If you are looking for a detailed introduction to the things that can go wrong when delivering cosmetic injectables and lip fillers then you are in the right place; introducing Dr Tim Pearce’s Ultimate Guide to Dermal Filler Complications, updated for 2020.
In this must-read guide, Dr Tim discusses the most common dermal filler complications associated with medical aesthetic treatment, including the most serious such as vascular occlusion and blindness, alongside how to recognise and manage them.
Dr Tim is on a mission to share his extensive knowledge of dermal filler injection techniques and complications management, accrued over more than a dozen years, with other like-minded healthcare professionals delivering medical aesthetic treatments. By sharing experiences, knowledge, and skills, we can all learn together to be the safest practitioners and truly raise the bar for patient safety.
What are the different types of dermal filler complication?
No matter how minor or serious the dermal filler complication, they will always be uncomfortable and traumatising for your patient, but also stressful for you as the clinician. Having to remain calm in what seems like a crisis, remember all that you learnt in training and find the best approach to recognising and treating a complication can be daunting and can knock your confidence if you struggle in such a situation or you feel underprepared.
If you lack confidence it will hold you back, it will stifle your creativity and impact on how you treat your patients and will ultimately affect the potential results you can achieve if you become too cautious or conservative with your treatments for fear of something going wrong. It is vital that healthcare practitioners who are delivering medical aesthetic treatments, such as lip fillers, jawline contouring, non-surgical rhinoplasty, or cheek volumising injectable treatments familiarise themselves with diagnosing, preventing, and treating different types of dermal filler complications.
The information in this Ultimate Guide to Dermal Filler Complications is based on Dr Tim’s own experience in clinic and his years of studying the potential adverse effects and unwanted outcomes that can happen both during, immediately post- and sometimes much later after aesthetic procedures are delivered.
The best way forward for all healthcare professionals practising aesthetic medicine is to focus your efforts on preventative measures to avoid or mitigate, as much as possible, the cause of a complication. It is vital that you increase your learning and begin that by understanding the pathogenesis of each of the most common complications which are explained in this guide. Each one has been researched for you and educational material made available below to discuss both avoidance and management, although this is only the start and we encourage you to undertake further training in mastery complications management. The dermal filler complications covered below include:
- Non-Inflammatory Lesions
- Inflammatory Lesions
- Bacterial Infection
- Nerve Injury
- Salivary Gland Injury
- Impending Necrosis
What are non-inflammatory lesions? Simply put, they are characterised as a lump or bump of isolated filler or fluid under the skin, which is generally not painful, but cosmetically unappealing.
When diagnosing a non-inflammatory lesion, you are looking for a soft, spongy lump which demonstrates fullness or oedema (swelling) in the area where you previously injected. When it comes to dermal filler complications, non-inflammatory lesions are probably the most common adverse effect you will see as an aesthetic practitioner, aside from bruising, and can commonly occur in the lips.
Although commonplace, thankfully, they are also the simplest to manage as there is no biochemical reaction going on between the filler product and the body. Often simple massage techniques can solve non-inflammatory lesions.
As well as managing the physical appearance of such lesions, clinicians should take into account the psychological and psychosocial impact for the patient. Small lumps, which may not be very visible, can often be left untreated and will resolve on their own; yet a more visible and obvious lump may seem like a significant and mountainous abomination to the patient, thus requires you to take a more aggressive approach to resolution, which would otherwise be unjustified.
Of course, if the lump or bump shows signs of inflammation, such as redness or tenderness to the touch then you are dealing with an inflammatory lesion caused by a foreign body or allergic reaction which requires a different approach. It is important to learn how to properly investigate and diagnose lumps caused by dermal fillers to distinguish between non-inflammatory and inflammatory lesions
By their nature, inflammatory lesions or nodules are a more serious prospect when it comes to dermal filler complications than non-inflammatory lesions. They can be caused by many different mechanisms, manifesting in slightly different ways, and thus needing managing in distinct ways, all of which must be investigated.
Depending on the cause, which may be post-procedural inflammation, infection, a viral reaction or a hypersensitivity reaction, the physical attributes will vary, so it’s important to learn how to diagnose inflammatory lesions or better still, prevent them from occurring through improved product selection, aftercare advice for patients and aseptic techniques. As they can have multiple causes, a complete diagnosis of the cause of an inflammatory nodule is seldom possible in clinical practice, but routes to resolution mean than management techniques are often successful.
