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I Treatment of Injectable Soft Tissue Filler Complications ANTHONY P. SCLAFANI, MD, FACS,yAND STEVEN FAGIEN, MD, FACSz BACKGROUND Increasing use of dermal fillers, especially with the U.S. introduction of long-term and permanent fillers, is expected to increase the number of complications seen after treatment with these materials. OBJECTIVES To provide physicians with an overview for treatment of dermal filler complications. RESULTS Complications of dermal filler use can be treated successfully based on a firm understanding of the mechanisms and limitations of filler action and wound healing. Complications can be classified as immediate, early, or delayed onset; available treatment options are presented. CONCLUSION Short- and long-term dermal fillers are increasingly becoming popular treatment options for signs of facial aging. Complications, although not common, can be treated effectively and excellent outcomes achieved. Dr. Sclafani is on the Speakers Panel for Medicis. Dr. Fagien is a consultant for Allergan, Bioform, and Medicis. He is also a clinical investigator for Allergan, Dermik, Medicis, and Mentor. njectable soft tissue fillers can provide an important element in facial rejuvenation with regard to volume restoration without significant inconvenience to the patient and without substantial associated recovery time. The apparent relative simplicity of the process and high patient satisfaction with the results can lead to a cavalier attitude toward fillers, but serious complications can and do occur after soft tissue filler injections. At

times, these complications may be related to the filler material itself yet more often can be most accurately attributed to poor patient or region selection and injection technique. A thorough understanding of these issues is essential to ensure the safe use of these soft tissue fillers and to maximize outcomes. This article discusses the treatment of soft tissue filler complications. Recognizing the Need to Treat The use of injectable filling agents for facial rejuve- nation has seen a dramatic rise in popularity. This in itself has fueled the appearance and availability of a host of products that each has its particular and unique characteristics. A casual view of the process of injecting filling agents into soft tissue suggests minimal invasiveness that provides aesthetic benefit to the patient, yet a host of potential risks must be considered. Other authors in this issue have described the nature of normal and pathologic tissue responses to these injections and these materials (see articles by Tvede, Piccolo and Brown, Christensen and Richardson, and Wiest and Pallua). Simply, the mechanical effects of introducing these agents through small-gauge needles aids in reducing injury because of minimal tissue trauma. Hence, postinjection pain, redness, ecchymosis, and swelling should be minimal. Some fillers, especially before tissue integration and while there is still some trauma-related edema, may be nodular or palpably distinct and separate from surrounding normal skin; this may even be transiently visible. However, these short-term effects most often fade quickly, with the ultimate goal being the patients description of the treated area as indistinguishable from the surrounding area. Deviations from this gentle blending process should be considered abnormal and should be scrutinized for the need for intervention. In contrast to the normal sequelae of filler injections, injectable filler complications are events that

&2009 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2009;35:16721680 DOI: 10.1111/j.15244725.2009.01346.x 1672 Division of Facial Plastic Surgery, New York Eye and Ear Infirmary, New York, New York;yNew York Medical College, Valhalla, New York;zAesthetic Eyelid Plastic Surgery, Boca Raton, Florida should not occur after treatment and can generally be avoided with proper technique and material se- lection. These complications1can be categorized as immediate-, early-, or late-onset events and subcat- egorized into mild, moderate, and severe. Immediate-Onset (02 Days) Complications Immediate-onset complications include under and overcorrection, implant visibility, and vascular compromise. Familiarity with the filler material, its unique characteristics and properties, mechanism of action (passive volume augmentation, dermal stimulation, or both), and proper technique and plane of placement are essential to placing the correct amount of filler at the appropriate skin depth that provides maximal correction of tissue deficit while avoiding visibility or nodularity of the filler. Improper technique and placement in the wrong tissue plane (typically injecting an agent more superficially than ideal) cause implant visibility. Placement of some hyaluronic acid derivatives too superficially will produce a bluish ridge (due to the Tyndall effect), whereas superficial injection of particulate fillers (e.g., calcium hydroxylapatite or polymethylmethacrylate) will leave superficial white bumps of visible material. In either event, treatment of this problem may require intervention. Firm massage is generally sufficient to flatten and disperse excessive, superficial, or unaesthetic hyaluronic acid derivative placement, although hyaluronidase can be injected and excessive filler replaced by a return of volume deficit. Particulate filling agents may require that the product be reduced using a number of methods including simple unroofing with a needle tip and evacuated or removed using superficial dermabrasion.

