Complications of temporary fillers

Published on 16/03/2015 by admin

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Last modified 16/03/2015

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26 Complications of temporary fillers

Summary and Key Features

Soft tissue augmentation with temporary fillers continues to be among the most commonly performed cosmetic procedures

There are a variety of temporary dermal fillers with an ever-increasing number coming to market. As more fillers become available, it is imperative that the aesthetic physician who injects dermal fillers has proper training in their use and understands the differences between them

Though generally safe, complications can occur with temporary fillers; physicians need to recognize and manage these complications when they present

Peri-procedural adverse events such as bruising, swelling, and pain are extremely common and usually resolve in less than 7 days

Proper injection technique is crucial to minimize visible and / or symptomatic papules and nodules

To minimize the risk of infection and biofilm formation, one should consider a skin preparation utilizing chlorhexidine and / or isopropyl alcohol

The cause of granulomatous reaction is multifactorial and may be due to a true foreign-body reaction to the particulate or gelatinous filler or to the emergence of a biofilm

Early institution of antibiotics, often for a prolonged period, is vital when a patient presents with inflammatory papules and nodules

Early recognition of impending necrosis after injection is critical; treatment with hyaluronidase, topical nitroglycerin, and massage may be required

Judicious use of injectables requires an appreciation of normal facial anatomy and the changes that occur with the aging process

There is an alarming trend of increasing numbers of non-aesthetic physicians and non-MDs using these products; one may expect to see potential complications in the office

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.

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.