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
start high flow O2
epipen-1:1000 0.5ml of IM adrenaline or epipen 90 degrees outer thigh-hold for 3 s
This can be repeated every 5 minutes uptil 3X before transferring to acute care setting
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 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
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 are the signs/symptoms of retinal occlusion?
How should you examine patient?
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
Signs/symptoms:
-sudden loss of vision
-pupil dilatation with light
-pain in the eye/headache/facial pain
-want to rule out stroke
Management:
-lie patient supine; massage ocular region to reduce intra-ocular pressure. firm pressure on sclera causing indentation by few mm 2-3X a s
-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
Specialist referral:
-call 999 to refer to nearest emergency eye hospital
-contact emergency eye specialist
25F presents to clinic with bluish discolouration under her eyes after tear trough filler.
Another lady presents to clinic with filler in her white roll area of her lip after lip injection.
What are the potential issues with placement problems?
How would you manage this?
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
Management
-use low pressure; smaller volume of injections instead
-firm massage over area to prevent migration
-stab incision and removal if there is too much filler
-if not high volume HA protocol
-if there is filler deficit after HA protocol-> use tiny amount of filler
25M comes to clinic with hot blisters around mouth corners after injections. He has been having mild fevers and malaise the last 3/7 Hx.
He mentioned that he had a slight flu 3 weeks ago.
What is your DDx? What is the difference between HSV 1 and 2 / Herpes Zoster or Varicella zoster? How may they present?
How should you manage this?
How can you avoid this in the future
Viral infection
-need to avoid treatment for at least 4 weeks after cold sores due to potential reactivation of viruses
-HSV1 /2 presents with sore fluid-filled blisters, with yellow crust in BILATERAL NON-DERMATOMAL distribution. Patient will also present w fever, malaise and lymphadenopathy
-Herpes Zoster or Varicella Zoster (a.k.a chicken pox/shingles) presents with painful blisters in stripe in UNILATERAL DERMATOMAL DISTRIBUTION. will also present with viral symptoms.
25F comes to clinic complaining of pain and tenderness around the injection site, 4/7Hx after procedure. O/E, you palpate a mass and there is localised erythema. She does not have any fever, rigors or other systemic symptoms.
What is your DDx? What are the important things to rule out?
How should you manage this?
Bacterial infection
-caused by poor aseptic technique
-could be localised (pain and tenderness over injection area) or systemic like cellulitis (fever, rigors, tachycardia) e.g periorbital cellulitis
Important to rule out systemic symptoms in history and examine area
Palpate for abscesses (hot and tender to touch)
Management
If systemic, likely cellulitis-> refer to A+E
If local-> start Abx
Flucloxacillin 500mg QDS or clarithromycin 500mg BD for 7/7
If persists-> start 2nd like Abx like co-amoxiclav
If there is an abscess-> incision + MC+S
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?
How should you manage this?
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
This is a clinical emergency and you should refer to A+E
28F presents to clinic with lumps in her lower lip after lip filler treatment. On palpation, you find cold, firm discrete lumps in her mucosa.
What is a nodule? How do you differentiate between a non-inflammatory vs inflammatory nodule? (think about the characteristics of each type of nodule)
How do you manage a non-inflammatory 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
-stab incision and removal
-if not-> large volume hyalase protocol
28F presents to clinic with lumps in her lower lip after lip filler treatment. She complains of soreness in the area when you palpate it.
What is an inflammatory nodule?
How do you manage this?
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 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
Haematoma/bruising
25 F presents with a haematoma on her lip immediately after lip filler treatment.
How do you manage a bruise post injection?
How do you manage haematoma post injection? (small vs large)
If haemosiderin staining persists 3-5 months after, what can you consider?
25F presents with pain and tenderness in her cheek over the parotid gland area after facial injections. Area swells with food intake and there is some discharge from the area.
What is your differential diagnosis? and its clinical features?
Which specialty should you refer to?
