FILLER COMPLICATIONS

AND WHAT WE CAN DO ABOUT THEM

It stands to reason that the recent, rapid growth in dermal filler use concurrently brings with it an increase in filler treatment related complications. The rise in popularity of filler treatments is self-evident due to their low recovery time, general simplicity, minimal invasiveness, and high satisfaction rates among patients. As such there is, however, a risk of cavalier attitudes towards the procedure, and although complications are not common, they can and do occur (Sclafani & Fagien, S, 2009). Some complications have an immediate onset, while others only present several days after treatment. A group of international cosmetic and dermatological professionals went to create a 10-point plan for avoiding hyaluronic acid dermal filler-related complications, which are subcategorized into patient-related factors, product-related factors, and procedure-related factors (Heydenrych et al., 2018). Considering those three areas and their related subcategories when providing treatment will go a long way to avoiding complications, which can fortunately be treated effectively and with excellent outcomes, even if they do occur (Sclafani & Fagien, S, 2009). 

What Complications Occur?

As mentioned above, complications can manifest immediately after treatment, or as much as a few days or weeks after. Understanding what brings them on can go a long way to avoiding them or reducing their occurrence. 

Immediate-onset Complications include:

• Under and overcorrection
• Implant visibility
• Vascular compromise

Though it can occur in any location, vascular compromise with impending skin necrosis most often occurs in the glabella, and treatment of this area with glutaraldehyde cross-linked bovine collagen (Zyplast, Allergan, Inc., Irvine, CA), the earliest widely used filler, was restricted due to reports of glabellar necrosis (Sclafani & Fagien, S, 2009). Immediate skin blanching is the first sign from the direct arterial embolization of filler material. Conversely, venous occlusion can occur if excessive amounts of fillers are placed in a small area, leading to excessive venous congestion. The patient may report persistent, dull, aching pain and swelling, and a purple discoloration of the area. Other symptoms of vascular compromise include worsening pain, dusky skin discoloration, livedo reticularis (later sign), and herpetic-like lesions that eventually can lead to blackened/ obviously necrotic tissue that can slough and scar.

Early-Onset (3-14 Days) Complications include:

• Persistent nodules and associated pain, tenderness, or redness
• Angioedema, commonly seen in the lips
• Localized edema

Depending on the complication, antibiotic or hyaluronidase treatments should be considered. If there is impending skin erosion or fluctuance, incision and drainage with culture should be performed (Sclafani & Fagien, S, 2009). 

Delayed-Onset (>14 Days) Complications include: 

• Persistent erythema and telangiectasias 
• Immune-mediated hypersensitivity 
• Inflammatory nodules, granulomas, and ‘‘sterile abscesses’’

It is important to keep in mind that all fillers are essentially the introduction of foreign bodies, and the normal and pathologic processes occur after implantation. The nature of some injectable fillers may prolong and perpetuate the inflammatory reaction due to features such as “particle size, surface porosity, roughness, and charge and hydrophobicity, bacterial colonization of these materials may also cause a peri-implant chronic inflammatory reaction. Clinically inflamed nodules, regardless of the time of onset, should be treated as foreign body infections first” (Sclafani & Fagien, S, 2009). 

How are Complications Avoided? 

It is said that the courage of a soldier is heightened by their knowledge of their profession (Publius Flavius Vegetius Renatus), but in everyday filler practice, it is often the lack of knowledge that emboldens the practitioner (Article 3). There are many steps that both practitioners and patients can take (upon the direction of their practitioner) to reduce the incidence of complications. 

Patient Related Factors:

• Patient Interview: setting realistic expectations will go a long way toward patient satisfaction. Understanding the patient’s motivation for undergoing treatment is crucial, with “internal” factors such as a desire to look better for themselves as opposed to “external” impulses to please others or improve their career should be identified and discussed. Although often difficult to do, practitioners should also try to identify signs of any underlying mental disturbance or dysmorphophobic tendency (Urdiales-Gálvez et al., 2017). More guidance on this can be found in our May article, What is Snapchat Dysmorphia? The perilous Path from Filters to Fillers. 
• Medical History: crucial in avoiding complications, the patient’s medical history should be examined for any medical illnesses, allergies, medications used and prior aesthetic procedures. Certain bleeding disorders or uncontrolled hypertension can increase the risk of bruising, anti-dsDNA antibodies can cross-react with collagen-based fillers and should therefore be avoided, and hypersensitivity to lidocaine should also be considered (Urdiales-Gálvez et al., 2017).
• Informed Consent: must be obtained before the procedure, outlining what kind of procedure is being performed, what materials are being used, potential outcomes, possible side effects, and post-procedural care. For more information on informed consent, read our September article, The Do’s and Don’ts of Informed Consent. 

