Dermal fillers in aesthetics: an overview of adverse events and treatment approaches

Aesthetic management of lips and perioral region with Hylacross® and Vycross® hyaluronic-acid based fillers: A document of recommendations

BACKGROUND

Lip volumization and perioral rejuvenation with hyaluronic-acid (HA) based dermal fillers are generating increasing interest and demand. However, this topic is still having many unmet needs nowadays. This document aimed to provide tips and recommendations that may help clinicians to achieve optimal and more predictable aesthetic outcomes.

METHODS

A multidisciplinary group of aesthetic medicine doctors from Spain and Portugal reviewed the tools used for assessing the patient and aesthetic outcomes, as well as the different techniques and products used in lips/perioral rejuvenation.

RESULTS

The consensus panel provided specific recommendations focusing on the basic information to collect before performing the aesthetic procedure; comprehensive approach to lips/perioral region rejuvenation; clinical and aesthetic assessment tools; product and technique selection; patient profile and needs; and safety issues (complications/adverse-events).

CONCLUSIONS

The rapid evolution of techniques and tools for assessing the patient and aesthetic outcomes, as well as the development of new HA-based fillers makes it necessary to update the clinical recommendations that guide the daily practice of clinicians, particularly those who have less experience with these procedures. This document addressed relevant subjects related to lip/perioral-region rejuvenation to perform the correct procedure, with the appropriate HA-based, on the right patient; to help specialists to obtain optimal and predictable aesthetic outcomes.

The role of oculoplastic surgeons in minimally invasive cosmetic injectables

PURPOSE OF REVIEW

In recent years, the field of aesthetic medicine has witnessed a paradigm shift with an increasing demand for minimally invasive cosmetic procedures, including cosmetic injectables. This review aims to delineate the distinctive role played by oculoplastic surgeons in the administration of cosmetic injectables, comparing their expertise to that of nonphysician practitioners.

RECENT FINDINGS

Complications arising from cosmetic injections are discussed, including skin discoloration, inflammation, necrosis, vision loss, retinal pathology, and central nervous system adverse effects. Injector expertise, patient factors, type of filler, location of injection, and management strategies are reviewed. Findings highlight diverse practitioner involvement, common adverse effects like skin necrosis and vision loss, with hyaluronic acid fillers being prominent. Areas at the highest risk for ocular complication include the glabella and nose with potential management involving dissolving fillers and reducing pressure. Emphasis is placed on expert injector selection and patient awareness.

SUMMARY

The administration of cosmetic injectables requires a profound understanding of facial anatomy, vasculature, and potential complications. In contrast to nonphysician practitioners, oculoplastic and aesthetic surgeons bring a level of anatomical precision and clinical acumen that is essential for navigating the complexities of cosmetic injectables. Emphasis on training and collaboration among practitioners will be essential in advancing the field while prioritizing patient safety and satisfaction.

Performance and Safety of Amino-Acid- and Hydroxyapatite Enriched-Hyaluronic Acid Intradermal Gel in Facial Skin Defects

Background and Objectives: The facial skin defects associated with aging are common concerns in the aging population. Hyaluronic-acid-based intradermal gels have established themselves as safe and effective treatments for addressing these concerns. Recently developed enriched products aim to enhance the efficacy of these gels, yet their effectiveness lacks thorough validation in the existing literature. Materials and Methods: In this retrospective analysis, we investigated the outcomes of intradermal gel treatments in 103 patients with soft tissue defects. This study included three groups: 35 patients received amino-acid-enriched hyaluronic acid gel, another 35 were treated with hydroxyapatite-enriched hyaluronic acid gel, and the remaining 33 underwent hyaluronic acid treatment only. The efficacy of the treatments was assessed using the Global Aesthetic Improvement Scale (GAIS) score, while patient satisfaction was gauged through a detailed questionnaire. Any adverse event was monitored. Results: The treatments demonstrated remarkable efficacy, as evidenced by mean GAIS scores of 1.714 points for those treated with amino acid-enriched hyaluronic acid gel, 1.886 points for individuals receiving hydroxyapatite-enriched hyaluronic acid gel, and 1.697 for those treated with hyaluronic acid alone, all showing statistical significance (p < 0.0001). Patient satisfaction was very high. Significantly, there were no recorded instances of major adverse events. Conclusions: Hyaluronic gels, particularly those enriched with amino acids and hydroxyapatite, are effective and safe interventions for addressing facial skin aging defects. They serve as valuable tools in mitigating age-related blemishes and contribute to the overall improvement of skin aesthetics.

Late-Onset Reactions after Hyaluronic Acid Dermal Fillers: A Consensus Recommendation on Etiology, Prevention and Management

Hyaluronic acid (HA) dermal fillers, generally considered low-risk, can lead to rare late-onset reactions (LORs) manifesting between 3 and 4 months postinjection, occasionally even as early as 24 h postinjection. The Complication Assessment and Risk Evaluation (CARE) board was established to review these reactions. In this publication, the authors aims to explore the etiological hypotheses underlying LORs, associated risk factors, prevention, and management approaches suggested by the CARE board. The CARE board identified three etiological hypotheses contributing to LORs. Firstly, the physicochemical structure of the filler, particularly low molecular weight HA, which may trigger an immune response. Secondly, infection, potentially introduced during injection or by dormant biofilm activation. Lastly, an imbalance in the host immune system, caused by factors like autoimmune diseases or viral infections, may lead to extended foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions. Based on these hypotheses, the board categorized various risk factors as patient-related (e.g., recent dental treatment, current medical status, active autoimmune disease), product-related (e.g., molecular weight), and procedure-related (e.g., aseptic technique and trauma). To reduce the risk of LORs, the CARE board recommends diligent patient selection, including comprehensive medical history assessment and informed consent. Practitioners should maintain an effective aseptic technique, and choose an appropriate product and injection depth for the anatomical location. Post-procedure, patients should receive education on proper filler care. Management of LORs depends on the suspected etiology, and the CARE board has proposed an algorithm to determine the most appropriate treatment. Hyaluronidase is recommended for noninflammatory reactions in the absence of active infection, while watchful waiting and/or steroid treatment may be preferred for inflammatory reactions. Hyaluronidase is not recommended as a first-line treatment for infections, which require drainage, bacterial culture, and antibiotic treatment. However, the board emphasizes the need for individualized evaluation and treatment in all cases.

