Welcome to my updated 2020 guide to dermal filler complications. In this guide, I will go through the 9 worst dermal filler complications such as vascular occlusion and blindness caused by aesthetic treatments.
My name is Dr Tim Pearce, and I’m on a mission to share over 12 years of injection technique experience with the very safest healthcare professionals so that together we can raise the bar for our patients.
Different types of Dermal Filler Complications
Filler complications aren’t just an uncomfortable and traumatising experience for your clients, but they can affect your confidence as a clinician.
A lack of confidence can limit your creativity and potential results when treating patients so it’s vital for aesthetic practitioners to familiarize themselves with the diagnosis, prevention and treatment of the different types of dermal filler complications.
The information below is based on my own experience and years of studying the different side effects that can happen during or after aesthetic procedures. It is vital for your efforts to focus on preventive measures. This starts with understanding the pathogenesis of each possible complication.
The 9 different types of filler complications I have researched and created management/avoidance tactics for are:
- Non-Inflammatory Lesions
- Inflammatory Lesions
- Bacterial Infection
- Nerve Injury
- Salivary Gland Injury
- Impending Necrosis
This complication is commonly referred to as lumps or bumps. A non-inflammatory lesion is a pocket of isolated or sterile filler or fluid.
The diagnosis of a non-inflammatory lesion would be a soft spongy lump, fullness or oedema in an area which you previously injected.
This complication is probably the most common side-effect you can get as an aesthetic practitioner along with bruising.
On the other hand, they are also the simplest to manage due to the fact that there is no biochemical reaction between the product and the body.
Unfortunately, if the body reacts to the product and does produce a biochemical reaction the lump becomes a complication itself and must be treated differently.
You can distinguish non-inflammatory lesions from inflammatory ones by investigating the affected area and checking for redness or any signs that would remind you of an inflammatory or allergic reaction.
Inflammatory lesions can be caused by several different mechanisms such as post-procedural inflammation, infection, viral reaction or a hypersensitivity reaction.
Aside from the medical diagnosis, it is important for the aesthetic clinician to take into account the psychosocial impact of any lesions.
A small lesion that is not visible may be left untreated and it will often resolve on its own.
Conversely, a lesion in a visible place may be completely intolerable to the patient and justify more aggressive treatment.
Inflammatory nodules are caused by infection or reaction and unfortunately, complete diagnosis certainty is seldom possible in clinical practice.
This reaction is exceedingly rare but can have higher chances of happening with patients that are immunosuppressed, including anyone with systemic illness.
You can do further reading about inflammatory lesion diagnosis and prevention here.
Bruising, Haematoma, Ecchymosis, Petechiae, Purpura… These are all different terms used to describe types of bruising.
Bruising is a major issue for patients as it affects their appearance on a dramatic scale and it is visible by the people around them.
This can have a negative psychological effect on their life as they will have to explain the bruise to worried colleagues and friends.
Bruising caused by dermal filler procedures is not a side-effect that should be ignored as it can negatively impact the following:
- Client Experience – patients will see bruising as a negative part of their client experience. They may lose trust in your skills as a clinician.
- Client Retention Rate – if the client is unhappy with your skills as a clinician it could result in them not coming back to you for their next treatment.
- After Care Workload – side-effects caused by the aesthetic procedure can create the need for after-care and paperwork.
- Reputation – If the client who had the bruise talks about their experience in a negative manner to friends and family it can damage your reputation.
After years of experience in the industry, I have substantially reduced the rate in which I cause bruises as a dermal filler complication. Find out some of the best practices to reduce bruising.
Bacterial infection following a dermal filler procedure can happen but fortunately it has very simple steps for preventive measures.
Bacterial infection from dermal filler can be divided into two different levels of severity:
- A transient inflammation before the body kills off any offending bacteria.
- Reactions like biofilm, abscess formation & even the chance of life-threatening septicaemia.
Most of the bacterial infection cases reported have been caused by external bacteria entering the skin.
It is vital for practitioners to clean the skin before injecting as well as to use sterile equipment in a well-disinfected environment.
Unfortunately, even if preventive measures are applied; the patient may touch injection points post-procedure causing bacteria to enter the wounds.
