Complications with dermal fillers are infrequent, and strategies to minimize their incidence and impact are easily deployed. Familiarity with each family of soft-tissue augmentation products, potential complications, and their management will optimize the use of these agents.

The patient’s medical history and subsequent evaluation must be comprehensive, and patients should be advised to include cosmetic treatments when giving their history.

Lip Filler Complication

This lip filler was carried out by an unqualified non-medical practitioner who caused an arterial occlusion followed by a subsequent infection and necrosis of the skin. The patient was left with scarring on her lip as well as distress and being out of work for a month.

All dermal fillers and filler procedures can lead to complications, which may be related to one of the following:

  • Product-related: Permanent non-resorbable products, antigenic nature of the material
  • Practitioner-related: Lack of knowledge, insufficient experience
  • Host-related: Altered host defence mechanism

Injecting in the correct plane is important for best results. It is important to know the differences in skin thickness in different parts of the face.

The table below shows early and late complications.

Early Complications

Multiple needle punctures might result in pain. If a sharp radiation pain occurs along the vascular course, during the filler injections, or within a few hours of the injection, it indicates a vascular problem that requires immediate attention.

Slowly introducing a needle with the narrowest gauge feasible helps reduce pain. Long needles, cold anaesthetic, and warming the filler to body temperature can all help to lessen pain.

After a procedure, transient erythema is frequent and normally goes away on its own. As a result of a hypersensitive reaction to various substances or illness, longer lasting erythema or persistent erythema is more likely. As a result, a thorough assessment and effective therapy are required.

Management includes avoiding erythema-inducing agents such as alcohol, exercise, and sun exposure. Topical steroids can be used for short periods to reduce the erythema. Appropriate makeup may be advised to cover the erythema.

Non-hypersensitivity-related swelling

Oedema may occur immediately after the injection because of manipulation and rarely persists for more than a couple of days.

Episodic swelling and oedema can occur after exposure too. This can be managed with gentle pressure cool packs or antihistamines. However, good consultation and advice to the patient usually ensures that there are no issues or worry from the patient.

Vasodilating stimuli such as sun exposure, exercise, or sauna bath following HA injectables. As this may occur without any other sign of allergic reaction, the treatment can be in the form of ice packs and topical steroids along with the avoidance of vasodilating situations. Properly explained aftercare advise should be given to the patient along with a take home leaflet


True hypersensitive-related swelling

oedema can also occur following true hypersensitivity reactions to injected products. This may occur as an angioedema at the site of injection or at distant sites with or without urticarial reaction over the body. This is treated with antihistamines and systemic steroids over a period of several weeks.


Delayed hypersensitivity-related swelling

Delayed hypersensitivity-related facial deem is usually non-antibody-mediated type IV reaction, which occurs days to months after the injection.

This is T lymphocyte mediated rather than antibody mediated and presents with induration, oedema, and erythema. It usually responds to oral steroids rather than antihistamines. The last and the best option is to remove the causative filler material.

Sterile folliculitis lesions occur because of occlusion of sebaceous or sweat gland openings and mimic bacterial infections or acneiform eruptions. If the filler is injected too superficially into the papillary dermis, it can be extruded through the sebaceous glands and appear like acne. Firm massaging soon after the injection may prevent the occurrence of these lesions. Topical treatment with astringents will help in cleaning these papulopustular lesions.

Bruising, hematomas, and ecchymoses may occur because of needle pricks and bleed from these points. It is more commonly seen in patients on anticoagulants or alcohol intake. This can be minimized by firm pressure at the site of needle insertion or by stopping the intake of anticoagulants; supplements including ginkgo biloba, vitamin E, omega-3 fatty acids, and St. John’s wort; alcohol; and mushroom 1 week before the procedure. Use of arnica, topical vitamin K, or bromelain has also been helpful to decrease the incidence of ecchymosis. In some situations, intense pulsed light and vascular lasers have been used to treat post injection bruises.

