Dermal Filler risks and how to minimise them
Dermal fillers are injections of gel like substances used to fill out wrinkles and creases in the skin.
They can also be used to increase the volume and definition of the lips and cheeks as well as defining and adjusting the shape and proportions of the face.
Dermal fillers are a common and safe treatment when carried out by suitably trained and experienced medical practitioners. However, it is very important that anyone considering dermal fillers is aware of the potential for side effects and complications and they understand that this is a medical procedure and therefore should be carried out by a suitably trained professional only.
What are the risks?
The risks of dermal fillers depend on whether the procedure was done correctly and the type of filler used. Permanent fillers have the highest risk of problems and are best avoided; there are plenty of alternative and technologically superior options available. The most commonly used and safest fillers are Hyaluronic Acid (HA) fillers including Juvederm, Restylane, Belotero, Teosyal etc. A major benefit of these fillers is that they can be dissolved immediately using an enzyme called hyaluronidase in case of both undesired cosmetic outcome as well as some complications. Every cosmetic practitioner offering dermal fillers should be able to administer hyaluronidase and be aware of the risks and side effects of the treatments they do.
If there are any complications that require medical attention, it is best that you go back to the practitioner who treated you. This is why it is vitally important that you chose a medically qualified practitioner who is able to assess, diagnose and manage any complications that may arise from the treatments they offer you.
So what should you do to minimise the risks of complications that may arise from dermal filler treatment?
Complications are best prevented with careful planning and sound knowledge. Thorough knowledge of both facial anatomy and the specific characteristics of each filler are critical. In addition, managing patient expectations is an important element in the pre-treatment preparation.
Anatomy. Skin thickness varies among facial areas, which affects optimal injection depth. In addition, areas such as the frown area are at increased risk of blood vessel blockage with excessive injection volume or incorrect placement.
Treatment area. The appropriate depth of placement is dependent on the product selected and area being treated and strongly influences the end result.
Patient expectations. Before treatment, the doctor should clarify the patient’s goals and expectations for both the procedure itself and the subsequent results, and the patient should be given the opportunity to identify desired treatment areas with a mirror. Standardised pre- and post-procedure photographs should be taken for documentation.
Informed consent. It’s essential that you are given the required information to be able to provide your informed consent; this should cover the discussion of potential side effects and all details of postoperative care.
Preoperative screening. The patient should be screened for any medical issues that could affect the application of filler, such as pharmacologic or pathologic clotting disorders, previous vagal episodes, history of seizures and allergies among others. A full medical history including any current treatments and medications should be taken by the treating doctor themselves.
Even with careful planning, knowledge and skills, complications can occur…so here are the ones that you should be aware of.
Complications: Early Onset
Early-onset complications are those that occur within the first two weeks after the injection.
Although most minor early complications can be avoided with proper injection technique and filler selection, even the most seasoned injector can induce bruising and swelling, which a patient may consider socially embarrassing. It is, therefore, crucial to the doctor-patient relationship for the physician to discuss all potential minor complications and their impact on the timing of the injection session. I usually discourage patients from scheduling injections within two weeks preceding important social events or at any times that they really do not want any evidence of treatment to be visible to others.
Bruising and swelling.
This can be limited by avoiding visible vessels while injecting. Pulling the skin taut in a well-lit room can aid this practice. After the session, the patient can apply a cold-pack for 15 minutes. It is not necessary for patients to stop blood thinners if they are appropriately counselled prior to the procedure regarding an increased risk of bruising, particularly if stopping these medications could lead to an increased risk of problems. I do advise my patients to not drink alcohol for 24 hours before a filler treatment as alcohol can thin the blood and increase the risk of bruising. Blunt-tipped cannulas instead of needles can also be used to minimise bruising. Arnica can also help reduce duration of bruising as well as avoiding exercise and extreme heat such as saunas for a few days after treatment.
Swelling occurs from both the inflammatory effects of the injection itself and the increased volume of the filler. In addition, particular fillers can increase the risk of swelling, particularly older technology fillers which can draw more water towards them. Not all fillers are created equal and even within a brand such as Juvederm there are different levels of technology (reflected in differences in price). It is important that you understand what is being used and why your practitioner is recommending that particular filler before you agree to the procedure.
Discomfort and pain.
Injection discomfort and tenderness can be a significant source of patient anxiety, especially for the first-time patient. Several techniques can be used in order to minimize the pain associated with injections, which include: the utilization of the small needle gauge or blunt-tipped cannulas, application of ice prior and after injection. We offer every patient local anaesthetic cream prior to filler injection. In addition, the physician can provide “vocal local” through engaging in conversation with the patient and by offering comforting physical contact, such as hand-holding.
