Complications of dermal filler Flashcards
What are the complications of dermal filler?
immediate vs early vs delayed
Immediate
-anaphylaxis
-vascular occlusion
-retinal occlusion
-bleeding and bruising
-placement issues (injecting too superficially or too much)-> tyndall infect; undesired change
Early to delayed
-swelling / oedema
-nodules (non-inflammatory)
-nerve damage
Late
-nodules (inflammatory) at 4 months typically
Anaphylaxis
what products can potentially trigger anaphylactic reaction?
What kind of fillers can stimulate a delayed hypersensitivity reaction?
Scenario:
34F presents with itchy, red skin changes and stridor after HA injection with lidocaine. She has had no previous aesthetic Hx/PMHx or known allergies.
After assessing her, you notice that her voice sounds hoarse and she is breathing rapidly. You quickly measure her O2 saturation.
How should you manage this in clinic?
Hyaluronic acid fillers rarely trigger anaphylaxis due to body naturally having HA. However, hyaluronidase or lidocaine agents can trigger anaphylaxis.
Delayer T-cell hypersensitivity reaction can occur with semi-permanent or permanent fillers that are injected into dermis because of presence of T cells
Anaphylaxis
A-E approach
lie patient flat or raise legs
epipen-1:1000 0.5ml of IM adrenaline or epipen 90 degrees outer thigh-hold for 3 s
35 F develops swelling on her R cheek following filler injection 3 days ago. She recently recovered from a viral flu
What kind of reaction is this? What are the potential triggers and how long does it take for the reaction to happen?
How would you treat this?
Delayed Type IV hypersensitivity reaction
-caused by T cells. Triggered by antigen from virus-> causes delayed type IV hypersensitivity reaction. Patients may present with a viral flu before this or vaccination. Takes 24-72 h
Treatment is with oral steroids-prednisolone 40mg over 5 days. Tapering course by 10mg
28F develops sudden swelling on her lips immediately after the lip filler treatment.
What kind of reaction is this? What is the pathophysiology?
What should you rule out in your assessment?
How would you treat this
Type I hypersensitivity reaction
-immediate onset. Caused by IgE-mediated cells releasing histamine.
It is important to rule out anaphylaxis-check out tongue swelling and listening to voice for stridor/airway compromise
Treatment
-antihistamines like cetirizine or loratidine
What is the difference between venous and arterial occlusion?
Venous occlusion-not normally painful. Site will be swollen and have dark discolouration
Arterial occlusion-painful due to tissue hypoxia.
30F presents with pallor in injection site where glabella filler was injected.
Site:
-where can discolouration occur?
Describe the changes in the event of vascular occlusion:
timeline of an arterial occlusion-seconds, minutes, minutes to hours, hours to days, days to weeks, months
Discolouration can occur in injection site area or where distribution of artery is.
Skin changes in vascular occlusion
sec- pallor in skin
minutes-bluish/purplish mottling
minutes to hours-dark purple due to poor tissue oxygenation
hours to days-blisters/pustules
days to weeks-skin breaks down (skin necrosis). Abscess can occur if there is infection. Black eschar can occurs
Months-recover
What should you do in the event of visual changes after filler injection?
How should you examine patient?
How long do you have until it is irreversible?
Retinal occlusion
-there are 6 types of retinal occlusion depending on which artery is affected.
Supratrochlear and supraorbital-> opthalmic artery embolisation
zygomato-orbital artery-> posterior ciliary artery embolisation
Management:
-lie patient supine; massage ocular region to reduce intra-ocular pressure
-GTN sublingual spray or ask them to rebreathe into paper bag (CO2)-> causes vasodilatation-> allows blood flow
Assess for neurological signs to rule out stroke; assess visual loss
12-15 minutes until it becomes irreversible
Specialist referral:
-emergency eye specialist
What are the potential issues with placement problems?
How do you avoid this with injection techniques?