Theses can occur as result of inadvertent arterial injection of filler material and could result in serious injury in the form of cutaneous necrosis, blindness, or stroke.

Cutaneous necrosis can also occur as a result of excess material causing external vascular compression, and thereby reduced perfusion leading to scar formation. An intra-arterial injection can cause mechanical obstruction and damage of endothelial cells leading to ischemic changes in the skin. The common sites of necrosis reported after filler injections are the glabella, nasal ala, and NLF area.

The importance of early detection and response cannot be overstated. The first sign of injection necrosis is painless blanching during the treatment followed by acute pain. Stop injecting right away and carefully massage the affected region. Ischemia is frequently followed by a bluish discoloration and subsequently necrosis of the skin.

Blindness occurs from filler embolism to the ophthalmic vasculature. Visual loss usually occurs immediately and is accompanied by pain in the affected eye. Visual complications usually occur following injections in the glabella, nose, forehead, and periocular regions.

The underlying mechanism of retinal artery occlusion is secondary to retrograde embolization from peripheral vessels into the ophthalmic artery system.

Rarely when greater force is applied during injection, the filler emboli can enter the internal carotid artery and then be pushed into the intracranial circulation leading to cerebral ischemic events.
Unilateral blindness and left-sided hemiplegia because of retrograde flow of autologous fat following fat injections in the glabellar region have been reported.
Vascular complications are best avoided by a proper understanding of the anatomy and proper injection technique. Aspiration must be performed before each injection and the filler should be injected slowly and injection of small volumes per pass in two or more treatment sessions.

In cases of suspected intravascular injection, one should immediately stop the procedure, massage the area gently, and apply warm compresses. Topical nitro-glycerine paste can be used for vasodilation. Aspirin, low-molecular-weight heparin, and intravenous prostaglandins have all been advocated. New high dose pulsed hyaluronidase protocol appears to be a simple, safe and successful way to manage adverse vascular events of HA fillers.

Here, the 25 dosing depends on the number of tissues adversely affected. In case of blindness, immediate ophthalmologic consultation, ocular massage, and retrobulbar injections of hyaluronidase should be given. Unfortunately, the prognosis in such cases is grave regardless of the treatment given. In cases of cutaneous necrosis, proper wound care and antibiotics to minimize scarring is recommended. If scarring occurs, it may be treated with light dermabrasion, scar revision surgery, or dermal filler.

Infections clinically present as warm, tender erythematous fluctuant nodule with or without systemic signs such as fever and malaise. Usually, early low-grade infections are due to Staphylococcus aureus and occur as a result of contaminated filler depots and organize into biofilms, whereas late presentation raises suspicion of atypical mycobacterial infections. Bacteria present in biofilms remain dormant for a long time and emerge from their biofilm following activation by an external triggering factor such as a minor injury or manipulation, leading to low-grade infections, granulomas, or abscesses. Risk of infection is found to be higher in human immunodeficiency virus (HIV)-positive patients.

There is a potential risk of accidental intracranial penetration while performing the deep temple injection technique with direct pressure on the bone as the thickness of the bone is variable at the pterion.

Therefore, a good knowledge of the anatomy combined with gentle injection technique is mandatory while injecting fillers into the deep temporal fossa.

Late Complications

Granulomas are rare and occur as a result of type IV hypersensitivity reaction to a foreign body. Usually, they occur after a latent period of months to years after injection.

A proper medical and cosmetic treatment history is essential to make a correct diagnosis. The inflammatory reaction may be triggered by systemic infection, excessive sun exposure, impurity of dermal fillers, or consecutive injections of different fillers in the same facial region. A tissue diagnosis fulfilling the pathologic criteria of granuloma consisting of epithelioid cells and multinucleated cells is necessary to distinguish it from an inflammatory nodule.

Hypertrophic scarring can occur with superficial placement of fillers. This rarely leads to permanent scar consisting of extracellular matrix components such as collagen, fibroblast, and small vessels.

