The use of fillers in aesthetic treatments is increasing worldwide. A new consensus provides tips on managing adverse effects and complications. Which “red flags” should you be aware of?
Background: With the increasing use of fillers in aesthetic treatments worldwide, more and more reports on potential complications of this procedure can be evaluated. A multidisciplinary group of experts took advantage of this at the beginning of the year.
The new consensus recommendations in the journal Aesthetic Plastic Surgery are based on a broad literature review on the topic. They provide practical guidance and tips on managing adverse effects and complications during surgical injections and afterward. Some key recommendations are presented below in abbreviated form.
Immediate and early effects
Ecchymoses/”bruises
- frequent, disturbing, but reversible
- can be reduced prophylactically e.g. with arnica, or treated directly after the procedure with cold compresses
- special attention in patients with bleeding tendency and under blood thinners
Swelling and edema
- transient swelling immediately after injection is normal and to be expected, but its severity also depends on the product used
- in addition to injection volume and technique, patient factors also influence swelling (mechanical irritation of the skin)
- lips and the periorbital region are most frequently affected
- Not to be confused with angioedema, which is very rare (but then should be approached with antihistamines and/or oral steroids and monitored closely).
- According to the consensus, anti-inflammatory enzymes, arnica or cold compresses can be used prophylactically.
- can also be treated in mild symptoms with anti-inflammatory enzymes, cold compresses or observation.
Erythema
- directly after injection, normal reaction
- Rosacea treatments can be effective
Infections
- all procedures that penetrate the surface of the skin carry some risk of infection, filler injections are no exception
- Acute infections caused by common skin pathogens such as Staphylococcus aureus or Streptococcus pyogenes are typical with acute inflammation or abscesses at the injection site and can lead to sepsis if left untreated, especially in elderly or immunocompromised patients
- Mild forms can be treated with oral antibiotics, more severe forms may require inpatient intravenous antibiotics.
Herpes outbreak
- Reactivation possible
- Do not treat patients with active lesions
- Patients with a history of herpes should receive prophylactic therapy
Knots and “bumps
- are among the most common complications
- can be classified by type (inflammatory, non-inflammatory, infectious) and by time of presentation
- diagnostic workup necessary
- Often the result of suboptimal technology
- Nodes early after injection partly react to massage
- if the non-inflammatory nodule persists, the overcorrection can be treated, e.g. with hyaluronidase (beware of possible allergy)
Vascular hazard (see tissue necrosis).
- more frequent than expected, but fortunately still rare
- Intravascular injection into an artery that causes an embolism, obstructing blood flow
- primary signs are noticeable directly upon injection: Pain and change in skin color (in the case of arterial occlusion, immediate severe pain and extensive paling of the skin = “blanching”).
- Stop injection immediately
- Hyaluronidase throughout the supply area of the presumably affected vessel; continue where signs and symptoms exist
- warm compresses
- Massage or tapping
- Nitroglycerin paste to stimulate vasodilation
More effects
Tyndall effect
- bluish discoloration of the treated region due to scattering of light by the filler particles
- if certain HA fillers are applied too superficially
- Dissolution with hyaluronidase may be necessary if Tyndall effect is found to be very disturbing
Biofilm
- “Encapsulated” microorganism colonies around the injected material.
- In some cases lead to severely delayed inflammatory complications
- currently much discussed
- bacteriological culture may be negative, fluorescence microscopy may be necessary for detection
- often difficult to reach for antibiotics
Foreign body granulomas
- the body’s own immune system reacts to foreign bodies
- very rare, usually appearing only with a certain latency
- Hyaluronidase in HA fillers
Tissue necrosis
- rarely, due to vascular blockage
- Signs should be recognized immediately
- warm compresses, tapping and massage to facilitate vasodilation
- topical nitroglycerin (sublingual forms are also possible)
- Hyaluronidase
- possibly acetylsalicylic acid is also effective (not proven)
- In case of ocular symptoms (blurred vision, blindness, ocular pain) immediate referral to ophthalmologic center
Conclusion of the authors
Physicians using fillers should be aware of the signs and symptoms of a potential complication and be prepared to address them promptly and definitively. The consensus addresses several key components of adverse event management.