Placement problems
-tyndall effect: some fillers may contribute to this. Can occur if placed too superficially
-filler migration (seen in lip photos)
-undertreatment of area
To avoid this:
-low pressure; smaller volume of injections
-firm massage over area to prevent migration
Viral Infection
-why is it important to avoid filler treatment after cold sores?
-what is the difference between herpes zoster/ herpes simplex distribution?
Bacterial infection
-first line Abx; what to give if they have penicillin allergy
-2nd line Abx
If fluctuating mass develops, what are the next steps?
What are the important aseptic techniques to prevent infection
Avoid treatment for at least 4 weeks after cold sores due to potential reactivation of herpes simplex virus
-Herpes simplex: anywhere whereas herpes zoster appears in dermatomal distribution
Bacterial infection:
-ibuprofen/paracetamol
-Abx first line flucloxacillin 500mg QDS; clarithromycin if pencillin allergy
-if not getting better-2nd line co-amoxiclav
Abscess- palpate for a fluctuating mass. Will be hot and tender to touch
They will need an incision and aspirate-> send mc+s
In order to prevent a bacterial infection:
-important to use aseptic technique-sterile field, sterile gloves, not touching unsterile areas. Do not inject into area which is marked by white pencil
What are the risk factors for malar oedema? Why does it occur?
Injection:
What type of HA should be used for tear trough filler? What injection technique should be used to avoid malar oedema?
Lymph node drainage eyelid:
-medial to eye
-lateral to eye
How do you manage malar oedema? How long should it take to resolve?
Malar oedema occurs when lymphatic drainage is affected/too much filler in tear trough or placed too superficially. Common complication after tear trough filler
Risk factors:
-botox treatment at orbicularis oculi affecting drainage
-malar eyebags
-periorbital oedema on waking in morning
Injection:
Low conc HA should be used for tear trough filler
Avoid blunt trauma with cannula or needle particularly around medial SOOF (sub-orbicularis oculi fat) area where there are a lot of blood vessels
LN drainage:
-medial : submandibular LN
-lateral: parotid and deep cervical lymph nodes
Management of malar oedema:
Should resolve within 2-3 weeks
-head elevation; cold compresses and lymphatic drainage a few X a day
-if doesn’t resolve with conservative management-> hyaluronidase
45 F presents to clinic with large bruise around her eye following tear trough filler treatment?
What questions should you ask to rule out peri-orbital cellulitis
Peri-orbital cellulitis
-important to rule out to prevent life threatening complications. Seek opinion from opthalmology
Things to ask:
1. pain when moving eye/restricted movements
2. changes in vision-esp colour desaturation like ability to see red
3. protrusion of eye
Nodules
What is a nodule? How do you differentiate between a non-inflammatory vs inflammatory nodule? (think about the characteristics of each type of nodule)
Management of nodules:
Non-inflammatory
Inflammatory (monotherapy and dual therapy). Why should not use hyalase in an inflammatoy nodule?
Nodule is a small palpable collection within soft tissue. Non-inflammatory nodules appear typically early on due to product misplacement/high volume injections. They are cold, discrete and firm. Rule out inflammatory nodules in examination-warm to touch, tender, swollen, discrete border
Inflammatory nodules are due to infection/biofilms/foreign body granulomas. They are warm to touch, tender, swollen, discrete border. Can occur after 4 weeks- 1 year. If immune system is activated-> can cause abscess to form
Management of non-inflammatory nodules:
-due to product misplacement-> firm massage over area can help
Management of inflammatory nodules:
-PO Abx for 2 weeks. macrolide/Tetracyclines recommended due to anti-inflammatory/antibacterial agents: clarithromycin 500mg BD or doxycycline 100mg BD for 2 weeks. if persists beyond 2 weeks-> can continue for another 4 weeks.
Dual Abx therapy: can add clarithromycin 500mg BD for another 2 weeks in addition
Hyalase should not be used in active infection because it can disperse and spread infection
What is this?
What kind of filler is this associated with
Granuloma -purplish/red firm plaques or papules in the subdermal part of skin. Histiological diagnosis-multinucleated cells
It is associated with injection of agents that do not dissolve easily like semi-permanent filler
