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Journal of the Dermatology Nurses' Association:
doi: 10.1097/JDN.0b013e3182a5244b
Feature Articles

Complications of Dermal Fillers

Smith, Jesse M.; Davies, Brett W.; Hink, Eric M.; Durairaj, Vikram D.

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Author Information

Jesse M. Smith, MD, Oculoplastic and Orbital Surgery, Department of Ophthalmology; University of Colorado Hospital, Aurora, CO.

Brett W. Davies, MD, MS, Oculoplastic and Orbital Surgery, Department of Ophthalmology; University of Colorado Hospital, Aurora, CO.

Eric M. Hink, MD, Oculoplastic and Orbital Surgery, Department of Ophthalmology; University of Colorado Hospital, Aurora, CO.

Vikram D. Durairaj, MD, FACS, Oculoplastic and Orbital Surgery, Department of Ophthalmology; University of Colorado Hospital, Aurora, CO.

The authors declare no conflicts of interest.

Correspondence concerning this article should be addressed to Vikram D. Durairaj, MD, FACS, University of Colorado Hospital, 12605 E 16th Ave, Aurora, CO 80045.E-mail: Vikram.Durairaj@ucdenver.edu

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The use dermal fillers has become commonplace over the last decade owing to their low cost, near-instant results, and favorable side effect profile. Adverse events, while relatively uncommon, can and do occur with the use of dermal fillers. The most common complications are bruising, erythema, and pain at the injection site, all of which resolve after a short time. Rarer complications include infection and granuloma formation, both of which can share a similar clinical appearance but require different treatments. The most serious complications include tissue necrosis and blindness as a result of inadvertent injection of filler into a blood vessel. This article summarizes the relevant anatomy related to dermal fillers, the typical applications of fillers, as well as complications and methods of preventing complications.

Over the past decade, the use of dermal fillers has become commonplace in the arena of aesthetic medicine. The use of these products is growing rapidly, owing mainly to their effectiveness, relatively low cost, and favorable side effect profiles (Cohen, 2008). Cosmetic procedures in general are at an all-time high, with over 13 million procedures performed in the United States in 2011 alone (Levy & Emer, 2012). Minimally invasive cosmetic procedures, including dermal fillers, have increased by 123% since 2000 (Levy & Emer, 2012). These office-based procedures are usually safe and effective, but adverse reactions and serious complications can occur (Cohen, 2008). It is therefore important for dermatology nurses to recognize and understand the causes, clinical features, and prevention of these complications. This article will cover the important anatomy, typical applications, and adverse events associated with dermal fillers and methods of preventing them.

Dermal fillers are injected into the middle and deep dermis and subdermal space to restore volume and diminish the appearance of wrinkles, folds, acne scars, and AIDS-related fat atrophy (Lowe, Maxwell, & Patnaik, 2005). In the upper face, the most commonly treated areas are the horizontal rhytids of the forehead, the vertical furrows of the glabella, and the “crow’s feet” created by orbicularis oculi contraction. It should be noted that use of fillers in the upper face is off-label, and no filler products are currently recommended for use in the upper face. In the mid-face, the combination of bony remodeling of the maxilla and zygoma, progressive ligamentous laxity, and fat volume loss over time tends to result in the downward movement of the malar fat pad (Funt, 2011; Kahn & Shaw, 2010). These changes produce a hollowed-out appearance, and it has become a favored site for injection. In this area, hyaluronic acid and calcium hydroxylapatite are the most commonly used fillers (Funt, 2011). The most frequently treated area is the lower face. Nasolabial folds and “marionette lines” inferior to the oral commissures respond well to the volume restored by filler products. Anatomic danger zones for filler injection include the glabella (because of its tenuous blood supply and the proximity of the supratrochlear artery), the alar-facial angle (because of the nearby angular artery), and the dorsum of the nose (because of the dorsal nasal arteries) (Bray, Hopkins, & Roberts, 2010). It is vitally important to be aware of relevant anatomy as well as major nearby blood vessels when injecting filler products.

