate complications / Complication observed: (time of onset, findings, interventions, patient response, disposition)]

Warning signs during/immediately after injection: Blanching: [Absent / Present]; Disproportionate pain: [Absent / Present]; Visual symptoms: [Absent / Present]. (If any present, document assessment, interventions, and disposition in detail.)

Post-Procedure Instructions

• Expected local reactions: Swelling, bruising, tenderness expected; typical duration [X–Y days].
• Delayed results counseling: Biostimulatory improvement occurs gradually over weeks to months; immediate fullness is transient; final results typically require multiple sessions.
• Activity restrictions: Avoid strenuous activity for [duration]; avoid sun/heat exposure for [duration]; makeup may be applied after [duration].
• Product-specific aftercare: [PLLA: massage regimen provided (frequency and duration) / CaHA or PMMA: massage not recommended / Other specific guidance]
• Red flags requiring urgent contact: Increasing or disproportionate pain, progressive skin color changes (blanching/mottling), ulceration, fever or signs of infection, any visual changes. Emergency contact: [Contact pathway and after-hours instructions].

Follow-Up Plan

• Follow-up visit: [Date or interval]
• Next treatment session: [Planned timing or criteria-based timing]
• Criteria to proceed vs pause: [Resolution of adverse events, patient satisfaction, need for additional correction]
• Photography: Standardized photos planned at follow-up.