Etiology of Delayed Inflammatory Reaction Induced by Hyaluronic Acid Filler

The etiology and pathophysiology of delayed inflammatory reactions caused by hyaluronic acid fillers have not yet been elucidated. Previous studies have suggested that the etiology can be attributed to the hyaluronic acid filler itself, patient's immunological status, infection, and injection technique. Hyaluronic acid fillers are composed of high-molecular weight hyaluronic acids that are chemically cross-linked using substances such as 1,4-butanediol diglycidyl ether (BDDE). The mechanism by which BDDE cross-links the two hyaluronic acid disaccharides is still unclear and it may exist as a fully reacted cross-linker, pendant cross-linker, deactivated cross-linker, and residual cross-linker. The hyaluronic acid filler also contains impurities such as silicone oil and aluminum during the manufacturing process. Impurities can induce a foreign body reaction when the hyaluronic acid filler is injected into the body. Aseptic hyaluronic acid filler injections should be performed while considering the possibility of biofilm formation or delayed inflammatory reaction. Delayed inflammatory reactions tend to occur when patients experience flu-like illnesses; thus, the patient's immunological status plays an important role in delayed inflammatory reactions. Large-bolus hyaluronic acid filler injections can induce foreign body reactions and carry a relatively high risk of granuloma formation.

Personalization of Minimally-Invasive Aesthetic Procedures with the Use of Ultrasound Compared to Alternative Imaging Modalities

Ultrasonography is a well-tolerated procedure that aids in the targeted esthetic therapies of special cutaneous regions, as well as in the prevention (vascular mapping, identification of previous filler, and others) and management of potential complications (vascular occlusion, external vascular compression, product misplacement or migration, inflammatory reactions, and others). It has lately been promoted as the first-line imaging tool to address injectables. In this article, we aim to review the evolving role of ultrasonography in cosmetic filler procedures, from the fundamental ultrasound characterization of cosmetic fillers to the ultrasound-enhanced detection and management of cosmetic filler complications, including ultrasound's role in hyaluronidase-guided injections for cosmetic filler dissolution. Furthermore, the paper explores the integral role played by ultrasound in enhancing the precision, efficacy, and safety of additional minimally invasive aesthetic techniques such as mesotherapy, radiofrequency, cryolipolysis, and polydioxanone procedures.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.

TFOS Lifestyle: Impact of cosmetics on the ocular surface

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

Delayed inflammatory reaction to hyaluronic acid lip filler after the Pfizer-BioNTech COVID-19 vaccine: A case report

Hypersensitivity reactions can be a side effect to any vaccine, but they are usually rare. The COVID-19 vaccination may cause hypersensitivity, and several cases of delayed hypersensitivity (DH) to hyaluronic acid (HA) dermal filler have been documented. The current report presents a case of a 36-year-old female patient with DH to HA dermal filler after receiving the Pfizer-BioNTech COVID-19 vaccine. Symptoms, including dryness, swelling, and a painless nodule, appeared after the first and second doses of the vaccine. The patient was treated with intralesional hyaluronidase and triamcinolone in the outpatient clinic. Although HA is relatively safe and routinely used in aesthetic medicine, DH reactions must be considered. Therefore, an appropriate patient history should be obtained, and physicians should provide counselling on the potential reactions to avoid these adverse effects.

The Rheology and Physicochemical Characteristics of Hyaluronic Acid Fillers: Their Clinical Implications

Hyaluronic acid (HA) fillers have become the most popular material for facial volume augmentation and wrinkle correction. Several filler brands are currently on the market all around the world and their features are extremely variable; for this reason, most users are unaware of their differences. The study of filler rheology has become a wellspring of knowledge, differentiating HA fillers, although these properties are not described thoroughly by the manufacturers. The authors of this review describe the more useful rheological properties that can help clinicians understand filler characteristics and the likely correlation of these features with clinical outcomes.

Evaluation of Adverse Effects of Resorbable Hyaluronic Acid Fillers: Determination of Macrophage Responses

Resorbable tissue fillers for aesthetic purposes can induce severe complications including product migration, late swelling, and inflammatory reactions. The relation between product characteristics and adverse effects is not well understood. We hypothesized that the degree of cross-linking hyaluronic acid (HA) fillers was associated with the occurrence of adverse effects. Five experimental HA preparations similar to HA fillers were synthesized with an increasing degree of cross-linking. Furthermore, a series of commercial fillers (Perfectha^®) was obtained that differ in degradation time based on the size of their particulate HA components. Cytotoxic responses and cytokine production by human THP-1-derived macrophages exposed to extracts of the evaluated resorbable HA fillers were absent to minimal. Gene expression analysis of the HA-exposed macrophages revealed the responses related to cell cycle control and immune reactivity. Our results could not confirm the hypothesis that the level of cross-linking in our experimental HA fillers or the particulate size of commercial HA fillers is related to the induced biological responses. However, the evaluation of cytokine induction and gene expression in macrophages after biomaterial exposure presents promising opportunities for the development of methods to identify cellular processes that may be predictive for biomaterial-induced responses in patients.

A systematic review on COVID-19 vaccination and cosmetic filler reactions: A focus on case studies and original articles

Background

Tissue fillers are among the most popular cosmetic procedures performed and notably, cases of filler reactions after COVID‐19 vaccination have been reported.

Objective

The objective was to determine the characteristics of patients with filler reaction after COVID‐19 vaccination and address several considerations that have to be taken into practice.

Methods

A PRISMA compliant systematic search was conducted in Scopus, Web of Science, and PubMed/MEDLINE databases for articles published from inception up to October 21, 2021.

Results

Out of 106 initially retrieved articles, four of them were included in our study, and a total number of 13 cases were analyzed. In this study, we found that all of the patients who developed delayed‐type reaction (DTR) following COVID‐19 vaccination were middle‐aged women without any known history of allergy to foods or drugs. All patients had a history of hyaluronic acid (HA) filler injection in their head and neck and demonstrated symptoms particularly swelling, from <1 day up to 10 days after the first or second doses of vaccines. Lisinopril, hyaluronidase, and corticosteroids seemed to have good results in management.