Comment Dr. Kägi: “Experience, technology and product selection are decisive”.
In principle, many of the complications mentioned in the consensus can already be avoided or at least reduced by the correct injection technique and a good anatomical understanding of the injector. A physician who is very experienced in this field can already control and influence a lot through the technique and choice of needle. Today, the trend is towards thinner and thinner needles, which accordingly leave a smaller trauma and reduce the risk of bleeding. Medications that affect blood clotting should be discontinued one week in advance, if possible. As always, the localization of the injection, the physician’s assessment, and the patient’s sensation all play a role. As a physician, one must assess the risk of bleeding or discontinuation of the aforementioned medications – in addition, patients find temporary hematomas cosmetically bothersome to varying degrees. If stopping the medication is medically justifiable and possible, it should be done; the risk of bleeding will be reduced.
If bleeding occurs, immediate one- to two-minute application of pressure is most effective (cotton pad, finger, cotton swab). Pressure stops bleeding the fastest. After that, cold compresses (make vasoconstriction) can be used in the injection area. I recommend arnica prophylactically only in isolated cases for patients who, for example, have a pronounced bleeding tendency with repeated “bruises” and have delicate areas treated regularly (e.g. mesotherapy lower eyelid area or filler lips) or at the explicit request of the patient. There is no proven evidence on this. For erythema, the use of a brimonidine gel with a passager effect of four to six hours is conceivable (acts via vasoconstriction), but I personally have never used it to mitigate filler side effects.
Swelling after filler injection is strongly product-dependent. In addition, the localization and depth of the injection play a role (e.g., the lip region is more susceptible than the cheek region). The more superficial the injection, the more likely you are to see swelling. Here, patients must be informed accordingly, depending on the product and treatment region. When swelling appears, you can usually wait and observe. Careful massage and application of light pressure can help to distribute the product well and prevent irregular swelling. Cold tends to do little here. For certain products, NaCl injections are an option to liquefy the material to some extent. Of course, the above only applies to inert painless material accumulations without accompanying inflammatory reaction. If such unfavorable filler depots or excesses and nodules persist with disturbing and disfiguring side effects for the patient, hyaluronidase is an option. Angioedema-like late side effects of fillers are rare and usually show a benign course, usually occurring only briefly and resolving spontaneously within hours (otherwise, antihistamines and steroids are an option – as described in the consensus).
The Tyndall effect is mainly caused by an injection that is too superficial. If you inject deep enough and use newer generation products, you rarely encounter this complication today. The same applies to the so-called “biofilms”. These occur mainly when working frequently with cannulas and large amounts of product – this is less of a problem when injecting carefully with small amounts.
In addition to the correct technique, sterile work is of central importance – this largely circumvents the problem of infection in practice. I do not recommend herpes prophylaxis in general, but mainly to patients who have already reacted with herpes to lip filler treatment in the past. This is not mandatory in immunocompetent healthy patients with a history of herpes. On the other hand, people with active lesions should not be subjected to filler treatment. It is necessary to wait for the end of the thrust.
Finally, a few words about potential tissue necrosis resp. intravascular injections: Every physician who injects fillers should be prepared for this complication, i.e. the hyaluronidase must always be stored in their own practice. A contingency plan is necessary because even a routine injector may be confronted with it. Fortunately, such an emergency has never occurred in my practice, but attention should be paid to the symptoms listed in the consensus. Immediate injection of hyaluronidase is the primary, most important step. Warm compresses, massages, etc. for vasodilation then come secondarily. What effect topical nitroglycerin “on top” really has is difficult to assess. In case of occlusion of an artery towards the eye, referral to an ophthalmologic center is mandatory in any case; in this case, there are no further treatment options available in the practice.
Source: Urdiales-Gálvez F, et al: Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations. Aesthetic Plast Surg 2018 Apr; 42(2): 498-510.
DERMATOLOGIE PRAXIS 2018; 28(3): 37-39
