Management of Dermal Filler Complications

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As dermal fillers become increasingly common in dermatology and plastic surgery, it is only logical that complications arising from them will become more prevalent. These iatrogenic complications can be distinguished as either acute or chronic, with each event necessitating a unique algorithm for proper diagnosis, treatment, and management. We have identified several clinical pearls that may help the clinician manage adverse events associated with the injection of hyaluronic acid fillers (Figure 1), stimulatory fillers, or permanent biopolymer fillers (Figure 2). Many of these patients are self-referred, as they have been treated by outside clinicians, or illicit pseudo-clinicians, with no follow-up management.

Patients with complications arising from dermal fillers may present with uniquely challenging manifestations that may or may not fall within predictable patterns of presentation. It is important to gather history and physical examination data to ascertain whether the problem is acutely emergent or chronic in nature. Several clinical scenarios require immediate attention, including the presence of infection or vascular occlusion. Other dermal filler problems, such as transient swelling, ecchymosis, or asymmetry, may be more transitory and require mere reassurance.

We have developed a large clinical case series of patients who have sustained complications arising from permanent and semipermanent fillers, including those developed after the injection of polymethylmethacrylate and polysiloxane. In recent years, the increasing popularity of hyaluronic acid fillers has increased the number of patients referred to our centers for acute and chronic management. Mild complications include transient swelling, ecchymosis, asymmetry, loss of anatomic balance, migration, nodularity, and poor cosmetic results. More severe dermal filler complications include granuloma formation, granulomatous nodularity, progressive swelling, calcification, chronic edema, infection, abscess formation, seroma formation, nerve injury, vascular occlusion, facial reflex sympathetic dystrophy, skin changes, chronic pain, chronic hypersensitivity, and chronic inflammation. Our intent is to further streamline the process of identifying, diagnosing, and managing patients.

Identify Acute vs Chronic Complications
Early diagnosis of acute complications is imperative. A small subset of dermal filler complications is acute and time-sensitive in nature, often requiring emergency therapy. Vascular occlusion and infection must be ruled out in all patients presenting with complications arising from dermal fillers. In some cases, the signs of vascular occlusion or infection can be obfuscated by ecchymosis and transient hyperemia associated with the filler injection. Be alert to the possibility of vascular occlusion in patients with unilateral swelling; changes in skin turgor or color; the absence of skin perfusion; decreased capillary refill; skin blistering; diff use folliculitis; or loss of sensory, visual, or motor function.

Determine Filler Origin
The widespread availability of synthetic polysiloxane fillers, biopolymers, counterfeit dermal fillers, and online direct-to-consumer products has led to a rise in dermal filler complications. These complications can occur even with capable and experienced clinicians, but the rise in illicit products has dramatically increased incidence rates. Many dermal filler complications arise from the injection of products with questionable origin. Ask patients to provide medical records of previous fillers if available, including lot number and method of injection. Patients and outside injectors may be complicit in the use of unauthorized and unstudied dermal fillers.

Assess Filler Timelines
When treating chronic dermal filler complications, patient symptoms should correspond with the recognized longevity of the filler used. Most US Food and Drug Administration (FDA)-approved hyaluronic acid fillers have in-vivo longevity lasting between 6 and 18 months, often dependent on the area of injection and cross-linking of hyaluronic acid. According to clinical consensus, stimulatory fillers may last between 12 and 48 months, whereas permanent biopolymers are lifelong and rarely reversible. Patients with hyaluronic acid fillers who report having chronic swelling, nodularity, and filler volume after the 18-month point may potentially have other types of fillers, including silicone biopolymers, which may be permanent or semipermanent. Clinical suspicion for counterfeit fillers, permanent biopolymers, or polysiloxane fillers should be present in patients with long-term complications. For this reason, clinicians should “think outside the box” when managing these adverse events and suspect the presence of ancillary fillers, including stimulatory, semipermanent, or permanent fillers, in patients with chronic complications.

Establish Regional Referral Networks
Improving the management of dermal filler complications is best achieved by sharing clinical experiences with colleagues through peer-reviewed literature, clinical studies, anecdotal patient reports, or case reports. It is imperative that clinicians utilize all available sources of data to best manage dermal filler complications, including frank discussions with colleagues about their experiences and strategies for management. As an example, Dr Raed Rtail developed a national awareness program with the Ministry of Health in his native country of Lebanon to 1) increase public attention toward adverse dermal filler complications, 2) educate colleagues about the management of dermal filler complications, 3) develop algorithms for emergency management of dermal filler complications, and 4) highlight cooperative resources among plastic surgeons and dermatologists involved in the care of these patients. The resulting national media campaign has mobilized an entire nation against unsafe cosmetic surgery practices in Lebanon. In addition, the program has recruited a network of referral centers for acute and chronic management of these adverse events.

Utilize Clinic-Based Ultrasound
The availability of ambulatory ultrasound devices has made the real-time identification of subcutaneous dermal fillers much more tenable, objective, and measured. Hand-held, laptop, and stand-alone duplex ultrasound allow for the identification and early management of subcutaneous dermal fillers. In our practice, ultrasound is used to identify the depth of filler injection and the spatial distribution, location, density, and amount of dermal filler under the skin. In most cases, we have found ultrasound to be a useful adjunct to fine-cut computed tomography scanning or magnetic resonance imaging. In addition, color flow ultrasound can help identify regional vasculature and rule out the presence of purulent or sterile fluid pockets. Ultrasound, along with other diagnostic imaging, also allows for interval measurements of filler volume and displacement.

Create an Emergency Kit
Dermal filler complications can be clinically unpredictable and time sensitive. It is important to maintain an adequate amount of emergency supplies to help manage these adverse events. Hyaluronidase is a mainstay of therapy, owing to the popularity of FDA-approved hyaluronic acid fillers in the United States. Proper knowledge of the dosage, dilution, administration, and limitations of the product should be disseminated among clinicians in the practice. Hyaluronidase indications and contraindications, with a readily available consent form for its use, should be maintained in the emergency kit. In addition, sterile saline for dilution, needles, cannulas, and syringes should be kept available. There are protocols for the management of dermal filler complications that may include the use of intralesional corticosteroids, oral corticosteroids, topical vasodilators, and sodium thiosulfate (evolving data). These products should be available based on relevance to the practice. Of note, use of anesthetics with epinephrine may obfuscate capillary refill in patients with suspicion for vascular occlusion and should be used sparingly in favor of anesthetics without epinephrine. The emergency kit should be prepared based on clinical relevance, with algorithmic written protocols for ease of use.

Conclusion
Dermal filler complications are challenging and time-sensitive adverse events that present with variable and unpredictable clinical patterns. The simple techniques described in this article may help streamline the diagnosis, treatment, and management of these clinical scenarios and help optimize long-term results.