Second only to Botox, injectable fillers are a common method of facial enhancement. In but a few minutes, one can quickly add volume to small lips, deep nasolabial folds, skin depressions and areas of facial fat loss. With this ease comes millions of such injection procedures done per year by a wide range of physician and non-physician providers. With such varied educational and experience backgrounds, complications from fillers do occur. While not common, they can happen to anyone at anytime even in a patient who has had no prior filler problems.
The most likely injectable fillers problems are lumps and irregularities, but these are usually technique related and no real reactions to the filler material itself. Almost all of these will resolve on their own without any specific treatment due to the temporary nature of the fillers. Adverse reactions that require professional intervention include hypersensitivity reactions, infections, and skin compromise or necrosis.
Hypersensitivity reactions to injectable fillers are well known and are an acknowledged risk from the material. They have a low incidence and have been reported in every clinical trial from any filler that has ever been performed. They present within a few hours to a day with overall swelling and redness from the injection site. They are an immunologic reaction to a sensitivity of one of the filler components. There near immediate onset is an indication of an immune response. Immediate treatment with a Medrol dosepak (steroids) and aspirin will usually resolve it within a day or two. If it persists longer than a few days, then one needs to consider the possibility of an infectious problem.
Infection after injectable fillers is, in my opinion, more common than hypersensitivity reactions. Redness and swelling that does not quickly get better and is isolated in one region of the injected area (e.g., one lip when both have been injected) is most likely bacteria that has gotten tracked into the deeper tissues. The aggressive initiation of broad-spectrum oral antibiotics (e.g., Cipro) and even a small slit for drainage if it is localizing can turn it around in a few days. Patients should avoid putting heat on the swollen area.
Having seen a few infections over the years from fillers, I have gotten more cautious about how my technique. Prepping the skin is now routinuely done and I frequently change needles from one side of the face to the other. Longer needles can be helpful to treat some areas with a single injection site through the material is laid down as the needle is withdrawn.
The most feared injectable filler complication is skin necrosis. This can sometimes occur in spot areas where the filler is injected too close to the skin or directly into the skin itself causing a very localized ischemia. The more significant risk of avascular necrosis, however, is in the glabellar area where furrows are injected bilaterally. Inadvertent intra-arterial injection can cause a large area of vascular compromise leading to a midline area of skin necrosis. This initially appears as redness or even a purple color but its midline location indicates it is a vascular inflow problem. The application of nitroglycerin paste, oral aspirin, and massage is the first step. Injecting hyaluronidase as soon as possible into the injection may help dissolve the occluding filler material. Once can add an antibiotic and steroids but these are more psychotherapeutic than likely beneficial. One will then just have to wait as the skin demarcates and hope that is quite small.
While significant injectable fillers reactions are rare, the sheer number of treatments done in any geographic region makes it a certainty that most physicians performing these treatments will eventually seen one.
Dr. Barry Eppley
Indianapolis, Indiana