Management of hypertrophic scarring is softening the tissue with pulsed dye laser or intralesional steroids. In extreme cases, scar revision surgery may be needed.

There can be de novo appearance of telangiectasia or worsening of pre-existing telangiectasia at the injection site. In addition, treatment of erythema with prolonged topical steroid therapy can also induce telangiectasia.

Management of telangiectasia is by decreasing the volume of filler to minimize the pressure effect on vessels, and in addition, treatment with intense pulsed light therapy and pulsed dye laser can also be effective.

Fillers composed of suspensions of particles such as HA as microspheres like poly-L-lactic acid are capable of migration. It usually occurs when these fillers are placed in highly mobile areas where they get pushed by the activity of the muscle or because of gravitational forces. Migration to distant sites has also been described. It is influenced by gravity and occurs in patients with lax skin and subcutaneous tissue.

Management is to advise patients to limit all facial expressions for approximately 3 days after injection. In undesirable situations, the filler may be dissolved with hyaluronidase or removed completely.

Low-grade inflammation with negative bacterial culture may present as sterile abscess. In such cases, incision and drainage of e abscess and a course of tetracycline have been found to be effective.

Allergists recognize four types of allergic reactions:

  • Type I or anaphylactic reactions
  • Type II or cytotoxic reactions
  • Type III or immunocomplex reactions and
  • Type IV or cell-mediated reactions.

Allergic reactions are exaggerated sensitivities (hypersensitive reactions) that occur when your immune system responds abnormally to common substances such as pollen, dust and certain foods.

These substances, called allergens, are harmless in most people. But for those who are allergic, they can cause reactions upon skin contact or when they are breathed, swallowed, or injected.

Allergic reactions are quite common and may happen seconds to hours after contact with the allergen. Some reactions may take more than 24 hours to appear. Though many allergic reactions are mild, others may be dangerous or life-threatening. They may be localized, involving a small part of the body or may affect a large area or the whole body.

Certain metal jewellery or certain cosmetics may cause skin rash in some, for example. Others sneeze uncontrollably on exposure to dust or pollen.
An allergic reaction begins when you touch, inhale or swallow an allergen. In response to this trigger, the body starts making a type of protein called IgE or immunoglobulin E.

IgE molecules bind with the allergen molecules in an antigen-antibody reaction. This attachment of the antigen and antibody leads to the release of some chemicals (such as histamine) in the body. These chemicals cause the inflammatory symptoms of allergic reactions such as rashes, itching and sneezing.

When too much material is injected, overcorrection might manifest as lumps, nodules, or abnormalities. Hyaluronidase may quickly dissolve hyaluronic acid products. A simple puncture with a broad bore needle and drainage of the excess product may be sufficient in the case of non-hyaluronic acid.
A bluish discoloration also known as the Tyndall effect may occur if an excessive amount of HA is placed superficially under the skin, and this can be decreased by injecting hyaluronidase.

Antidote in this question is a medicine that reverses the effect of another. Hyaluronidase is the antidote for the non-permanent dermal filler, hyaluronic acid.
It is used off-label but is approved by the MHRA if the patient consents and will benefit from its use Hyaluronidase is an enzyme that depolymerises hyaluronic acid thus breaking it down

Hyaluronidase is received in a powder form of 1500 IU and is reconstituted with either saline or water. Bacteriostatic saline is usually preferred as it is less painful when injected. The ACE guidelines advise adding 1ml of saline from 10 mls to the hyaluronidase ampoule, once the powder is fully dissolved, this solution is added to the remaining 9ml of saline. The resulting concentration is 150 units/ml.

The number of units used will depend on the cross-linking of the hyaluronic acid and the area to be treated.

Whilst not common an allergic reaction can follow the use of Hyaluronidase, so a patch test is advised unless the treatment is an emergency. The rate of allergic reaction is said to be between 0.05% to 0.69% Hyaluronidase does interact with some drugs, so a full medical history is imperative.

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