Serious and rapid onset of inflammation due to hypersensitivity is thankfully considered to be quite rare but can occur in immunosuppressed patients or those with systemic illness, so proper patient selection and consultation is also paramount.
Haematoma, alongside ecchymosis, petechiae and purpura are medical terms used to describe what we usually all refer to as bruising. Bruising is the number one side effect, some argue, complication, from dermal filler treatment. It is, however, 100% a significant issue for patients and is something all healthcare practitioners should try to avoid causing as much as possible. Bruising affects a patient’s appearance, quite dramatically, and tells the world around them what they have been up to due to its visibility. Bruising, particularly around the eye area can have a negative psychological effect on an individual as they explain to worried friends, family or work colleagues that they haven’t been in a fight.
Despite its apparent insignificance as a complication, it should not be a side effect ignored by clinicians as it can negatively impact on your practice. Patients will not thank you for it and may lose trust in your skills and abilities. If they are really unhappy then you may risk retaining them as a patient as they seek out another clinician for their next treatment, plus they could help to damage your reputation if they tell their friends and family about their experiences. Similarly, any such side effects add to your after care workload as a patient with a bruise still needs managing, providing with emotional support and aftercare guidance, and you still need to write up the notes and do the paperwork. Avoiding giving patients bruises is therefore something we should all be doing and there are many best practical ways to help you to reduce bruising. Dr Tim is proud that after many years’ experience in aesthetic practice, he has substantially reduced the rate at which he causes bruising in his patients. You can learn these skills too.
Although bacterial infections can occur following a dermal filler procedure, they are generally regarded as rare, likely because with some simple preventative measures, which should always be taken, you can usually avoid their occurrence.
Bacterial infections can be categorised into different levels of severity, the least troublesome is a transient inflammation of the area which persists and then resolves as the body fights off the bacteria. More significant problems come with reactions such as biofilm or abscess formation, and worst-case septicaemia which can be life-threatening. The most common culprit when it comes to skin infections is staphylococcus aureus.
Most of the bacterial infection cases reported in relation to dermal fillers have been caused by external bacteria entering the skin. Therefore, it is vital that aesthetic practitioners use aseptic techniques and clean the skin before injecting, as well as use sterile equipment in a well-disinfected clinical environment.
Additionally, Dr Tim believes that the biggest risk of bacterial infection comes with injections around the lips, particularly at the oral commissures where the entry point is often closest to the wet-dry border. It can be normal for small amounts of saliva to reach that point immediately post-procedure which could be a significant risk for infection.
Sadly, even if you do your best to apply these preventive measures; the patient may leave your care and go on to touch the injection sites causing bacteria to enter the wounds. Good patient education is also vital to make sure they understand their aftercare.
It is important for aesthetic clinicians to recognise the signs of bacterial infection and how to manage those symptoms. You should familiarise yourself with understanding the management of skin infections such as impetigo, erysipelas and cellulitis.
A nerve injury is one of the most distressing, but thankfully rarest complications for patients.
This type of injury is typically caused by mechanical actions from a needle, cannula or by the filler product itself if it has a high viscosity, such as piercing, compressing, tearing or injecting a nerve during the administration of the dermal filler treatment.
It is worth also noting that as well as mechanical causes of a nerve injury, it has been hypothesised that trauma from a needle can trigger a varicella-zoster breakout; the virus which causes chicken pox and shingles. A shingles infection, which would require its own diagnosis and management, would also disrupt the proper function of the nerves. Learning to correctly identify and manage nerve injuries will increase your understanding of this rare complication.
There are three types of nerve injury which can be caused:
- Neuropraxia – the least severe, involving dysfunction to the myelin layer of the nerve,
- Axonotmesis – as well as damage to the myelin layer, this also includes damage to the axon of the nerve, however, the endoneurium is preserved so the nerve will recover,
- Neurotmesis – the most significant damage to the nerve fibres, which can vary but ultimately leads to either a slow regrowth, a poor and slow regrowth, or permanent damage and loss of nerve function.
The main preventative method against causing a nerve injury is for a clinician to educate themselves and undertake a training course in facial anatomy so they understand the location of the nerves within the face.
Salivary Gland Injury
A recent trend for chin and jawline contouring dermal filler treatments has led to an increase in salivary gland injuries, particularly as these are usually performed with a cannula.
