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Dr Tim Pearce
Delayed onset nodules following dermal filler treatment – also known as lesions, or simply just lumps – can strike fear into the hearts of even the most experienced aesthetic clinicians. Why? Because these dermal filler complications issues are not easy to diagnose or manage.
Firstly, the diagnosis needs to carefully consider:
- Are they lesions or just post-procedural trauma?
- Are they inflammatory or non-inflammatory?
- Are they bacterial or not?
Then, subject to your diagnosis, whether, when and how to treat the lesions consider:
- How long to watch and wait
- Whether to treat with antibiotics and/or steroids
- Whether to reverse the filler altogether with hyaluronidase
Expert Advice on Delayed Onset Modules
As seen on the Aesthetics Mastery Show
Dr Tim Pearce explains:
“Well, the first thing is don’t assume immediately that’s a filler reaction. That’s probably the first thing that I see new practitioners do too often, which is any problem that they’re presented with, they immediately assume, “Oh, it’s my treatment that’s caused this problem.”
“There are many medical causes of lumps and bumps, and you need to have your clinical hats on generally before you immediately start assuming that you’ve caused a complication with your treatment because much of the time it isn’t that problem at all.”
Inflammatory vs Non-Inflammatory Lumps & Lesions
One of the first challenges is to work out whether the problem is inflammatory or non-inflammatory; because it could just be a filler lump. Dr Tim explains how to tell the difference:
“One of the ways is to palpate the lump and if it feels tender, that’s a clue that there’s some inflammation going on because mostly filler on its own is not tender. So that would be one of the first things to help figure out whether it’s inflammatory or not. Some of this is down to gathering history. So you could ask them a series of questions that look for inflammatory causes. Have you had a cough or a cold? Have you had any dental work? Anything that could cause inflammation.
“These things may start to indicate an inflammatory response, but also what’s the history of the lump. Did it come up immediately after the procedure? And has it got worse since then? Because that’s very different to a lump that came on maybe three months after the procedure, has come on gradually and is a little bit tender. This would also be different to a lump that has no tenderness and has no real signal that there’s any infection, but is still present. They’re different possible causes resulting different treatments.
“I’d start with questions first. Is there any tenderness? Is there pain? How did it come on? What’s the sequence of events? Depending on the answers, this will tell you to lean more towards inflammatory or non-inflammatory response.”
Delayed onset nodule vs normal lump after fillers
“To differentiate delayed onset nodules and any other type of nodule, there should have been a period where there was no inflammation and a recovery. This could as little as three or four days or as much as three to six months. But you need a period where things seemed normal because that’s a good indication that it’s not a post-procedural response (keep in mind for every procedure, if there’s bruising, you can get lump). A bruise itself can result in induration and you get texture changes in the skin which feel like a lump, but it’s not reactive. So you’re looking for that period of quietness where everything was fine. And that’s the key that differentiates it from procedural injuries.”
Tim stresses the importance of keeping an open mind and not making the wrong judgement too early:
“…it’s very important to keep your mind open when patients first present. One of the most common ways that clinical mistakes are made is that something happens in the history taking process that makes the clinicians shut off their mind to many other differentials and they get tunnel vision.”
He explains that individual responses also vary:
“One set of patients develop hard lumps that left untreated will persist for months and months. Another set of patients may develop inflammation that if you do nothing, basically dies down with time. And then there are the ones that respond to antibiotics on their own, which we may not know for sure, but those would be more related to infection.”
How to treat patients with lumps and lesions
Tim suggests a safe and cautious approach:
“I think it’s safer to treat them as both. So you’d combine steroids and antibiotics, and then give that a reasonable amount of time to respond before you decide to use Hyalase. That’s a separate discussion , which is when to Hyalase”
Are delayed onset modules more common in lips?
“Well, that’s certainly my experience that they’re more common in lips. There are a number of possible reasons for this. It could be that lips are very sensitive and any little lump gets noticed and diagnosed quickly. Comparatively, if a patient is having a minor inflammation in the cheek and is on the periosteum it may remain unnoticed and the patient may not complain about it. So it could be that we’re more sensitive in the area of the lips.
“But of course, that area of your face has much more immune activity going on there. In fact, one of the biggest parts of your immune system involves defending that mucus membrane in your GI tract meaning there are many more white blood cells active in that area and so it could be that the lips become more easily inflamed and patients pick up on this readily.
“It could also be that there are more of these biofilm reactions because the mouth is, as we all know, full of bacteria. No matter who you are, no matter how often you brush your teeth, there’s plenty of bacteria that if they got into the wrong place might cause an inflammatory response. We know that from dental work, which is one of the possible causes of these inflammatory reactions, because patients get a temporary bacteraemia – an influx of bacteria that are quickly dealt with, but they stimulate the immune system to respond, and that causes temporary inflammation.”
Delayed Onset Modules Video
Aesthetics Mastery Show
Useful Links
Further reading about dermal filler complications and anatomy
You may find the following articles useful:
- 13-point-plan to reduce the risk of vascular necrosis
- Injection Techniques 101: Good Injection Techniques for Dermal Fillers
- 3 stages to Master Facial Anatomy
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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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