Conclusion

Although rare, DTR to fillers after COVID‐19 vaccination can happen. Physicians should be aware of the pathogenesis and management of this phenomenon.

A randomized, participant-and evaluator-blinded, matched-pair prospective study to compare the safety and efficacy between polycaprolactone-based fillers in the correction of nasolabial folds

BACKGROUND

Polycaprolactone (PCL)-based fillers are widely used for skin rejuvenation and wrinkle reduction.

OBJECTIVE

To compare the efficacy and safety of newly developed PCL-based fillers (SYB filler®; SF-01) and widely used existing PCL-based fillers (Ellansé-M®) for correction of moderate-to-severe nasolabial folds.

METHODS

In a randomized, participant-and evaluator-blinded, matched-pair, prospective study, participants were randomized for injections of SF-01 or Ellansé-M® in both nasolabial folds. Efficacy was evaluated using the Wrinkle Severity Rating Scale (WSRS), Global Esthetic Improvement Scale (GAIS), and a 3-dimensional (3D) scanner. All adverse events (AEs) were examined and reported.

RESULTS

At month 12, both SF-01-and Ellansé-M®-treated groups showed statistically significant improvements in the WSRS, GAIS, and 3D scanner scores compared to baseline. The difference in changes in WSRS scores at month 12 between the two groups was 0.08 ± 0.34 compared to baseline. The upper limit of the 95.0% confidence interval was 0.0031, which was lower than the predefined margin for non-inferiority (0.35). All AEs were injection site-related (swelling, pain, and erythema) and disappeared within 30 min after the procedure.

CONCLUSION

SF-01 was non-inferior to Ellansé-M® and demonstrated favorable efficacy and safety at 12 months after correcting moderate-to-severe nasolabial folds.

Consensus Recommendations on the Use of Hyaluronic Acid-Based Fillers for Nonsurgical Nasal Augmentation in Asian Patients

BACKGROUND

Nonsurgical nasal augmentation using dermal fillers such as hyaluronic acid is increasing in popularity because of its less invasive nature and shorter downtime compared with traditional surgery. However, the complexity of the nasal vasculature makes it a high-risk procedure without proper training. Appropriate patient and product selection and safer standardized injection techniques are warranted to minimize complications and to achieve reproducible aesthetic results. In this article, recommendations for nonsurgical nasal augmentation using hyaluronic acid fillers are outlined, with focus on the dorsum, tip, and columella.

METHODS

A consensus meeting was conducted to develop recommendations on nonsurgical nasal augmentation in Asian patients using hyaluronic acid-based fillers. Literature review was performed using PubMed and Google Scholar. Relevant studies were included to formulate recommendations. Consensus statements were graded using the criteria outlined by the Grading of Recommendations Assessment, Development and Evaluation Working Group.

RESULTS

Nonsurgical nasal augmentation is an advanced procedure that warrants in-depth knowledge of the nasal anatomy. The panel recommends thorough preinjection assessment and counseling to fully align the patient's expectations with aesthetic goals. Injections must be deep and at the level of the periosteum or perichondrium to minimize risk of intravascular injection. Aliquots of hyaluronic acid must be introduced using slow, low-pressure, and low-volume injections. Optimal aesthetic effect is achieved with hyaluronic acid dermal fillers that are highly elastic, cohesive, and with good adaptability to their environment.

CONCLUSIONS

Hyaluronic acid injections are safe and effective in nonsurgical nasal augmentation. In-depth knowledge of vascular anatomy and proper injection techniques using suitable products are necessary to achieve aesthetic goals safely.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Delayed Onset Nodules After Hyaluronic Acid Fillers: A Case Series

Non-surgical techniques with hyaluronic acid fillers to rejuvenate face are very popular treatment due to ease of administration and achievement of faster improvement. Although they are considered to be safe procedures, few rare adverse effects have been reported in literatures. The number of these cosmetic procedures being performed is increasing every year. Simultaneously, the rate of filler complications has also increased. This case series presents three clinical cases of delayed onset nodules after hyaluronic acid fillers after 1-5 months post-procedure. Juvederm Volift was used in all the mentioned patients. Granulomatous reactions can occur with any of the hyaluronic acid fillers. These are generally localized immunological reactions. An awareness about these rare side effects helps us in the assessment and ensurance of accurate diagnosis and treatment.

Safety of Aesthetic Medicine Procedures in Patients with Autoimmune Thyroid Disease: A Literature Review

Autoimmune thyroid diseases are the most common organ-specific autoimmune diseases, affecting 2–5% of the world’s population. Due to the autoimmune background of thyroid diseases, we analyzed a wide range of cosmetic procedures, from minimally invasive cosmetic injections (mesotherapy) to highly invasive procedures, such as lifting threads. Out of the seven categories of treatments in aesthetic medicine analyzed by us—hyaluronic acid, botulinum toxin, autologous platelet-rich plasma, autologous fat grafting, lifting threads, IPL and laser treatment and mesotherapy—only two, mesotherapy and lifting threads, are not recommended. This is due to the lack of safety studies and the potential possibility of a higher frequency of side effects in patients with autoimmune thyroid diseases.

Safety and Effectiveness of Hyaluronic Acid Filler, VYC-20L, via Cannula for Cheek Augmentation: A Randomized, Single-Blind, Controlled Study

BACKGROUND

Using cannulas to deliver facial fillers may reduce adverse events (AEs) compared with needle injection.

OBJECTIVE

To evaluate the safety and effectiveness of VYC-20L (20 mg/mL hyaluronic acid gel with lidocaine) via cannula for midface age-related volume deficit.

MATERIALS AND METHODS

This multicenter, evaluator-blind, randomized, within-subject, controlled study enrolled adults with moderate to severe Mid-Face Volume Deficit Scale (MFVDS) scores. VYC-20L was administered in one cheek via cannula (with optional needle use in the zygomaticomalar region) and in the other cheek via needle. The primary effectiveness end point was the mean (95% confidence interval [CI]) paired difference between treatments in MFVDS score change from baseline to Month 1; an upper CI limit of less than 0.5 determined noninferiority. Injection-site responses (ISRs), procedural pain, and AEs were assessed.