Dermal fillers are most commonly categorized by their composition (Lowe et al., 2005). Materials include autologous fat; collagens; hyaluronic acids such as Juvederm (Allergan, Inc., Irvine, CA) Restylane, and Perlane (Medicis Aesthetics, Inc., Scottsdale, AZ); poly-L-lactic acid (PLLA, Sculptra, Valeant Aesthetics, Bridgewater, NJ); calcium hydroxylapatite (Radiesse, Merz, Sherman Oaks, CA); and polymethylmethacrylate (PMMA, Artefill, Suneva Medical, San Diego, CA; Levy & Emer, 2012). Of late, hyaluronic acid has represented the largest market share for dermal filling products because it is less inflammatory, more convenient than other filler products, and importantly, reversible with the application of hyaluronidase (Park, Seo, Kim, & Chang, 2011).

All dermal fillers can cause complications (Andre, Lowe, Parc, Clerici, & Zimmermann, 2005). The most common complications are minor and include bruising, erythema, and pain at the treatment site (Levy & Emer, 2012). More serious complications can include granuloma formation, tissue necrosis, and blindness (Lazzeri et al., 2012; Levy & Emer, 2012; Lowe et al., 2005; Park et al., 2012, 2011). In general, the categories of adverse reactions are injection site reactions, inappropriate placement of the filler, hypersensitivity reactions, filler migration, infection, tissue necrosis, and blindness.

The most serious reported dermal filler complications have been tissue necrosis and blindness, both of which are rare but can occur when filler product enters into a blood vessel and results in a vascular occlusion (Cohen, 2008; Lazzeri et al., 2012; Levy & Emer, 2012; Park et al., 2012). This happens when an artery in the face (usually the dorsal nasal, supratrochlear, or angular artery) is accidentally cannulated and filler is injected (Levy & Emer, 2012; Park et al., 2012). The force required to inject the product overcomes systemic arterial pressure and results in particles of the filler travelling inside the vessel. In cases of blindness resulting from filler injection, the filler travels in a retrograde fashion from the arteries of the face into the ophthalmic artery, which provides blood supply to the eye and orbit (Lazzeri et al., 2012; Park et al., 2012). The glabella and nasolabial folds are the most common injection sites resulting in blindness, likely because of their proximity to the supratrochlear, dorsal nasal, and angular arteries, all of which have anastomoses with the ophthalmic artery. Tissue necrosis likewise results from injection of the product into a vessel or, in other cases, from direct compression of a vessel (Cohen, 2008; Levy & Emer, 2012). The most commonly affected area is the glabella, which has almost no collateral circulation, making it vulnerable to ischemia and, therefore, necrosis (Levy & Emer, 2012). Immediate, severely painful blanching reactions are the hallmark of vascular occlusions (Park et al., 2011). Methods suggested to decrease the risk of vascular occlusion include aspirating before injecting, utilizing a smaller needle or a blunt cannula, and injecting with minimal pressure (Lazzeri et al., 2012; Levy & Emer, 2012). Should ischemia occur, prompt intervention is critical to minimize necrosis and subsequent scarring. Hyaluronidase is the reversal agent for hyaluronic acid filler. In cases of ischemia after hyaluronic acid injection, 75–150 units of hyaluronidase (Vitrase, ISTA Pharmaceuticals, Irvine, CA) should be injected into the area. Other treatments that have proven valuable in the management of vascular occlusion include warm compresses, topical 2% nitroglycerin paste (Nitro-BID, E. Fougera & Co., Melville, NY), topical oxygen infusion cream (Dermacyte Oxygen Concentrate, Oxygen Biotherapeutics, Inc., Durham, NC), oral antiplatelet therapy (aspirin 325 mg once a day), and hyperbaric oxygen therapy (Dayan, Arkins, & Mathison, 2011).