Understanding the anatomy of this area is paramount when performing such treatments as you risk tearing or penetrating the parotid and submandibular glands.
Salivary gland injuries can be difficult to spot so it’s important to understand the ways that you can diagnose a salivary gland injury as they have similar symptoms and manifestations as inflammatory lesions, which can catch out even the most experienced aesthetic clinician.
Blindness, both temporary and permanent, caused by dermal filler injection to the face is often regarded as the most serious and terrifying complication documented in relation to this treatment. The earliest paper on this came from Lazzeri et al in 2012 who published a study which discussed blindness following cosmetic injections of the face. Since then, many more studies of published cases have been undertaken and been peer-reviewed, including a review of the world literature on avoiding and treating blindness from fillers which analysed 98 reported cases. The conclusion of this review by eminent doctors stated:
“Although the risk of blindness from fillers is rare, it is critical for injecting physicians to have a firm knowledge of the vascular anatomy and to understand key prevention and management strategies”.
Thankfully, causing vision loss with dermal filler treatment is rare, but with increases in the trend for filler procedures in the mid and upper face, particularly non-surgical rhinoplasty, the number of reported incidences in the literature has also increased.
Due to the distressing nature of this complication, the immediate onset of symptoms, and the limited time frame available for rapid management to restore blood flow and avoid permanent damage to the retina, it is essential that healthcare practitioners who are delivering cosmetic injectables understand the potential causes of blindness from dermal filler injections, the best practice for preventing blindness, and how to diagnose and manage the complication.
Blindness is caused by the injection of a dermal filler product into a facial artery or vein. The filler material then travels through the vascular system into the ophthalmic region resulting in a vascular occlusion which cuts off the blood supply to the eye(s).
To make matters worse, it is now known that facial anatomy varies from person to person, but a good understanding of key anatomical features and so-called dangers zones for injecting can help you to prevent this complication from ever happening, although 100% certainty is never a guarantee.
Impending Necrosis – a Product of Vascular Occlusion
Vascular occlusion, or VO, is a hot topic amongst medical aesthetic practitioners and is one of the most common complications possible when delivering dermal filler treatments. If an artery is blocked or occluded by product during a dermal filler procedure, it means that oxygenated blood cannot reach an area of tissue. With a lack of oxygen, cell function will become impaired, eventually leading to cell destruction which is referred to as impending necrosis – skin necrosis caused by a vascular occlusion.
One method for preventing vascular occlusion is by aspirating to ensure that you are not in an artery. This is performed by pulling back on the syringe plunger once the needle placement is where you want it, holding the plunger for several seconds and checking for flashbacks of blood which would indicate a positive aspiration and a sign that you have placed your needle within an artery. This allows you to retract your needle and choose an alternative entry point or angle for injection which is away from the artery. Learning how to aspirate and how long to wait when performing a dermal filler injection can help you to prevent both vascular occlusion and impending necrosis.
Dr Tim explores his own case study and experience in dealing with a vascular occlusion during a lip filler treatment in a recent podcast: A true story: emergency reversal of filler. You can also download a free step-by-step guide to the emergency reversal protocol.
The likelihood of causing a stroke from a dermal filler treatment is very slim as the product must enter the intracranial circulation and come to rest in an artery supplying part of the brain. Blockage of a vessel in this region will cause hypoxic damage to the brain in a matter of three minutes.
There are two main routes by which filler can enter the cerebral circulation. The first is by retrograde flow of filler product from the facial artery into the common carotid artery and then into the internal carotid. The second is by filler product entering through the ophthalmic artery via one of the three vessels in the orbit, the supratrochlear, supraorbital or lacrimal arteries.
Understanding the FAST acronym for rapid assessment of stroke should be within every clinician’s armament.
Learn everything you need to know about dermal filler complications
Understanding, preventing, diagnosing, and managing complications from dermal filler injections can seem like a terrifying prospect. The various complications discussed in this ultimate guide carry unique symptoms and tell-tale signs which apply to treatments across the whole face, with different areas including the lips, cheeks, nose and tear troughs all carrying their own particular risks, anatomical understanding, and specific preventative treatment techniques.
By learning all the relevant complications knowledge, you will be able to implement measures to help prevent dermal filler complications and treat more safely. This will, in turn, boost your confidence and allow you to be more creative when designing a treatment plan for your patients, without fear of what might happen. However, this guide should only be the starting point of your general understanding, as you journey towards mastering dermal filler complications.