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Complications in Injectable Dermal Fillers

Nonsurgical injectable dermal fillers and other non-invasive cosmetic procedures have overtaken invasive surgery in popularity in recent years. Although they are minimally invasive, they are not immune to complications. In fact, the most extreme cases of cosmetic surgery in the news are usually ones of overdone injectable dermal fillers.

Dermal fillers are gel-like materials which are either synthetic (Artefill) or made from biological materials (e.g., Radiesse, Restylane) but modified for use in cosmetic surgery. The biological fillers persist in the body for variable durations. Restylane and Juvederm, the hyaluronic acid fillers, last 4-12 months, depending on who you ask. Radiesse, which is made from hydroxyapatite crystals, lasts longer but is generally gone by 2 years. Artefill is made from methylmethacrylate particles which is not broken down in the body, so it has the potential to persist indefinitely.

These materials are usually used in the face to fill in deep folds, such as the nasolabial folds. They can be used to raise up or flatten depressions from atrophy, such as the tear trough or cheek hollows. Fillers can also be added to bony prominences, such as the cheekbones or the nose for specific effects, including lifting or smoothing out contour irregularities.

It is quite easy to overdo or improperly perform such procedures. The most common mistake is to over-inject the lips. Everyone is familiar with “collagen lips.” After Angelina Jolie became famous, it seemed that lip augmentation procedures boomed in popularity. However, it is very hard to duplicate natural dynamic full lips by using fillers for lip augmentation. One can achieve a subtle enhancement that augments thin lips into mildly full lips and no one is the wiser. However, overdoing it creates a job that is obvious and unappealing. It’s the old adage of “too much of a good thing.” A little more is not necessarily better in cosmetic surgery. (Same goes for breast augmentation.) Another issue with lip injection, is that not all fillers give good results in the lips. Collagen and hyaluronic acids have a good track record for lip augmentation. However, using a longer-lasting filler such as Radiesse or Artefill can lead to lumps or granulomas that can be very long-lasting. Worse yet, a permanent filler will not go away with time, so if it needs to be removed, it must be done so surgically.

Another source of frustration for patients is uneven filling. Certain procedures, such as cheekbone augmentation, require symmetry both in the vertical and horizontal plane. Our eyes are very sensitive to any lack of symmetry we see in another’s face. We associate symmetry with beauty. Mild asymmetries can be corrected with a little extra injection, so it is not the end of the world if it can be fixed.

Infections of injected fillers are unusual but still possible. In the case of biological fillers, treatment is with antibiotics. No removal of the material is possible or necessary. With a permanent filler, there is a potential for longer-lasting infection of the foreign body. However, unlike solid surgical implants which require removal or become extruded when they get infected, permanent filler infections should still respond to antibiotics, although a longer course may be required than with typical skin infections.

Allergic reactions used to be quite common in the era of bovine collagen (collagen made from cow tissue). Skin testing for allergic reactions was previously required. With the new generation of collagens and other fillers, skin testing ceased to be necessary. However, a very low-risk of allergic reaction is still quoted. A severe allergic reaction can manifest with hives, difficulty breathing and airway narrowing. Such a reaction requires intramuscular epinephrine and treatment in the emergency room.

Scarring or granuloma formation are unusual complications of injectable fillers, as they are with surgical implants. It is possible for the body to gradually reject the injected foreign material and to start to form granulomas which can lead to scarring. This kind of reaction is extremely uncommon with hyaluronic acid but is possible with hydroxyapatite or methylmethacrylate. The resulting deformity can be quite distressing, but fortunately is relatively unusual.

In summary, injectable dermal fillers can achieve many of the same goals originally fulfilled by invasive cosmetic surgery. They are not free of the possibility of complications, although most of these are temporary and fixable. However, if using a permanent filler, such complications take on a much longer or permanent time frame, so extra care must be taken in such cases.





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