On the other hand, vascular compromise with impending skin necrosis can occur from a number of reasons mostly related to technique. Although vascular compromise can occur in any location, the glabella is the most classically detailed area of skin necrosis after injection. Treatment of this area with the earliest widely used filler, glutaraldehyde crosslinked bovine collagen (Zyplast, Allergan, Inc., Irvine, CA), was restricted because of reports of glabellar necrosis, although most feel that this complication can occur with the use of any injectable dermal filler. Direct arterial embolization of filler material will generally cause an immediate skin blanching that may appear in a geographic distribution; pain may vary from severe to minimal. Conversely, venous occlusion can occur if excessive amounts of fillers are placed in a small area, leading to excessive venous congestion. This is associated with persistent dull, aching pain and swelling, with the development of a violaceous discoloration of the affected area; these findings can easily be misinterpreted and dismissed as early discomfort and bruising after treatment, but pain out of proportion (in terms of severity or persistence) to the treatment or for the individual patient should be further investigated. Treatment of vascular occlusion should be swift and aggressive (Table 1).2,3Arterial occlusion typically becomes apparent immediately. Injection should be stopped and aspiration attempted, which may relieve the blanching. The area should be massaged (vigor- ously in the case of hyaluronic acid derivatives, to disburse the bulk of the filler) and warm compresses applied to increase vasodilatation. Additionally, 2% nitroglycerine paste can be considered (based on the patients health) to cause further vasodilatation. In this situation, injection of hyaluronidase (Amphadase, Vitrase, Hylenex) may offer some benefit. Venous obstruction and occlusion may occur when larger volumes are injected into a small area and will present with prolonged pain and swelling and a dark discoloration. Nitroglycerin paste and warm compresses should also be used in this situation. Again, hyaluronidase can be injected locally. One might also consider the use of hyperbaric oxygen in the case of dramatic vascular compromise and impending ne-

crosis. Localized skin breakdown should be treated with topical (with or without systemic) antibiotics. Venous obstruction is typically associated with shallower skin breakdown, whereas arterial occlusion may lead to broad and deep skin loss. 35:S2:OCTOBER 2009 1673 SCLAFANI AND FAGIEN

Conservative debridement should be performed when necessary. The patient should be followed closely and seen frequently to facilitate healing with minimal cosmetic deformity and to provide reassurance (Figure 1). Once healed, depressed scars and persistent erythema should be dealt with appropriately. Although it may be impossible to prevent all episodes of vascular occlusion, several steps should be taken to minimize the risk of this occurrence, espe- cially when treating the glabella. Small-gauge (30- or 32-G

needles) should be used whenever possible and material injected with needle withdrawal. Complete awareness of injection plane may also reduce or eliminate this complication because product should be directed intra- rather than subdermally. The smallest possible volume capable of producing the desired effect should be injected in small, discrete aliquots. If this cannot be achieved with a reasonable volume, the patient should return in 7 to 14 days for additional correction. Proper pretreatment informed consent should discuss this uncommon complication. Early-Onset (314 Days) Complications Because all fillers are foreign bodies implanted within or beneath the dermis, physician and patient may note a certain palpability over the first few days to a week after injection, but nodularity that persists TABLE 1. Avoidance, Recognition, and Treatment of Vascular Occlusion After Dermal Filler Injection Arterial Occlusion Venous Occlusion Presentation Immediate or early, blanching, severe pain Delayed, dull pain, dark discoloration Management Stop injection, attempt aspiration Massage Massage Warm compresses Warm compresses 2% nitroglycerin paste 2% nitroglycerin paste Injection of hyaluronidase (if caused by hyaluronic acid product) Injection of hyaluronidase (if caused by HA

product) Consider hyperbaric oxygen in cases of impending massive skin necrosis Antibiotic therapy (topical, parenteral, or both) in cases of skin breakdown Antibiotic therapy (topical, parenteral, or both) in cases of skin breakdown Conservative debridement Conservative debridement Frequent follow-up Frequent follow-up Prevention Informed consent Informed consent Smallest possible needle Smallest possible needle Smallest possible volume injected Smallest possible volume injected Proper plane of injection Proper plane of injection Based on patients medical condition. TABLE 2. Management of Early-Onset Nodules After Dermal Filler Injection Noninflammatory Nodules Inflammatory Nodules Massage Fluctuant nodules Consider hyaluronidase (if hyaluronic acid product used)

Incision and drainage, culture Antibiotics Nonfluctuant nodules Empiric antibiotic therapy (1- or 2-drug treatment) Reevaluation in 48 hoursFif no improvement, punch biopsy and aerobic and anaerobic culture, 1021 days Antibiotic treatment for 4 to 6 weeks Once signs of infection subside, consider hyaluronidase (if hyaluronic acid product used) to remove nidus or intralesional corticosteroids DERMATOLOGIC SURGERY 1674 INJECTABLE SOFT TISSUE FILLER COMPLICATIONS TxofInjectableSoftTissueComplications-SclafaniandFagien Download this Document for FreePrintMobileCollectionsReport Document Report this document? Please tell us reason(s) for reporting this document

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