OJHAS Vol. 10, Issue 3:
Sajad Ahmad Salati,
Professor of Surgery, College of Medicine, Qassim University, Saudi Arabia.
Dr. Sajad Ahmad Salati,
Address for Correspondence
Professor of Surgery,
College of Medicine,
Salati SA. Complications of
Dermal Filling. Online J Health Allied Scs.
Submitted: Jul 28,
2011; Accepted: Oct 22, 2011; Published: Nov 15, 2011
have globally become sought after drugs due to the desire of aging population
to regain the youthful looks without any surgical operations. But like
other procedures, dermal filling can become complicated. Besides the
profitability have introduced the factor of malpractice which can bring
in misery rather than beauty and youthful body contours. This article
briefly reviews the common adverse effects of dermal fillers.
Dermal fillers; Complications; Consent; Malpractice
have brought in a virtual revolution in the field of cosmetic surgery
in recent years 1-2. These fillers have provided a safe and
effective method for neutralizing the effects of aging and stress and
regain a youthful and healthy appearance without coming under the sharp
knives of surgeons and with minimal down time. These drugs have been
widely advertised and marketed by pharmaceutical companies and the concept
of soft tissue augmentation is continuously attracting aging people
who are eager to look better.
with the widespread surge on the use of dermal fillers for body rejuvenation,
a new disease entity in the form of adverse outcomes and complications
of these cosmetic procedures are being reported in the literature
3-7. The adverse effects to dermal fillers can be attributed to
the procedure itself, the procedural technique, and the agent injected
5. Among these factors, the injection techniques have been reported
to be most significant in present era of temporary fillers 6.
The faulty techniques by novice or unqualified or greedy practitioners
have been the cause for most of the miserable outcomes after these cosmetic
Complications of Dermal Fillers
of dermal fillers are varied and include:
certain transient and predictable complications which include erythema,
edema and ecchymoses. They may occur immediately after the procedure
or present hours after the injections are completed. In some studies,
such transient adverse events related to dermal filling have been reported
in as high as 21.5% 6 of the injections. Ecchymoses is usually
minor and resolves without intervention after 2 to 3 days. Although
ice packs and cooling after injections can increase patient comfort,
they have not been found to be efficacious in reducing postoperative
More significant ecchymoses may develop in patients who consume alcohol, anticoagulants or nonsteroidal anti-inflammatory drugs, or
certain herbal medications associated with prolonged bleeding; examples
include vitamin E, ginger, garlic, ginseng, and gingko biloba.
The herbal medications are often underreported by patients in the screening
process. Ciocon et al recommend discontinuing these agents at least
1 week prior to major procedures although bleeding time may take 2 to
3 weeks to fully correct.8
Besides the technique and expertise of the injector are also important
determinants of immediate complications. In this regard, Gladstone et
al has reported that the fanning injection technique for dermal fillers
can also increase the likelihood of bleeding.9
1: Edema and ecchymosis after gluteal dermal filling
associated with dermal filling can appear early as acute infection or
late as chronic infection. Acute infections generally occur due to breach
of aseptic techniques should be rare in expert hands. These early infective
lesions in form of inflammation or even abscesses may be due to common
skin and soft tissue pathogens, including Staphylococcus aureus.5
Lesions that develop more than 2 weeks post dermal filling might even
suggest the presence of an atypical infection, and mycobacteria also
need to be considered as causative organism. Besides, dermal filling
can lead to reactivation of herpes infections. Infection may also be
due to faulty products and outbreaks of mycobacterial infections have
been reported to use of tainted dermal fillers by nonphysicians.10 Similarly there are reports of chronic abscess formation due
to organisms like E –coli even as late as seven years after dermal
filling with Bio- Alcamid.11
2: Multiple gluteal abscesses after dermal filling
skin discoloration can occur at the site of treatment; this typically
occurs immediately after injection and generally resolves within a few
weeks as mentioned before.3 Reddish discoloration signifies
an inﬂammatory response, whereas pallor at the injection site can
be attributed to overcorrection or the color of the injected substance.
Hyperpigmentation (which can be treated with depigmentary cream) and
bluish discoloration have also been reported, particularly in cases
of products containing hyaluronic acid. The bluish hue may represent
both traces of hemosiderin associated with vascular injury and visual
distortion from light refraction to the ﬁller through the skin (Tyndall
effect) due to superficial deposition. Hypersensitivity
fillers are essentially foreign bodies and some patients may develop
hypersensitivity to injected products due to an exaggerated immune response.
Such reactions generally occur within minutes of exposure to a challenging
antigen owing to the release of histamine, and manifest as edema, erythema,
pain, and itching. These allergic reactions can be severe 15,
and cases of severe angio-edema and anaphylactic shock have been reported
may be inﬂammatory or noninﬂammatory and infection-or noninfection-related
and may present subcutaneously or in the dermis14-15.