Additionally, it is my view that the biggest risk for infection are 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.
Therefore, any practising clinician must be able to recognise the signs of infection and know how to manage the symptoms. You can read more about the different types of infection here.
A nerve injury caused by dermal filler would typically occur by piercing, compressing, tearing or injecting nerves during an aesthetic treatment.
There are three types of nerve injury you can cause while performing a treatment:
Nerve injury can happen through mechanical causes such as compression of the nerves or directly injuring the nerve with the instrument of the procedure.
An understanding of the anatomy of the face can prevent you as a clinician from directly injecting into or near the nerve system of the face.
In addition to the mechanical cases of the nerve injury, it’s also hypothesized that trauma from the needle can trigger a varicella-zoster breakout.
This would cause nerve injury from an infective cause and would require different management.
Salivary Gland Injury
With a recent rise in chin filler treatments and jawline filler treatments, there has been an increase in salivary gland injuries caused by dermal filler.
As you are performing this treatment, whether it is a cannula or standard needle, particularly over the masseter muscle & near the inferior border of the mandible, the instrument may tear or penetrate the surface of the parotid & submandibular glands.
Damage to these glands can cause perplexing symptoms to the uninformed client or clinician.
The symptoms are very similar to inflammatory lesions which makes it difficult to diagnose if you’ve never experienced it before.
Blindness from injections was first documented in 1963 when a patient suffered visual loss after injections of steroid into the scalp while treating alopecia.
Due to the nature of this particular complication, it is essential for any aesthetic practitioner to understand blindness caused by dermal filler in great detail; especially given the short duration of time where the complications can be managed.
In its most basic form, blindness from dermal filler can occur when the filler is injected in a facial artery or vein.
The filler will travel through the vascular system in the ophthalmic region of the face causing a vascular occlusion which may cut out blood supply for the eyes.
There are various routes which the dermal filler can take towards the ophthalmic blood supply.
To make matters worse, it has been discovered that facial anatomy can have variations from person to person so not even a clear understanding of facial anatomy will be able to prevent this complication from ever happening with 100% certainty.
Symptoms of blindness from dermal filler occur almost immediately.
Clinicians have up to 90 minutes to restore blood flow and save the retina.
It is a clinicians duty to understand how to diagnose, manage and prevent this complication. Click for more guidance for blindness caused by dermal filler.
Impending Necrosis – a Product of Vascular Occlusion
Impending necrosis is the term used to describe skin necrosis due to vascular occlusion resulting from a dermal filler procedure.
The blockage of an artery means that oxygen cannot reach cells.
As there is a lack of oxygen, the cells aren’t getting enough to meet their needs, which leads to the dysfunction and eventual destruction of the cell (tissue death).
This is what we refer to as impending necrosis.
One method you can use to make sure that you are not in an artery and don’t cause a vascular occlusion is by aspirating.
Aspirating is the act of pulling back on the needle and checking for flashbacks of blood.
If you have a positive aspiration (blood enters the needle) it can be a positive sign you are in an artery.
In this case, you should retract the syringe and make a new injection point away from the artery that you have previously penetrated by choosing a different entry point or angle of injection.
I’ve actually experienced a vascular occlusion during one of my treatments. You can listen to a podcast episode where I go through my experience here.
To cause a stroke form dermal filler, the product must enter the intracranial circulation & then come to rest in an artery supplying part of the brain.
Blockage of a vessel will cause hypoxic damage to the brain in a matter of 3 minutes.
There are two main routes by which filler can enter the cerebral circulation.
- Retrograde flow of filler from the facial artery into the common carotid artery and then into the internal carotid.
- Dermal filler entering through the ophthalmic artery via one of the 3 vessels in the orbit, the supratrochlear, supraorbital or lacrimal arteries.
All of the above filler side effects don’t just apply to one area of the face.
Each treatment, whether it’s a lip filler treatment, cheek treatment or a tear trough treatment carries its own risk.
By learning all of 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, allow you to be more creative when designing a treatment plan without fear of what might happen.
This guide should be only the starting point for a general understanding of dermal filler complications.
Each complication has unique subtleties and symptoms which will help you implement preventive measures in your daily practice; which is where most of your effort should be.