RESULTS

Of 60 randomized and treated subjects, the mean change in MFVDS score from baseline to Month 1 was -1.8 with cannulas and -1.9 with needles, providing a mean (95% CI) paired difference of 0.1 (-0.05 to 0.25). Most ISRs were mild/moderate and resolved within 2 weeks. Procedural pain was minimal, and no serious AEs were reported.

CONCLUSION

VYC-20L for cheek augmentation was safe and effective using a cannula and noninferior to needle injection.

The safety and efficacy of a cosmetic camouflaging agent for post-procedural bruising

INTRODUCTION

A challenge of minimally invasive esthetic procedures (eg, injectables and threads) is managing adverse events (AEs), such as post-procedural bruising. Implementation of post-procedural camouflage therapy may minimize the appearance of bruising and mitigate AEs.

AIMS

A physician and patient user experience program was designed to evaluate the safety and efficacy of a concealer for the cosmetic camouflage of post-procedural bruising.

METHODS

Thirty female patients with a mean age of 42.03 years participated in the program. Physicians and patients completed various questionnaires regarding the safety and efficacy of the investigational product (Dermablend™ Professional Cover Care Full Coverage Concealer) at three timepoints: Visit 1 (Day 0); Visit 2 (Day 3); and Visit 3 (Day 14 ± 3 days).

RESULTS

All patients presented with mild-to-moderate bruising following treatment with either esthetic injectables or threads. On average, users required 1.55 (SD: 0.72) coats to sufficiently cover their bruise(s). After application of the concealer, 78.18% of users displayed "clear skin with no signs of erythema" and 21.82% displayed "almost clear skin, with slight redness." No physician-reported AEs related to product use were reported throughout the evaluation period. No allergic reactions upon application nor intolerance to the product after prolonged use (ie, up to 14 days ± 3 days) was observed. Throughout the duration of use, 98.81% of subjects were at least slightly satisfied with results. At Visits 1 and 2, 100% of physicians were at least slightly satisfied with results.

CONCLUSION

Cosmetic concealer use can ameliorate the post-procedural experience for patients presenting with mild-to-moderate bruising.

Complications of Nonpermanent Facial Fillers: A Systematic Review

Background:

A variety of complications after injection of nonpermanent fillers for facial rejuvenation have been reported so far. However, to date, the overall complication rate is still a matter of debate. The aim of this study was to perform a systematic review of literature to assess the type and severity of associated complications following injections in different anatomical regions of the face.

Methods:

The entire PubMed/Medline database was screened to identify case reports and clinical studies describing complications that have occurred after injection of nonpermanent fillers in the face. These complications have been reviewed and analyzed according to their occurrence in different anatomical regions of the face.

Results:

Forty-six articles including a total of 164 patients reported on a total of 436 complications during the time period between January 2003 and February 2020. The majority of the complications were reported after injections to the nose and the nasolabial fold (n = 230), the forehead and the eyebrows (n = 53), and the glabellar region (n = 36). Out of 436 complications, 163 have been classified as severe or permanent including skin necrosis (n = 46), loss of vision (n = 35), or encephalitis (n = 1), whereas 273 complications were classified as mild or transient, such as local edema (n = 74), skin erythema (n = 69), and filler migration (n = 2). The most severe complications were observed in treatments of nose, glabella, and forehead.

Conclusions:

Nonpermanent facial fillers are associated with rare but potentially severe complications. Severity and impact of complications depend on the anatomical region of the face and eventually require profound knowledge of facial anatomy.

Laser Doppler Imaging for Treating Vascular Complications from Procedures Involving Dermal Fillers: Case Series and Literature Review

Vascular occlusion is a rare but severe complication of dermal filler injections. Early treatment of this complication produces better outcomes. Current diagnostic methods for vascular occlusion in the skin are subjective and imprecise; these include capillary refill time, skin color, and reports of pain. This study aimed to assess the use of laser Doppler imaging (LDI) in the evaluation and treatment of vascular complications caused by dermal filler injections. This retrospective study used laser Doppler imaging (LDI) in 13 patients who developed vascular occlusion after facial dermal filler injections, with subsequent follow-up. The precise areas of perfusion observed on LDI were compared with the findings of clinical and photographic evaluation. The results showed that LDI accurately identified areas of vascular occlusion and improved treatment precision among these thirteen patients. The procedure was more precise than visual inspection or photographic evidence. Satisfactory outcomes were achieved for all patients, and no procedure-related complications were reported. Collectively, LDI provides fast, noninvasive, and accurate delineation of areas of vascular occlusion caused by complications of dermal filler injections and avoids several subjective shortcomings of visual and photographic evaluations. Thus, LDI effectively tracks treatment outcomes. However, large-scale studies are required to confirm the present findings.

Clinical Management of Nasal Skin Necrosis Caused by Hyaluronic Acid Filler

ABSTRACT

Nose augmentation with Hyaluronic acid (HA) fillers has been considered the preferred technique for minimally invasive cosmetic procedures. Despite severe complications related to HA injection are rare, none of the existing treatment protocols has been established as standard. The aim of this report is to present an alternative approach to treat nasal skin necrosis related to HA injection. A high dose of hyaluronidase - 6000 IU was applied in the nose, for the purpose of reversing a necrotic process. The present findings suggest that a high dose of hyaluronidase could be a promising approach to treat severe nasal skin necrosis caused by HA filler.

Filler Migration to the Orbit

BACKGROUND

Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications.

OBJECTIVES

We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed.

METHODS

A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections.

RESULTS

Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively.

CONCLUSIONS

Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

LEVEL OF EVIDENCE: 4

Management of Tear Trough with Hyaluronic Acid Fillers: A Clinical-Practice Dual Approach

INTRODUCTION

Tear trough deformity (TTD) is currently a major concern for many individuals that seek periorbital rejuvenation. Among the different options currently available for treating TTD, hyaluronic acid (HA) filler injections have become increasingly popular.

PURPOSE

To provide a dual approach, direct and indirect strategies for treating TTD with HA fillers according to patient facial structure.

METHODS

The current paper combined the authors' experience with the currently available scientific evidence.