Non-erythematous, painless nodules occurring earlier than 2 weeks are
likely related to uneven filler placement 16, but pain, erythema
and fluctuation may indicate infection. Intermediate to late nodule
complications, arising 2 weeks to 1 year post injection, and delayed
nodules noted beyond 1 year, may be immune responses to the filler or
infectious granulomas. Delayed onset fibrotic nodules may be seen with
poorly placed particulate stimulatory filler, such as poly-L-lactic
acid and calcium hydroxyl apatite, especially in mobile areas, such
as the lip, or with the use of poly-L-lactic acid, particularly because
of the inadequate dilution of filler.
3: Multiple nodules over dorsum of hand one year after dermal filling
fillers may temporarily produce a bloated appearance but a major complication
which occurs as a result of poor filling technique is under/over correction
leading to asymmetry and ugly outcomes. Overcorrection of the upper
lip can lead to a “duck bill” appearance. Asymmetry due to temporary
fillers resolves with time but if permanent fillers are injected, the
asymmetry will be a cosmetic and mental disaster.
4 : Asymmetrical lips after dermal filling
necrosis is a rare but clinically important and serious potential complication
of dermal filling. This results from interruption of the vascular supply
to the area by compression, injury, and/or obstruction of the vessel(s).17-18 It may occur when the material is injected into the angular
artery of the nasolabial fold or the supratrochlear artery in the glabellar
region. Compression of the supratrochlear vessels during injection of the filler
has been proposed as a technique to minimize this complication.
5: Skin necrosis over dorsum of hand after dermal filling
literature, there are many other complications reported with use of
dermal fillers which are uncommon but are potentially serious. These
injections in the gluteal area have been reported by Coronado-Malagón
M et al 19 to result in fat embolism. Pulmonary embolism
has been reported by Hyung Joo Park et al 20 as a serious
consequence of vaginal filling with hyaluronic acid based filler. Even
cerebral artery embolism with resultant neuro-deficit have been reported.21
retinal artery and posterior ciliary arteries are proximal branches
of the ophthalmic artery. Multiple superficial arteries of the
face are distal branches of the ophthalmic artery (supraorbital, supratrochlear,
dorsal nasal, angular artery of the nose). A cannula or needle used
to inject a soft tissue filler can accidentally perforate the wall of
one of the distal branches and enter the artery’s lumen and when the
plunger of the syringe is pressed to propel the injectable filler out
of the syringe, the filler gets injected into the lumen of the cannulated
artery. The filler displaces the arterial blood and travels as a column
proximally past the origin of the retinal artery. As the forced injection
ceases at the end of procedure, the arterial systolic pressure propels
the filler anterograde flow into retinal central artery and anterior
and long posterior ciliary arteries leading to blindness, corneal and
iris ischaemia, and total ophthalmoplegia. There are many such reports
published in literature.22 -25
can presents as lumps and bumps simulating malignant lesions. The diagnostic
difficulties are more in cases that conceal the history of dermal filling
and result in battery of investigations. Many times the issues are settled
only after histopathological analysis of the lesions.26
Management of Complications
of the complications of dermal fillers depends on the nature of the
adverse effect and the nature of the filler. But due to profitability
of this cosmetic procedure, unscrupulous practitioners are being reported
globally to inject substandard and unauthorized products without detailing
the patients about the nature of products. Or else, the patients might
be reluctant to volunteer the history of dermal filling due to social
inhibitions and may create a challenging situation in diagnosis and
management. In our series, majority (51%) of the cases was unaware of
the nature of the injected filler. If however the nature of filler
is known, multiple medical means to reverse the adverse effects can
be tried. These include the use of local/ systemic steroids, hyaluronidase,
antibiotics, analgesia and anti-inflammatory drugs besides counseling
and physical methods like cold sponging. Wiest
LG et al
have successfully treated granulomas arising from permanent fillers
containing microparticles with a hydrophobic surface like hydroxymethylmethacrylate
and ethylmethacrylate were treated with good results with a regimen
of allopurinol and intralesional injections with a mixture of fluorouracil
and low-dose triamcinolone.27 Surgical intervention has
a role in management complications 28 and may include drainage
of abscesses, revision of scars, and excision of granulomas and nodules.
such ocular complications, Coleman R S recommends using larger, blunt
cannulas and epinephrine at the injection site, while avoiding the injection
of large boluses of soft tissue filler in the face.29
Administration of dermal fillers without proper informed consent widely
mentioned in literature.30 It is must that the
people are informed about all the aspects of dermal filling with particular
emphasis on complications before embarking on these procedures.
fillers are an important recent advance in cosmetic dermatology but
it has the potential to produce complications particularly in hands
of untrained or uncertified hands. There is need to improve the level
of knowledge among the general population regarding positive and negative
effects of dermal fillers.
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- Campana M, Lazzeri
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formation 7 years after soft tissue augmentation with bio-Alcamid in
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embolism: a critical consequence of an illegal cosmetic vaginal procedure.
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- Silva MTT, Curi AL. Blindness and total ophthalmoplegia after
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