Dermal fillers have seen an increasing frequency of their use across the world (British College of Aesthetic Medicine (BCAM), 2019) with the American Society of Plastic Surgeons (2019) reporting a rise from 1.8 million procedures in 2010 to 2.7 million in 2017. Although the incidence of complications with dermal fillers such as hyaluronic acid (HA) and collagen is low, the high number of procedures leads to an increase in the number of complications (Chiang, Pierone and Al-Niaimi, 2016).
The most common and immediate complication of dermal fillers is bruising (Urdiales-Gálvez, Delgado, Figueiredo, Lajo-Ortiz, Marti, Moreno et al., 2018). Transient swelling, oedema and erythema are also very common and can be seen as procedure-related expected side effects (Bhojani-Lynch, 2017).
A more severe reaction is angioedema, which is an immunoglobulin E (IgE)-mediated immune response or a hypersensitivity reaction to the injected dermal fillers (Van Dyke, Hays, Caglia and Caglia, 2010). However, delayed hypersensitivity reactions are mediated by T cells and not antibodies (Urdiales-Gálvez et al., 2018).
Acute infections can also occur and appear as inflammation and abscesses at the site of injection with an incidence of 0.04 to 0.2% (Ferneini, Beauvais and Aronin, 2017). Dermal filler injections can also reactivate the herpes virus causing a herpetic outbreak in patients with a history of severe cold sores (Urdiales-Gálvez et al., 2018) with an incidence of 1.45% for HA fillers (Gazzola, Pasini and Cavallini, 2017).
Nerve damage can also occur and is due to direct trauma, injection of filler into the nerve or tissue compression and this happens in 0.1 to 1% of cases (Urdiales-Gálvez et al., 2018). Effects can be transient or permanent with the most common sites being the infraorbital nerve (Fitzgerald, Bertucci, Sykes and Duplechain, 2016).
Vascular compromise is an immediate and severe complication arising due to the injection of filler into an artery or vein, causing embolism and impedance of blood flow (Urdiales-Gálvez et al., 2018). This major complication appears to have a high incidence with 62% of experienced injectors having experienced at least one such case (Goodman, Roberts and Callan, 2016). One of the most severe examples includes occlusion of the central retinal artery (CRA) or one of its branches (Beleznay, Carruthers, Humphrey and Jones, 2015).
Late/delayed onset complications
Abscess formation a week up to years post-treatment is extremely rare, with 0.3% of treated patients affected (Conrad, Alipasha, Thiru, and Kandasamy, 2015). Additional complications from midfacial and periorbital infections are intracerebral infections, but this occurs in extremely rare cases (Funt and Pavicic, 2015).
Inflammatory nodules are often also due to biofilm formation, but these can also be a delayed hypersensitivity reaction (Rzany and DeLorenzi, 2015). The occurrence of delayed-onset nodules due to hypersensitivity are thought to occur in 0.6 to 0.8% of the patient (King, Bassett, Davies and King, 2016).
Foreign body granulomas usually occur after months of obtaining the dermal filler. They are also very rare with an incidence of 0.01 to 1% (King et al., 2016) and this is caused by the body’s immune system responding to the foreign body which cannot be eliminated by the usual mechanisms.
Tissue necrosis is associated with the injection of dermal fillers and is due to vessel occlusion. Necrosis occurs with types of fillers, and in the case of collagen, this occurs in 9 out of 100,000 cases and for all other fillers in 1 out of 100,000 cases (King, 2018).
Due to their efficacy and safety, dermal fillers have gained widespread use; however, when complications do occur, these can be very severe if managed inappropriately.
American Society of Plastic Surgeons (2019) New Statistics Reveal the Shape of Plastic Surgery. https://www.plasticsurgery.org/news/press-releases/new-statistics-reveal-the-shape-of-plastic-surgery. Accessed 06/08/2019.
Beleznay K, Carruthers JD, Humphrey S, Jones D (2015) Avoiding and treating blindness from ﬁllers: a review of the world literature. Dermatology Surgery 41(10), 1097–1117
Bhojani-Lynch T (2017) Late-onset inflammatory response to hyaluronic acid dermal fillers. Plastic and Reconstructive Surgery 5(12), 1532.
British College of Aesthetic Medicine (BCAM) (2019) Dermal Fillers. https://bcam.ac.uk/about-aesthetic-medicine/what-you-should-know/dermal-fillers/. Accessed 06/08/2019.
Chiang YZ, Pierone G, Al-Niaimi F (2016) Dermal fillers: pathophysiology, prevention and treatment of complications. Journal of European Academy of Dermatology and Venereology 31(3), 405 – 413.
Conrad K, Alipasha R, Thiru S, Kandasamy T (2015) Abscess Formation as a Complication of Injectable Fillers. Modern Plastic Surgery 5, 14-18.
Ferneini EM, Beauvais D, Aronin SI (2017) An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment. Journal of Maxillofacial Surgery 75(1), 160-166.
Fitzgerald R, Bertucci V, Sykes JM, Duplechain JK (2016) Adverse reactions to injectable ﬁllersFacial Plastic Surgery 32(5), 532–555
Funt D, Pavicic T (2013) Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clinical Cosmetic Investigations in Dermatology 6, 295–316.
Funt D, Pavicic T (2015) Dermal ﬁllers in aesthetics: an overview of adverse events and treatment approaches. Plastic Surgery Nursing 35,13–32
Gazzola R, Pasini L, Cavallini M (2017) Herpes Virus Outbreaks After Dermal Hyaluronic Acid Filler Injections. Aesthetic Surgery Journal 32(6), 770 – 772
Goodman GJ, Roberts S, Callan P (2016) Experience and management of intravascular injection with facial ﬁllers: results of a multinational survey of experienced injectors. Aesthetic Plastic Surgery 40(4), 549–555
Haneke E (2015) Managing complications of fillers: rare and not-so-rare. Journal of Cutaneous and Aesthetic Surgery 8(4), 198 – 210.
Homsy A, Rüegg EM, Jandus P, Pittet-Cuénod B, Modarressi A (2017) Immunological reaction after facial hyaluronic acid injection. Case Reports in Plastic Surgery and Hand Surgery 4(1), 68–72.
King M (2018) This month’s guideline: Management of Necrosis. Journal of Clinical Aesthetics in Dermatology 11(7), E53–E57.
King M, Bassett S, Davies E, King S (2016) Management of Delayed Onset Nodules. Journal of Clinical Aesthetics in Dermatology 9(11), E1–E5.
Rzany B, DeLorenzi C (2015) Understanding, avoiding, and managing severe ﬁller complications. Plastic Reconstruction Surgery 136(5 Suppl), 196S–203S
Urdiales-Gálvez F, Delgado NE, Figueiredo V, Lajo-Ortiz JV, Marti M, Moreno A, Ortiz-Marti F, Rio-Reyes Rosa, Romero-Alvarez N, Ruiz Del Cueto S, Segurado MA, Rabenaque CV (2018) Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations. Aesthetic Plastic Surgery 42(2), 498–510.
Van Dyke S, Hays GP, Caglia AE, Caglia M (2010) Severe acute local reactions to a hyaluronic acid-derived dermal ﬁller. Journal of Clinical Aesthetics in Dermatology 3(5), 32–35