Introduction

Soft tissue fillers are used to fill wrinkles and folds, to add volume lost during senescence, to sculpt facial structure, and to correct defects such as scars and facial lipoatrophy. Soft tissue augmentation utilizing temporary fillers continues to be among the most commonly performed cosmetic procedures. The increasing demand is due to a population demanding facial rejuvenation with less invasive approaches, fast actualization of results, and minimal morbidity. In 2009, approximately 1.5 million injections of temporary filler agents were performed amongst all board-certified physicians practicing cosmetic surgery, representing a significant increase over previous years. Given their favorable safety profiles, effectiveness, and versatility, and the availability of multiple filler options, it is expected that the popularity of these products will continue to increase. Despite their impressive safety record, complications and adverse events can occur. The number of complications may increase as more people begin seeking this type of intervention and more injectors begin providing these services. In particular, there has recently been an alarming trend of increasing numbers of untrained or poorly trained physicians and non-physicians using these products; therefore one needs to be prepared to see complications in our offices even if we were not the injector.

Materials approved for soft tissue augmentation can be divided into biodegradable, semibiodegradable, and non-biodegradable products. These classifications correlate with their duration of effect as being temporary (approximately 6–12 months), temporary-plus (duration up to 18 months), or permanent (Box 26.1). As more fillers become available, it is imperative to understand the differences between them, the complications that can occur from each, and how best to avoid and treat them when they do occur.

Potential complications associated with temporary soft tissue fillers can be categorized by the time of onset (Box 26.2). In general, adverse events can be subdivided into acute and delayed reactions. Acute reactions are procedural or related to injection technique. They are usually transient and are manifested by erythema, edema, ecchymosis, pruritus, and pain in the first week after injection. Delayed reactions are related to the product itself, or the interaction between the filler and the host response. They are usually manifested by persistent erythema, swelling, nodules, and indurations developing months to years after. The nature of these reactions and their treatment will be summarized in this chapter.

Injection site reactions

The most common adverse events associated with fillers are local injection site reactions, manifested by pain, erythema, and edema. They are typically mild, localized, and transient, resolving within 4–7 days. A recent study by Brandt et al evaluating the efficacy and safety of biphasic hyaluronic acid Restylane^® and Perlane^® in the lower face revealed that the majority of patients treated with both small and large gel-particle hyaluronic acid experienced at least one injection site reaction. The reported events in decreasing order of occurrence consisted of bruising, tenderness, swelling, and redness. In another study comparing hyaluronic acid (Restylane^®) with collagen (Zyplast^®) for the treatment of nasolabial folds in contralateral sides, injection site reactions occurred at 93.5% and 90.6% of the hyaluronic acid and collagen treated sites, respectively. The bruising can be severe, especially in patients who have taken antiplatelet agents such as aspirin or non-steroidal anti-inflammatory agents, as shown in Figure 26.1.

Figure 26.1 Severe periocular ecchymosis 7 days following injection of hyaluronic acid deep into the supraperiosteal fat pads.

Pain

Pain is often one of the commonly reported adverse events associated with filler agents. Pain is often attributable to hydrostatic dissection of tissue during injection, as well as the discomfort of numerous needle punctures during the implantation of the product. Certain anatomical sites such as the lips and perioral region are more sensitive as a result of increased sensory innervation of these sites. A number of techniques may be utilized to minimize the pain associated with injections. These include the use of topical anesthetics, application of ice before and after injection, and vibratory distraction. Some clinicians also utilize infraorbital and mental nerve blocks. Placement of small aliquots of lidocaine along a few points of the gingival sulcus has also been found to be beneficial in minimizing pain associated with injections of the lips. In the past 18 months, a number of fillers have begun to package the filler syringe pre-mixed with lidocaine.

Edema and ecchymosis

Some of the most common post-procedure adverse events are bruising and swelling secondary to local trauma from the injection (Fig. 26.1). Reviewing all medications and supplements with the patient can minimize the degree of edema and ecchymosis. Avoidance of agents that inhibit coagulation is recommended, including aspirin (unless taking for ‘therapeutic’ indications) and non-steroidal anti-inflammatory medications, as well as supplements such as garlic and Ginkgo biloba that have an inhibitory effect on platelets. Other supplements such as vitamin E, fish oil, glucosamine, ginger, ginseng, green tea, and celery root can inhibit coagulation pathways and further increase bleeding and bruising. It is recommended to withhold these supplements at least 5 days prior to treatment.

Bruising can often be minimized by choosing the injectable filler least likely to cause this problem. Collagen-based fillers were less likely to cause ecchymosis secondary to their inherent platelet-aggregating properties. However, they are not available at the time of this writing. Conversely, it has been suggested that hyaluronic acid fillers have an anticoagulant effect and can cause more swelling and bruising because they are structurally similar to heparin.

When bruising occurs there are a few things that can be employed to minimize the degree and duration of the ecchymosis. Some advocate supplements such as bromelain and homeopathic Arnica in reducing post-treatment ecchymosis. Bromelain been shown to decrease vascular permeability in animal models by lowering the levels of bradykinin, thereby potentially resulting in less edema, pain, and inflammation. Helenalin, an extract of Arnica, has been shown to possess anti-inflammatory effects and inhibits platelet function in vitro. Clinical studies of both these compounds have provided conflicting results, with some revealing a decrease in post-treatment bruising, whereas others show no statistical difference. Further investigations are needed to substantiate their effect. Aside from these ‘natural’ remedies, some physicians choose to minimize post-treatment ecchymosis by utilizing their vascular laser at purpuric treatment settings.

Nodules and papules

Inappropriate placement of fillers may result in the development of subcutaneous nodules and papules. The majority of these are manifested as palpable and / or visible bumps under the skin. Injecting too superficially can lead to lumps of visible product, or bluish bumps under the skin explained by the Tyndall effect with hyaluronic acid fillers (Fig. 26.2). Such reactions can, for the most part, be prevented by use of correct technique. Treatment of visible papules can often be accomplished by firm digital pressure, by aspiration, or by incision and drainage. When persistent papules and nodules are due to the use of a hyaluronic acid filler, the enzyme hyaluronidase can be utilized to treat them.

Figure 26.2 The Tyndall effect is shown following injection of the hyaluronic acid Restylane^® intradermally in the superior modiolus.

The incidence of injection site nodules from temporary fillers appears to be higher in patients receiving poly-l-lactic acid (PLLA; Sculptra^®