RESULTS

The current study presents the authors clinical experience regarding TTD treatment and serves as a guide on the best therapeutic approach with HA fillers. For achieving good aesthetic outcomes, especially in TTD, it is crucial to have a detailed understanding of both facial anatomy and the individual characteristics of the HA fillers. Proper management of full-face facial rejuvenation should have into consideration three main pillars: structure, contour, and refinement.

CONCLUSION

Treatment of TTD should be addressed from a comprehensive perspective, including potential lack of structural support, as well as interventions on the dynamic processes involved in the problem. Additionally, HA fillers can be used to modulate mechanically muscle movement by either facilitating their action or decreasing contractility by reducing their movement. Clinicians can benefit from ongoing guidance on the use of these products in order to tailor and optimize treatments to patient's requirements. Although HA filler injections have low rates of side effects, TTD was listed as the most challenging area to treat with HA. Therefore, TTD treatment should be performed only by well-trained and experienced specialists.

Complications and Adverse Effects of Periocular Aesthetic Treatments

The popularity and variety of temporary and permanent periocular aesthetic treatments has increased over the past decade. Patients frequently present to eye clinics with ocular complications and side effects following these treatments, their severity ranging from ocular irritation from dry eyes to visual loss from vascular occlusion. A careful, thorough history is essential, as many patients may not associate aesthetic procedures with ocular complications, and some may be embarrassed to disclose this information. All ophthalmologists should understand the potential ocular sequelae of these treatments and be able to initiate treatment in sight-threatening cases. Wesummarises the current literature on ophthalmic complications of the most common periocular aesthetic treatments.

Model-Based Prediction to Evaluate Residence Time of Hyaluronic Acid Based Dermal Fillers

Dermal fillers are gel-type substances for nonsurgical medical-device use to achieve facial rejuvenation. Currently, the most widely used skin fillers are hyaluronic-acid-based dermal fillers. This study aimed to explain the change in the volume of injected dermal fillers by developing a mathematical kinetic model for various dermal fillers. The kinetics of the injected fillers were separated by a biphasic phenomenon. We attributed an increase in filler volume to the hydration of hyaluronic acid molecules and injection-site reaction and a decrease in volume to enzyme-mediated degradation. To explain these in vivo characteristics of dermal fillers, we proposed a two-compartment model, divided into a depot compartment (where the filler was injected) and a subcutaneous compartment (an observation compartment where the fillers swell and degrade), assuming that the swelling and degradation occurred in accordance with the swelling and degradation rate constants, respectively. The model was developed using five hyaluronic-acid-based dermal fillers and NONMEM. We determined that the rate-limiting step for the complete degradation of the dermal fillers in vivo was the swelling phase, as described by the swelling rate constant (K_swell). This study could enable scientists developing novel dermal fillers to predict the in vivo behavior of fillers.

Establishing a Standardized Facial Cosmetic Preinjection Safety Tool: The ACIST

In the past 20 years, the American population has seen an increased demand for nonsurgical minimally invasive facial rejuvenation solutions for the aging process. This widespread and increased demand for cosmetic injections brings a greater propensity for complications and adverse events. Choosing suitable patients for dermal filler is essential, as is concrete knowledge of the factors related to adverse events; however, there was no standardized tool to facilitate this process. The Joint Commission's Universal Safety checklist tools have been integrated into hospital surgical operating rooms and ambulatory outpatient settings across America and internationally and have successfully reduced errors in patient safety and outcomes. This article establishes the importance of integrating the Assessment Cosmetic Injection Safety Tool (ACIST), a standardized preinjection safety tool, into the cosmetic practice to decrease the incidence of adverse events associated with dermal filler and to achieve optimal patient satisfaction and outcomes. The ACIST was designed from the scientific literature, piloted at an urban cosmetic practice in the southern United States, finalized on the basis of feedback from participating staff members at the pilot study center, and disseminated to cosmetic nurse injectors.

Injectable fillers: imaging features and related complications

Background

Injectable fillers are currently widely used in the clinical practice; there are many indications for injectable fillers including facial and gluteal rejuvenation, management of post-traumatic facial disfiguring, and pathological volumetric loss secondary to certain disease medications like human immune deficiency virus (HIV) medications.

Radiologists should be familiar with the specific imaging features of the injectable fillers, characteristic anatomical locations, and possible complications to avoid diagnostic pitfalls especially when incidentally discovered while imaging of other pathological process like neoplastic work up or granulomatous lesions follow-up.

Results

The study included 48 patients (45 females and 3 males): 44 patients with facial injectable fillers and four patients with pelvic injectable fillers.

Of the 48 patients, 37 patients showed unremarkable fillers features with normal morphological features and anatomical distribution, and eleven patients showed complications: six patients showed one complication, and five patients showed more than one complications.

Dedicated fillers imaging study was done in 22 patients, while in the other 26 patients, imaging was done for other reasons, and fillers were notified and documented.

Magnetic resonance imaging (MRI) was done for 46 patients; two patients were subjected to combine ultra-sonographic and CT examinations with no clinical indication for MRI study assessment.

Conclusion

Magnetic resonance imaging (MRI) is an effective tool for evaluation of facial and gluteal region fillers with delineation of their imaging features and related potential complications.

Differentiation between fillers and neoplastic or granulomatous lesions could be accurately done with MRI.

Granulomas and nongranulomatous nodules after filler injection: Different complications require different treatments

Dermal fillers are widely used for facial rejuvenation and reconstruction and present fewer risks than surgical approaches. Nevertheless, several complications may occur, including nodule formation. A nodule is a clinical sign corresponding to different etiologies, such as overcorrection, infection, allergic reaction, or granuloma. However, their treatment represents a diagnostic challenge. We present a retrospective review of 26 consecutive patients who underwent a biopsy for facial nodule formation more than 3 months after filler injections, to determine the diagnosis of the nodule and type of filler used. All patients were women (mean age, 57.8 years). Some patients suffered from different localizations: lip, 14 cases; nasolabial folds, 6; cheeks, 5; infraorbital region, 5; the glabella, 2; the temporal region, 1; and chin, 1 case. Only 5 (19.2%) patients knew the type of filler used, and in another 4 cases, the injector was able to provide some information. In 65.4% of cases, the filler type was unknown. Histopathological analysis revealed a "granulomatous" nodule in 30 sites and a "non-granulomatous" nodule in 4 cases. Concerning the type of filler, 5 different histopathological patterns were found. Our results demonstrate that a clinical history and histopathological analysis whether to confirm or not to confirm the diagnosis of granuloma and to identify the type of filler are essential tools to achieve an accurate diagnosis of the problem-oriented treatment of nodules after dermal filler injections. We propose an algorithm for the management of nodules after filler injection.