Procedure Related Factors: 

• Patient and Theatre Preparation: is essential to be standardized  to achieve the most desirable outcomes. Preparing the skin with the combined use of a quaternary ammonium compound with 70% ethyl alcohol, or of chlorhexidine and 70% ethyl alcohol is recommended, however “it is important to note that chlorhexidine should be avoided in the periocular area due to the potential risk of keratitis and possible ocular damage” (Urdiales-Gálvez et al., 2017). Chlorhexidine mouthwash should be employed to rid the mouth of bacteria if oral area is being injected, and gloves and thorough hand washing, with all necessary materials at hand before the procedure begins, is essential (Heydenrych et al., 2018). The cannula or needle should not be touched, non-sterile areas should not be touched with the cannula/needle, and the cannula/needle should be kept in its cap when not in use, with antiseptic solution put into the cap (Urdiales-Gálvez et al., 2017). 
• Clinical Assessment: is a wide ranging process that includes an analysis of the patient’s proportions, ethnicity, skin types and issues, dental treatments and previous aesthetic treatments and injections (Heydenrych et al., 2018). Standardized photographic scales should be employed to analyze craniofacial morphology, and to establish facial profiles, and “ultrasonography may be a useful tool to evaluate the surface topography of the skin and to assess what may happen to the filler beneath the surface of the skin” (Urdiales-Gálvez et al., 2017). For a quick overview on Gender Differences when Considering Aesthetic Treatments: Massaging the Face, or the Message? read our October article.
• Injection Anatomy: perhaps most essential to all cosmetic aesthetic treatments is a good knowledge of facial anatomy. Training in nonsurgical syringe therapy is highly advisable, as optimal placement and injection depth is central to the esthetic success of dermal fillers (Heydenrych et al., 2018). For example, injections too superficial can cause effects such as surface irregularities and the Tyndall effect. For a more in-depth overview at the importance of anatomy, check-out our November article, The Importance of Anatomy: Measure Twice, Inject Once. 
• Injection Technique: The application of anatomical knowledge is found in technique; to identify and respond to any adverse reactions, injections must be performed slowly and with caution. The amount of filler administered should be accommodated to each individual patient and injected in small quantities at multiple points to avoid overfilling (Urdiales-Gálvez et al., 2017). Some claim that aspiration is a useful prophylactic measure, particularly in highly vascularized areas, though this practice is a bit controversial, as outlined in our February article, To Aspirate or to Not Aspirate: That is the Question. 

Product Related Factors:

• Product Characteristics: are imperative to be familiar with as the type of HA product being used, as it can lead to increased swelling due to the nature of hyaluronic acid; “the HA concentration and the extent of cross-linking determine the product’s characteristics (viscosity, elasticity, resistance to degradation, G′ [G prime/ elastic modulus], G′′ [G double prime/viscous modulus], and Tan Delta) and ultimately its clinical efficacy at different tissue depths” (Heydenrych et al., 2018). For a deeper dive into filler characteristics and products, check-out our March article, The Basics Behind Filler Rheology & Product Choice: Go With The Right Flow.
• Product Reversibility: HA fillers can be liquefied by the use of hyaluronidase, but this does require the clinician to know the reconstitution and dosage necessary for the treatment of both intravascular complications and cosmetically unsatisfactory results. But the reversibility of HA fillers makes it highly appealing as it allows most complications induced by these fillers to be addressed (Heydenrych et al., 2018). However, one must keep in mind that hylaronidase can also lead to complications and other side effects.
• Product Layering: further underlining the importance of gathering a patient’s medical history, practitioners should be aware that layering of different products, either intentionally or inadvertently, can induce long-lasting complications such as foreign body granulomas; “due to the inherent longevity associated with minimally biodegradable fillers, there is a portended increased incidence in more delayed-onset adverse events” (Heydenrych et al., 2018). 

Above are outlined the key steps that should be taken by practitioners and patients to avoid filler complications. With their rise in popularity, all parties involved can benefit from increased education and awareness of potential issues, and more importantly how to avoid them. The size of the market has grown substantially, with a large  increase in cosmetic surgery between over the past decade, according to the American Society for Aesthetic Plastic Surgery (Urdiales-Gálvez et al., 2017). By 2017, there were an estimated 160 products available worldwide, supplied by more than 50 companies (Urdiales-Gálvez et al., 2017), which brings to mind one more important step in the process – documentation; “To trace negative effects that might arise from manufacturing discrepancies, the batch number sticker provided with the filler should be attached to the patient’s consent form or medical chart” (Urdiales-Gálvez et al., 2017). For  documentation guidelines, refer to your college regulations, you can also request a copy of an example documentation through our contact form https://maiapro.com/contact/ .  As the world of filler grows and our awareness grows with it, vigilant pursuit of informed consent, education, and documentation will go a long way to ensuring patient satisfaction, favourable outcomes, and ultimately further growth. 

References

Sclafani, A.P. and Fagien, S. (2009), Treatment of Injectable Soft Tissue Filler Complications. Dermatologic Surgery, 35: 1672-1680. https://doi.org/10.1111/j.1524-4725.2009.01346.x 

Urdiales-Gálvez F, Delgado NE, Figueiredo V, et al. Preventing the Complications Associated with the Use of Dermal Fillers in Facial Aesthetic Procedures: An Expert Group Consensus RepoS180904rt. Aesthetic Plast Surg. 2017;41(3):667-677. doi:10.1007/s00266-017-0798-y

Heydenrych I, Kapoor KM, De Boulle K, et al. A 10-point plan for avoiding hyaluronic acid dermal filler-related complications during facial aesthetic procedures and algorithms for management. Clin Cosmet Investig Dermatol. 2018; 11:603-611. Published 2018 Nov 23. doi:10.2147/CCID.

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