Review of Literature: Management of Dermal Filler Complications

Abstract

The use of dermal fillers has increased to a greater extent in cosmetic indications owing to their in time results and nominal recovery period. The application of dermal fillers in soft tissue augmentation and facial rejuvenating procedures is popular. Undoubtedly, instead of being regarded as safe tools for skin, dermal filler techniques can sometimes cause complications. These complications may range from mild swelling and infection of superficial skin to the development of granuloma, skin necrosis, itching and pain, skin discolouration and formation of bumps and biofilm. Different dermal filling agents are used: Hyaluronic Acid, Calcium Hydroxylapatite, Polymethylmethacrylate and Poly-L-Lactic Acid. Because of the broad-spectrum use of dermal filling procedures and arising adverse effects, this review aims to describe the associated complications and how to diagnose, manage and avoid them by applying practical strategies.  Esthetic experts conducted detailed research using Google Scholar, PubMed and peer-reviewed articles on different terms as soft filler complications, injectable complications and dermal fillers complications. Based on the literature database and the author’s experiences, various recommendations on managing and avoiding filler-associated complications are provided. And if ever they occur, how should clinicians manage and prevent them by knowing the actual symptoms and causes. This document would provide the basic information for clinicians using dermal filling techniques to identify the underlying critical issues of complications and how to avoid those using readily available agents in the office and action protocol in emergencies.     

Introduction:

Cosmetic surgery is the gold standard for people who need it but with dermal filers we can achieve long-lasting corrections with less side effects that’s why in the last 5 years, dermal fillers are popular in the US and also many other countries .It is important to know the different groups of dermal fillers and know each usage and the area which of them can be used. The longevity of the aesthetic-enhancing effects depends on the type and amount of filler, and injection technique utilized and, treatment location. Case selection and understanding the facial anatomy, aesthetics, and techniques to get a good result in minimally invasive procedures like using dermal fillers are also important factors to get a good result.

Non-invasive improvements in one’s appearance and healthier skin through modern medical practices in the cosmetics industry are becoming highly popular. Variation and demand for dermal fillers have increased drastically during the last few years. [1]

Wide use of dermal fillers over the past three decades has been reported in improving the looks of an ageing face through soft tissue augmentation. This practice is increased from 1.6M/year in 2011 to 2.6M/year in 2016. With an increase in the number of soft tissue filler injections applications, it is inevitable to see their adverse effects. [2]

It is essential to know that proper selection and intelligent application of filling products can help manage and avoid complications. [3]

High use of hyaluronic acid filler than the others is explained by its efficacy, versatility, and safety profiles. [4]

Skin gains volume and fullness by applying dermal fillers, which are available in different forms. Every product contains its risks and benefits. Potential threats could be reduced by using sterilized and professional appliances and injections. In facial rejuvenation, soft-tissue fillers have gained importance [5]. 

However, these complications resulting from soft tissue augmentation are infrequent with mild adverse effects, and there are meagre chances of any severe adversities but repeated. The growing use of the same filling products may lead to some severe skin concerns. But it can be managed by deploying some effective treatments and preventive measures [6]. 

Different factors govern the type of complications related to dermal fillings. Noteworthy are the time of onset (late or early), level of severity (severe, moderate or mild) and nature of the problem (ischemic or non-ischemic). Skin granulomas have been observed in patients late after filler injections treatment. At the same time, skin necrosis is seen in the case of filler vascular blockage and sometimes irreversible blindness [7-10].

The FDA database reported over 2800 cases of adverse effects in the USA in five years between 2013 to 2017 [11]. 

The main objective of the present review is based upon the study of various complications associated with dermal fillers and practical ways to avoid them or overcome them.

Table 1: Problem List of Dermal Filler 

1-Granulomatous foreign body reaction

 

2-Tyndall effect 

 

3-Bumpy and lumpy

 

4-Overcorrected with Hyaluronic Acid

 

5-Edematous

 

6. Vascular compromises

 

7. Delayed complications: Nodule formation, Migration, Immune reactions, persistent discoloration, fistula formation, sensory dysfunction

Complications

Pain is common following injection. Using small needles can decrease the injection pain, but viscous filler agents may require larger needles for injection. It is also recommended to use topical or regional anesthesia prior to filler injection to reduce injection discomfort (11).

Acetaminophen is also effective to manage post-injection pain, but aspirin or NSAIDs are contra-indicated due to their anticoagulation effects and they should be discontinued prior to injection if possible. Blood-thinning medications are also no exceptional because of their ability to increase the risk of bleeding. Post-operative infections are rare, but people with the history of herpes simplex infections should be treated with prophylactic antiviral agents (12). Granuloma formation is common with alloplastic filler agents and semi-permanent and permanent materials, but it is also reported with using biologic filler agents (11-14).