Collagen-Based Materials Modified by Phenolic Acids-A Review

Collagen-based biomaterials constitute one of the most widely studied types of materials for biomedical applications. Low thermal and mechanical parameters are the main disadvantages of such structures. Moreover, they present low stability in the case of degradation by collagenase. To improve the properties of collagen-based materials, different types of cross-linkers have been researched. In recent years, phenolic acids have been studied as collagen modifiers. Mainly, tannic acid has been tested for collagen modification as it interacts with a polymeric chain by strong hydrogen bonds. When compared to pure collagen, such complexes show both antimicrobial activity and improved physicochemical properties. Less research reporting on other phenolic acids has been published. This review is a summary of the present knowledge about phenolic acids (e.g., tannic, ferulic, gallic, and caffeic acid) application as collagen cross-linkers. The studies concerning collagen-based materials with phenolic acids are summarized and discussed.

Evaluation of the Rheologic and Physicochemical Properties of a Novel Hyaluronic Acid Filler Range with eXcellent Three-Dimensional Reticulation (XTR™) Technology

Soft-tissue fillers made of hyaluronic acid and combined with lidocaine have recently become a popular tool in aesthetic medicine. Several manufacturers have developed their own proprietary formulae with varying manufacturing tools, concentrations, crosslinked three-dimensional network structures, pore size distributions of the fibrous networks, as well as cohesivity levels and rheological properties, lending fillers and filler ranges their unique properties and degradability profiles. One such range of hyaluronic acid fillers manufactured using the novel eXcellent three-dimensional reticulation (XTR™) technology was evaluated in comparison with other HA fillers and filler ranges by an independent research laboratory. Fillers manufactured with the XTR™ technology were shown to have characteristic rheological, crosslinking and biophysical factors that support the suitability of this filler range for certain patient profiles.

[Eruptive granuloma after injection of Ellansé® successfully treated using methotrexate]

BACKGROUND

Collagen stimulators such as Ellansé® are soft tissue fillers able to induce nucleogenesis. We describe a case of eruptive foreign body granulomas following injection of Ellansé® that were successfully treated using methotrexate.

CASE REPORT

A 47-year-old woman received injections of Ellansé® for the wrinkled aspect of her cheeks. She had previously undergone injections of hyaluronic acid on the nasolabial folds. Nine months after the Ellansé® injections, the patient consulted for the recent appearance of multiple nodules on her face. Histological analysis of one of these nodules confirmed the presence of foreign-body granulomas developed in contact with spherical gaps of a size substantially identical to the Ellansé® vacuoles. Methotrexate 10mg per week for 3 months followed by 20mg per week for 9 months resulted in complete regression of the nodules.

DISCUSSION

Ellansé® is composed of two biocompatible and bioabsorbable polymers: carboxymethylcellulose, responsible for immediate volume creation, and polycaprolactone, which promotes collagen synthesis. However, any injected product can cause varying degrees of granulomatous reaction. Hyaluronic acid was previously injected at several other sites on the patient's face. These lesions were not the result of poor injection technique.

CONCLUSION

Although collagen stimulators are biocompatible and bioabsorbable substances, the development of foreign-body granulomas, while rare, is still possible. Methotrexate resulted in significant regression of nodules as of the third month of treatment.

Polycaprolactone: How a Well-Known and Futuristic Polymer Has Become an Innovative Collagen-Stimulator in Esthetics

Compared to other domains, tissue engineering and esthetics have dramatically expanded in recent years, leading to both major biomedical advances and futuristic perspectives. The two share a common approach based on biomaterials, especially polymers. This paper illustrates this with the example of polycaprolactone (PCL), a polymer synthesized in the early 1930s, and one of its most recent applications, a PCL-based collagen stimulator, a filler used in esthetics. PCL is biocompatible and biodegradable. Its specific physicochemical and mechanical properties, viscoelasticity and ease of shaping led to the production of PCL-based products with various shapes and durations dependent on its biodegradation kinetics. PCL has been safely used in the biomedical field for more than 70 years, from sutures to tissue and organ replacement by 3D printing. The PCL-based collagen stimulator is composed of PCL microspheres suspended in a carboxymethyl-cellulose gel carrier providing immediate and sustained volumizing effects when injected; the morphology, the biocompatibility of the PCL microspheres embedded with the collagen fibers produced all contribute to the creation of a unique 3D scaffold for a sustained effect. Its safety has been investigated in clinical studies and vigilance surveys. Recently published experts' recommendations on injection modalities and techniques should help further optimize treatment outcome and safety. This paper also integrates reviews and recommendations on the prevention and management of adverse events related to dermal and subdermal fillers including the PCL-based collagen stimulator. In addition, in terms of efficacy and safety, this product benefits from its daily clinical use in esthetics worldwide and continuous extensive fundamental and clinical research, both on it and the PCL polymer. Forthcoming data from further investigations will reinforce knowledge of the product and procedures in the field.

Safety And Efficacy Of Princess® FILLER Lidocaine In The Correction Of Nasolabial Folds

Purpose

Nasolabial folds (NLFs) are one of the most noticeable signs of facial aging. NLFs negatively affect self-confidence and social acceptance often leading to a person’s desire to improve their appearance using dermal fillers. The hyaluronic acid injectable gel implant Princess^® FILLER Lidocaine (PFL) is a minimally invasive easy to administer the product. In this investigation, we assessed the safety and efficacy of PFL to correct moderate to severe NLFs over a 36-week period.

Methods

Adult women and men with moderate to severe NLFs received one injection of PFL to both NLFs. After 2 weeks, a touch-up treatment could be performed, if deemed necessary by the investigator. The change in NLF severity was assessed using the Nasolabial Fold Severity Rating Scale (NFL-SRS) developed by Croma-Pharma and the Global Aesthetic Improvement Scale (GAIS).