Infection is another rare but serious complication of dermal fillers. Most infections associated with cosmetic procedures include common skin and soft tissue pathogens such as Staphylococcus aureus and Streptococcus species, although there are reports of atypical mycobacterial infections as well (Lowe et al., 2005). Clinically, most infections appear as single or multiple tender, fluctuant erythematous nodules within the first week after injection (Lowe et al., 2005). In these cases, any exudate should be cultured, and a course of oral antibiotics such as clarithromycin (500 mg by mouth, every 12 hours for 6 weeks) is recommended until culture data become available (Cohen, 2008; Narins, Coleman, & Glogau, 2009). It has also been reported that fillers may cause reactivation of herpes simplex virus in patients with previous outbreaks (Narins, Jewell, Rubin, Cohen, & Strobos, 2006). Prophylactic antiviral treatment is recommended in these patients, and active herpetic lesions are a contraindication to dermal filler application (Narins et al., 2006). Standard skin preparation with antiseptic such as chlorhexidine remains the most reliable method of preventing infection (Levy & Emer, 2012).

Dermal fillers, by definition, involve the placement of foreign material into the body. This naturally elicits an immune response, which can range from subclinical to severe (Andre et al., 2005). Granulomatous inflammation is a late complication that represents an immune response to a foreign body, and it can manifest clinically from nonvisible, palpable nodules to “angry red bumps,” which typically occurs days to months after the injection but may present up to 24 months after the procedure (Cohen, 2008). Granulomas have been associated with every filler type, although bovine collagen (also a component of PMMA treatments) and PLLA have the highest incidence, and silicone-related granulomas are known to develop years after initial treatment (Cohen, 2008; Levy & Emer, 2012). Given the fact that red nodules can represent both infection and granuloma formation, Narins and colleagues developed an algorithm for approaching these lesions (Narins et al., 2006). It consists of antibiotic treatment first, followed by intralesional steroids if there is no improvement. If the nodules persist despite steroid therapy, then biopsy is recommended (Levy & Emer, 2012). Surgical excision is another therapeutic option, and it is typically successful for well-circumscribed lesions (Lowe et al., 2005). Overall, the incidence of granuloma formation in dermal fillers is low, but a working knowledge of their clinical appearance and differential diagnosis is useful.

Injection site complications range from erythema, bruising, and pain to visible nodules and migration of the filler away from the original treatment site. Slow, precise injections; small-gauge needles; and immediate cold compresses are most effective at preventing common complications (Levy & Emer, 2012). Less commonly, nodules may form around the site of the injection. These nodules are usually the result of uneven distribution of filler product but may also represent transient granulomatous reactions (Lowe et al., 2005). PLLA, for example, can cause a transient granulomatous reaction in up to 44% of patients treated for HIV-related facial lipoatrophy (Lowe et al., 2005).

With any injected products, skin discoloration typically occurs immediately at the site of injection and resolves within a week. Redness is the result of local inflammation, whereas whiteness can be from excessive product injected, local ischemia, and the color of the product itself (Lowe et al., 2005). A bluish discoloration known as the Tyndall effect can occur just under the skin in cases of excessively superficial injection of hyaluronic acid (Cohen, 2008). Injection of 75 U of hyaluronidase can decrease the prominence of the Tyndall effect (Hirsch, Brody, & Carruthers, 2007).

Migration of fillers is another cosmetically difficult complication. It is historically most commonly associated with silicone fillers but has been reported in with all fillers (Lemperle, Morhenn, Pestonjamasp, & Gallo, 2004). Silicone has the ability to migrate far from the original treatment site, at times giving the appearance of granulomatous disease and even tumor growth (Lowe et al., 2005). The spread of silicone occurs along tissue planes and has been reported to involve distant organs (Prather & Jones, 2006). It should be noted that silicone as a dermal filler is not FDA approved and should not be used as a cosmetic injectable. Fillers consisting of suspensions of particles (hyaluronic acid, for example) or microspheres (PMMA, PLLA) are also commonly associated with migration (Lemperle et al., 2004). Figure 1 shows an example of hyaluronic acid filler migration causing upper lip ptosis.

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Dermal fillers generally offer versatile treatment options, near-instant results, and favorable safety profiles. Although rare, complications do occur, and dermatology nurses must be familiar with the relevant anatomy and be able to recognize potential complications. Patients should be made aware of the risks as well as the benefits of dermal fillers before selecting a treatment. In this capacity, dermatology nurses have an important role to play in setting realistic expectations, helping patients anticipate adverse events, and facilitating informed consent.

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Complications; Face; Fillers; Indications

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