If patients experience minor pain, tenderness, and/or headache after filler injection, they should be advised to use Paracetamol on the treatment day and to avoid NSAIDs and aspirin for one week, as these can contribute to further bruising. Immediate post-injection discomfort should not be dismissed by the doctor as an expected side-effect, as it could indicate a more serious problem….
Worsening of patient appearance after filler injection will be regarded by the patient as a major complication and should be addressed promptly. As I previously mentioned, one of the great advantages of the hyaluronic acid fillers is that they can be dissolved by the injection of hyaluronidase. Hyaluronidase can be injected multiple times if needed and can be utilized throughout the anticipated duration of the filler.
Nodules. Although patients are normally able to palpate the filler after injection, the physician should be concerned about red, painful, or tender nodules. These signs may indicate the presence of infection and should be cultured if fluctuant. The patient should be placed on empiric oral antibiotics and rechecked within 48 hours.
Vascular compromise. This is the most feared early complication. Proper injection technique, choice of injection site, and choice of filler can limit the risk of vascular compromise. The frown region between the eyebrows is at particular risk, given its anatomy and blood supply. Blockage of blood vessels is extremely rare; however, every clinic should be prepared for such an event as the consequences of not being able to immediately manage this issue can have disastrous consequences.
Symptoms can vary from extreme pain with geographic discoloration to a dull persistent ache. Any concern raised by either the patient or the staff should be taken seriously and managed swiftly. The area of concern should be massaged and aspirated. Hyaluronidase can be injected if hyaluronic acid filler was used. Ice should be avoided. Oral steroids are also a consideration if swelling is thought to be compressing a vessel. The patient should be followed daily until significant improvement is noted and referred for a second opinion if needed.
Complications: Delayed Onset
Delayed-onset complications are those that occur after the first two weeks post-injection.
The most common complications in this category are palpable or visible material, blanching, nodules, and hypersensitivity reactions.
Bumps, blanching, and nodules. If the injected material is placed too superficially or in excess quantity, it can result in visible bumps or blanching/ bluish discoloration of the surrounding area.
The bumps can sometimes appear bluish due to differential light scattering, which is known as the Tyndall effect. The under eye area is particularly prone to this complication given the thin skin in that area. In some instances, this discoloration can persist beyond the effective duration of the filler itself.
Even if it is not visually apparent, material can persist as lumps which can be felt. This is more likely to occur if medium-weight fillers are injected too superficially. Areas at higher risk include the nasolabial folds, lips, fine periorbital and perioral lines, and tear troughs. To minimize this occurrence, it is important to inject at the correct depth.
If blanching occurs during the injection, immediate firm massage may resolve the discoloration, although blood supply problems must be ruled out. Options for treating the Tyndall effect and palpable but nonvisible nodules include attempted aspiration with a needle, steroid injection, massage, dermabrasion, puncture and expression, injectable hyaluronidase or surgical excision. Most practitioners’ first choice is hyaluronidase injection.
Hypersensitivity reactions. These are rare, and allergy testing for approved fillers is not generally required. Such a reaction should prompt a referral for allergy testing.
More significant complications include migration of the filler away from the injection site, granuloma formation, and infection.
Migration. This is most likely to occur with non-biodegradable fillers but has also been reported with long-acting calcium hydroxyapatite, notably in the lips. Migration can cause discomfort. Treatment, either by repositioning or excision, can be complicated. This is another reason I do not offer these types of fillers in our clinic.
True granulomas. These are rare and occur in less than 1 in 1000 cases. Granuloma formation typically occurs within six months but has been reported as late as 15 months post-injection. Granulomas are most likely to occur after injection with products that either do not biodegrade completely or only partially biodegrade.
Standard treatment is with either oral or injected steroids. The latter require judicious use, as they have been associated with significant side-effects of their own. If other treatments fail, surgical excision can be attempted as a last resort.
Delayed infection. This often presents as a tender, red, warm nodule that may be fluctuant. The patient may also develop systemic symptoms of malaise, body ache, fever and generally feeling unwell. Appropriate antibiotic therapy should be started and further investigations including laboratory tests may be indicated particularly if there is no improvement on antibiotics after 48 hours.
This may be more information than you think you need but I would advise anyone considering injectable cosmetic treatments to have as much knowledge as they feel they can handle before deciding on having a treatment. Non-surgical cosmetic treatments like dermal fillers are safe, effective and a great option for many people. It is up to you to make sure you chose the correct person to deliver this treatment; doing so will ensure you get the best results as well as feeling safe and secure that the practitioner can minimise and manage any side effects and complications effectively.