Results

Out of 60 analyzed subjects, 59 (98.3%) had improved their NLF severity by at least 1 grade on the NFL-SRS at week 4, 58 subjects (96.7%) at weeks 24 and 36. All subjects showed aesthetic improvement (GAIS), at weeks 4 and 24. The investigator judged the aesthetics as very much improved (score of 1) in 45 (75.0%) at week 4, 48 (80.0%) at week 24, and in 39 of 60 subjects, respectively (65.0%) at week 36. Thirty-six weeks post-initial treatment, 56 of 60 subjects (93.3%) were very satisfied or satisfied with the treatment. Adverse device effects (ADEs) were mild or moderate and resolved at latest 25 days post-onset. The most commonly reported ADEs were injection site hematoma and injection site pain.

Conclusion

PFL was safe and effective in reducing the severity of NLFs. Most subjects were (very) satisfied with the treatment outcome throughout a 36 weeks investigation period.

Establishing a Standardized Facial Cosmetic Preinjection Safety Tool: The ACIST

In the past 20 years, the American population has seen an increased demand for nonsurgical minimally invasive facial rejuvenation solutions for the aging process. This widespread and increased demand for cosmetic injections brings a greater propensity for complications and adverse events. Choosing suitable patients for dermal filler is essential, as is concrete knowledge of the factors related to adverse events; however, there was no standardized tool to facilitate this process. The Joint Commission's Universal Safety checklist tools have been integrated into hospital surgical operating rooms and ambulatory outpatient settings across America and internationally and have successfully reduced errors in patient safety and outcomes. This article establishes the importance of integrating the Assessment Cosmetic Injection Safety Tool (ACIST), a standardized preinjection safety tool, into the cosmetic practice to decrease the incidence of adverse events associated with dermal filler and to achieve optimal patient satisfaction and outcomes. The ACIST was designed from the scientific literature, piloted at an urban cosmetic practice in the southern United States, finalized on the basis of feedback from participating staff members at the pilot study center, and disseminated to cosmetic nurse injectors.

Management of Lip Complications

This article discusses complications that may occur after procedures on the lips, specifically focusing on injectable fillers. Evidence-based guidelines and suggested methods to manage these complications are presented in a systematic format.

Delayed hypersensitivity reaction to hyaluronic acid dermal filler following influenza-like illness

Background: Delayed reactions after facial hyaluronic acid injection are relatively rare complications. Their cause may be infectious or immune-mediated in origin, and their outbreak can be triggered, for example, by an influenza-like illness. Objective: To describe potential adverse event of influenza like illness following dermal filler injection. Methods: We report fourteen unusual cases of delayed hypersensitivity reaction to several brands of hyaluronic acid dermal filler following influenza like illness. Results: Increasing evidence implicates influenza infection in the pathogenesis of late onset filler reaction. Conclusion: Although there is a low risk of late onset adverse reaction with hyaluronic acid fillers, injecting physicians must be aware of the possible filler reaction following the influenza infection.

Minimally Invasive Facial Cosmetic Procedures

Minimally invasive procedures including neurotoxins, dermal fillers, deoxycholic acid, lasers, peels, and microneedling offer powerful, less permanent adjuncts to surgery that are highly effective in select patients. Injectables and skin resurfacing techniques target facial irregularities including wrinkles and fine lines, decrease in volume and contour, and unwanted fat. Determining the best approach for a given patient involves careful consideration of the patient's health conditions, unique anatomic characteristics, tissue quality, and desired results. A detailed understanding of facial anatomy, aesthetics, and techniques is necessary to master these approaches. This article addresses the spectrum of nonsurgical cosmetic procedures to rejuvenate and optimize the face.

Hyaluronic Acid Filler Emergency Kit

Widespread use of facial filler has led to a rise in reports of associated complications. The aim of this kit is to encompass all needed items to treat the patient and to be organized and prepared to provide correct treatment in urgent situations. A search was performed to gather information on the treatment of complications that occur after injection of soft tissue fillers. The search included reports published in English up to June 2018. We focused on reports of complications arising from emergent/urgent situations following the use of hyaluronic acid injectables; these included filler embolization resulting in impending skin necrosis, blindness or partial loss of vision, and anaphylaxis. We collated treatment of emergent complications from our search of published articles. There were 2 described protocols for filler complications in the literature. One protocol, the “old” protocol, was based on a low dose of hyaluronidase with longer intervals of injections and ancillary treatment. This protocol did not show good results in comparison with the “new” protocol, which was needed to improve these results. The new protocol demonstrated that a high dose of hyaluronidase had better efficacy; this protocol involves hourly injections with no ancillary treatment required except for aspirin. We propose a filler emergency kit (FEK) to deal with complications of hyaluronic acid fillers according to the new protocol to manage the stresses caused by these situations. Every physician needs to be prepared for any potential complication; therefore, there is a need to have a FEK as a crash kit in the clinic to avoid distressing the physician and the patient.

Development of Poly(HEMA-Am) Polymer Hydrogel Filler for Soft Tissue Reconstruction by Facile Polymerization

The number of breast reconstruction surgeries has been increasing due to the increase in mastectomies. Surgical implants (the standard polydimethylsiloxane (PDMS) implants) are widely used to reconstruct breast tissues, however, it can cause problems such as adverse immune reactions, fibrosis, rupture, and additional surgery. Hence, polymeric fillers have recently garnered increasing attention as strong alternatives for breast reconstruction materials. Polymeric fillers offer noninvasive methods of reconstruction, thereby reducing the possible adverse effects and simplifying the treatment. In this study, we synthesized a 2-hydroxylethylmethacrylate (HEMA) and acrylamide (Am) copolymer (Poly(HEMA-Am)) by redox polymerization to be used as a biocompatible filler material for breast reconstruction. The synthesized hydrogel swelled in phosphate buffered saline (PBS) shows an average modulus of 50 Pa, which is a characteristic similar to that of the standard dermal acrylamide filler. To investigate the biocompatibility and cytotoxicity of the Poly(HEMA-Am) hydrogel, we evaluated an in vitro cytotoxicity assay on human fibroblasts (hFBs) and human adipose-derived stem cells (hADSCs) with the hydrogel eluate, and confirmed a cell viability of over 80% of the cell viability with the Poly(HEMA-Am) hydrogel. These results suggest our polymeric hydrogel is a promising filler material in soft tissue augmentation including breast reconstruction.