Granulomas can often be treated with simple excision and incision/drainage. Hyaluronidase is also recommended for hyaluronic acid fillers. To prevent complications such as filler palpability and lumps, care should be taken to inject more viscous and large-sized particle filler agents into the deep dermis and less viscous and small-sized particle filler agents more superficially (11). Major complications are rare but serious. Allergic reactions can occur with animal-derived products and allergy testing prior to injection of these materials is required (14-15). Some other serious complications such as skin necrosis, blindness and death are also reported (16).

Post – operative care

There are several post-treatment considerations that patients should mind following filler injection. The patients are recommended to use cold compresses for 24 to 48 hour to reduce swelling and the patient should have 30 degrees head elevation for the first 24 hours. Physical activities and facial expressions should be limited immediately after injection to prevent filler migration. They also should avoid excessive sun exposure until erythema and swelling disappears. Aspirin, NSAIDs and blood-thinning medications should be avoided for 24 to 48 hours before and after injection to minimize the bruising which may last 7 to 10 days. Acetaminophen is usually enough for pain control. Oral antihistamines can blunt the histamine release and resultant early edema and may be most useful in patients who develop more edema than usual or redness immediately after injection. Swelling occurs following injection and usually last for 2 days but it may continue for up to 3 weeks. Oral antihistamines can help to decrease the early edema (11-16).

                              

Figure 1: Edema 24 hours after lip injection 

Local Adverse Reactions Infection:

Though mainly fillers are harmless and well-tolerated, sometimes any one of the filling agents become the cause of some unfavourable side effects. This adverse reaction is directly proportional to the staying time of filler in the skin. As long as the fill remains in the skin, as does the infection, and if the filler removes out earlier, the condition goes away along with it [12]. 

American Academy of Dermatology reported that swelling, redness, bruising, pain, itching and rash-like signs are found around the injection areas. But these signs are not permanent, and they mostly clear away within a week or two [13].

Except for the symptoms mentioned above, some other side effects could be observed as filler leakage, infection, bumps, nodules, lumps, granulomas, filler movement under skin and injury of blood capillaries [14].

Different types of fillers cause different adverse reactions primarily characterized through time course. Hyaluronic acid and collagen cause reversible (temporary) effects. Calcium hydroxylapatite, dextranomer beads in Hyaluronic acid, Poly-L-Lactic Acid (PLLA) and alginate 

become the cause of long-term or late development. Whereas permanent and delayed effect is caused by paraffin, Vaseline, silicone oil, polyacrylamide, polyalkylimide gels, hydroxyethyl, polymethylmethacrylate and hydroxyethyl methacrylate fragments [15-16].

Superficial Filler Placement:

Superficial Filler Placements are observed for filling the fine lines and wrinkles appearing on the face, mainly under the eyes and around lips. Complications resulting from this procedure can be avoided if taken care of correctly [17].

Manifestation of superficial filler placements varies and depends upon the injection area and quality of the product being injected. Particular caution is needed during the superficial application of fillers [18].

There are higher risks of product visibility in Tear Trough areas and can only be performed by an experienced person in the relevant product and technique [19].

   

Fig 2: Tear Trough sharp needle injection on an old (93 years old female) body. 

A: Diagram showing subperiosteal injecting technique B: an overview of corpse injection image

C: View of subcutaneous layer D: Periosteal View

Injection Technique:

Nowadays, injectable fillers are at the top of facial rejuvenation, and they have contributed a lot to the significant success of this modern aesthetic treatment [20].

A wise and intelligent selection of proper injection techniques for a particular patient is mandatory to ensure positive outcomes and minimize the adverse reactions to the maximum level. Different patterns were described for proper placement of dermal fillers as linear threading, serial puncture, fanning and cross-hatching. The site of injection and the applied product govern the type of selected pattern. Selection of proper pattern helps the ineffective treatment of the area under observation [21, 22].

                                

Figure 3: complication of poor injection in peri orbital area .

Management of complications 

Hyaluronidase treatment techniques are rapid. Tiny needles are placed in the previous HA filler areas for injection, such as the lips, cheeks, nose, and eyes. Most patients do not require pretreatment numbness. Discomfort, bruising, or swelling is usually mild and short-lived.

The results are noticeable within minutes of the hyaluronidase injection and may continue to function over time. If necessary, repeated injections may be required to dissolve all the fillers. It is not known that injection of Hyaluronidase permanently dissolves HA that is naturally present in tissues. Hyaluronidase can be injected at any time after HA filler treatment, even months after the first filler injection.(23-25).

Table 2 : 

Conclusion:

People are confident of using dermal filling agents following several techniques. Instead of adopting some safety measures, there are very few complications to occur. To reduce or avoid these filler associated complications, it is highly needed to undergo the procedures by experienced clinicians only with proper product knowledge and its dealing and knowing the anatomy of the desired area to be injected or filled. 

Conflicts of Interests:

There are no conflicts of interest amongst the authors’ w.r.t the publication and authorship of the research paper. 

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