Granuloma as a complication of polycaprolactone-based dermal filler injection: ultrasound and histopathology studies

In aesthetic medicine, there has been an ongoing search for an ideal dermal filler to offer zero complication rate. Polycaprolactone-based dermal filler (PCL) has been available since 2009. The purpose of the paper was to present a case of granuloma as a complication of PCL injection, which has not been reported so far by other researchers. A 68-year-old female was injected with PCL. One year later, nodules accompanied by bluish skin discoloration developed within the injection site. Ultrasound and histopathology studies were performed. The examinations confirmed the presence of foreign body granuloma after PCL, which makes it the first reported case worldwide. The published data analyses showed general lack of studies and case reports to address this issue. The PCL, like an injection of any soft tissue filler, may lead to serious complications, such as granuloma formation. This makes further research legitimate and necessary.

Filler Nodules: Inflammatory or Infectious? A Review of Biofilms and Their Implications on Clinical Practice

BACKGROUND

The numbers of minimally invasive cosmetic procedures performed in the United States have steadily increased each year. Concurrently, the rates of filler complications have also increased. Delayed filler reactions and granulomas have recently been attributed to biofilm infections.

OBJECTIVE

The biology and pathogenesis of biofilms, and their diagnosis, treatment, and prevention will be discussed.

METHODS

The relevant and recent literature on delayed filler reactions and biofilms was reviewed.

RESULTS

Increasing evidence implicates biofilm infections in the pathogenesis of delayed filler reactions. Therapeutic and preventative measures can be taken to minimize the occurrence of these potentially devastating consequences of dermal fillers.

CONCLUSION

Awareness of biofilm infections is key in the assessment of filler reactions in order to ensure timely and accurate diagnosis and treatment.

Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations

Background

Dermal fillers have been increasingly used in minimally invasive facial esthetic procedures. This widespread use has led to a rise in reports of associated complications. The aim of this expert consensus report is to describe potential adverse events associated with dermal fillers and to provide guidance on their treatment and avoidance.

Methods

A multidisciplinary group of experts in esthetic treatments convened to discuss the management of the complications associated with dermal fillers use. A search was performed for English, French, and Spanish language articles in MEDLINE, the Cochrane Database, and Google Scholar using the search terms “complications” OR “soft filler complications” OR “injectable complications” AND “dermal fillers” AND “Therapy”. An initial document was drafted by the Coordinating Committee, and it was reviewed and modified by the experts, until a final text was agreed upon and validated.

Results

The panel addressed consensus recommendations about the classification of filler complications according to the time of onset and about the clinical management of different complications including bruising, swelling, edema, infections, lumps and bumps, skin discoloration, and biofilm formation. Special attention was paid to vascular compromise and retinal artery occlusion.

Conclusions

Clinicians should be fully aware of the signs and symptoms related to complications and be prepared to confidently treat them. Establishing action protocols for emergencies, with agents readily available in the office, would reduce the severity of adverse outcomes associated with injection of hyaluronic acid fillers in the cosmetic setting. This document seeks to lay down a set of recommendations and to identify key issues that may be useful for clinicians who are starting to use dermal fillers. Additionally, this document provides a better understanding about the diagnoses and management of complications if they do occur.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Adverse Events Associated With Aesthetic Dermal Fillers: A 10-Year Retrospective Study of FDA Data

This study investigates the reported adverse events arising with various aesthetic dermal fillers by type and brand name. It reveals rare but dangerous complications associated with a widely used elective procedure. The authors queried and compiled the MAUDE database for injury cases reported with aesthetic dermal fillers between January 2007 and July 2017. A total of 5024 individual cases were then queried for adverse events using specific keywords and grouped into categories for analysis. Categories and keywords were determined after querying a large portion of the samples for common adverse events. The most common complications associated with aesthetic dermal filler use were nodule formation (2952 cases), infection (2575 cases), inflammation (711 cases), allergic complications (594 cases), and vascular complications (590 cases). The most common fillers associated with an adverse event were Juvederm Voluma XC (1050 cases), Sculptra (879 cases), and Radiesse (620 cases). These fillers represent 3 filler types: hyaluronic acid fillers, poly-l-lactic acid fillers, and calcium hydroxylapatite fillers, respectively. Injectable dermal fillers are frequently used cosmetic products around the world. To safely and effectively use these products, health care providers and patients must be fully aware of the proper techniques and risks associated with each product. Many of the complications reported were known to be possible, but others were previously only reported as individual case studies. The rates of occurrence for both well-known and lesser known complications may be higher than originally thought.

Late-Onset Inflammatory Response to Hyaluronic Acid Dermal Fillers

Objective:

Even though injectable hyaluronic acid (HA)–based fillers are considered safe, rare complications, such as late-onset inflammatory reactions have been reported. Possible causes and effective treatments have not been formally described, so this work aims to discuss these and offer a formal protocol for treatment.

Methods:

This article presents 5 clinical cases of late-onset inflammatory response occurring at least 3 months after uneventful injection of HA dermal filler.

Results:

Inflammation appeared spontaneously, usually 4–5 months after the last injection, but in 1 patient, almost 14 months later. One patient was injected at the same time with fillers manufactured by 2 different technologies. In this case, all areas treated with the same filler showed diffuse swelling of inflammatory nature, whereas the lips, treated with the second filler brand, remained unaffected. Four patients reported a flu-like illness or gastrointestinal upset a few days before the onset of dermal filler inflammation.

Conclusion:

Late-onset inflammatory reactions to HA fillers may be self-limiting but are easily and rapidly treatable with oral steroids, and with hyaluronidase in the case of lumps. It is likely these reactions are due to a Type IV delayed hypersensitivity response. Delayed inflammation associated with HA fillers is nonbrand specific. However, the case where 2 different brands were injected during the same session, but only 1 brand triggered a hypersensitivity reaction, suggests that the technology used in the manufacturing process, and the subsequent differing products of degradation, may have an influence on potential allergic reactions to HA fillers.