Etiology

Aging is characterized by volume deflation, facial descent and surface irregularities in the skin.

Dermal fillers treat volume loss, improve facial support, and reduce skin irregularities.

Scars may also be treated with soft-tissue fillers.

Use of an injectable agent for cosmetic enhancement was reported in 1899 by Robert Gersuny, who injected paraffin to create a testicular prosthesis (Kontis, Facial Plast Surg 2009). Materials with better biocompatibility are now available.

Epidemiology

• Age-related volume loss and skin surface irregularities
• Severity of aging relates to intrinsic factors (genetics) and extrinsic factors of ultraviolet exposure, smoking, diet and lifestyle choices.
• Society favors a youthful appearance. Improved facial appearance contributes to psychological well-being and to positive social function.

History

• Have patient identify areas of concern.
• History of previous surgery or filler treatment
• Current medications and supplements, especially blood thinners and anti-platelet agents
• Medical history and allergies including prior response and reactions to similar products, underlying autoimmune disease, HSV infection and pregnancy
• Informed consent should be obtained.

Testing

• Photographs to document before and after treatment
• Skin testing for allergy not generally indicated except for historic materials such as bovine collagen

(Hassouneh, Facial Plast Surg Clin N Am 2013; see also Fischer, Bentkover, Montes, Woerle, Gladstone, Niamtu, Christensen, Sharad)

Common and less serious

• Bleeding and bruising
• Prevented by discontinuation of aspirin and other nonsteroidal anti-inflammatory drugs, vitamin E, herbals such as gingko biloba, St. John’s wort, ginseng, ginger, and garlic
• Use of ice and arnica can help minimize bruise.
• Use of fine needles or blunt cannulas can help avoid unnecessary bruising.
• Allergic reactions
• Rare in most fillers
• Allergic reactions may include delayed hypersensitivity reaction with redness and swelling to rare anaphylaxis.
• Chronic inflammation responds to systemic or intralesional corticosteroids and lessens with time.
• Bacterial infection
• Infection is a rare complication and the most likely pathogens are skin flora.
• Heralded by increasing pain and erythema at injection site beginning 24–72 hours after treatment
• Cultures and appropriate treatment indicated
• Biofilms have been implicated and can be prevented by thorough cleansing of the area with antiseptic solution such as stanhexidine and local application of topical antibacterial agent.
• Viral infection
• Usually reactivation of herpes simplex virus (occasionally varicella zoster virus) in the perioral area
• Potential to prevent with antiviral prophylaxis Valcyclovir 500 mg BID, begin 2 days pretreatment, continue 5 days post-treatment
• Visible filler with beading or pooling of product
• Avoided with appropriate placement and quantity of injection
• Generally resolves with time, but may needle overlying skin and express product if a persistent problem
• Over-augmentation
• May respond to observation or needling and expressing
• Hyaluronate fillers (Restylane, Juvederm) can be treated with small injections of hyaluronidase into the overfilled area and will be broken down and removed in 3–48 hours.

Serious

• Tissue necrosis: possibly from vascular compression in area of injection or if product is placed too superficially into the epidermis; white blanching of skin and resistance to injection may indicate wrong level of injection.
• Embolic event: rare and due to direct intravascular injection with resulting tissue necrosis, CRAO, or other ischemic event in the head and neck area where the product was injected
• Avoid by withdrawing the plunger slightly before injecting, particularly in areas of known large vessels in the glabella and medial canthus.
• Some doctors recommend keeping nitroglycerin paste on hand; however, many patients develop problems hours after treatment rather than at time of injection. In addition, this is so rare that there is no clinical evidence that vasodilation helps (Hwang, Ophthal Plast Reconstr Surg. 2015).

• Avoidance of blood thinners and nonsteroidal anti-inflammatory drugs pretreatment
• Ice and elevation of treated area immediately post-treatment for 24–48 hours
• Sculptra treatment requires massage of injected area for several days.
• Soft lumps or bulges after hyaluronate or other product treatment can be minimized with gentle massaging of the area to disperse the product.

1. Anderegg U, Simon JC, Averbeck M. More than just a filler – the role of hyaluronan for skin homeostasis. Exp Dermatol 2014; 23:295.
2. Bentkover SH. The biology of facial fillers. Facial Plast Surg 2009; 25: 73.
3. Buck DW, Alam M, Kim JYS. Injectable fillers for facial rejuvenation: a review. J Plast Reconstr Aesthet Surg 2009; 62:11.
4. Carruthers JDA, Carruthers JA, Humphrey S. Fillers and Neocollagenesis. Dermatol Surg 2014; 40:S134.
5. Christensen L, et al. Adverse reactions to injectable soft tissue permanent fillers. Aesth Plast Surg 2005; 29:34.
6. Dayan S, Arkins JP, Somenek M. Restylane persisting in lower eyelids for 5 years. J Cosmet Dermatol 2012;11:237.
7. Fischer TC. A European evaluation of cosmetic treatment of facial volume loss with JuvedermTM VolumaTM in patients previously treated with Restylane Sub-QTM. J Cosmet Dermatol 2010; 9:291.
8. Gladstone HB, Cohen JL. Adverse effects when injecting facial fillers. Semin Cutan Med Surg 2007; 26:34.
9. Hassouneh B, Newman JP. Lasers, Fillers, and Neurotoxins. Avoiding complication in the cosmetic facial practice. Facial Plast Surg Clin N Am 2013;21:585.
10. Hwang CJ, Morgan PV, Pimentel A, Sayre JW, Goldberg RA, Duckwiler G.Rethinking the Role of Nitroglycerin Ointment in Ischemic Vascular Filler Complications: An Animal Model With ICG Imaging. Ophthal Plast Reconstr Surg.2015;March [epub ahead of print]
11. Kontis TC. Contemporary Review of Injectable facial fillers. Facial Plast Surg 2013; 15:58.
12. Kontis TC, Rivkin A. The history of injectable facial fillers. Facial Plast Surg 2009; 25:67.
13. Montes JR. Volumetric considerations for lower eyelid and midface rejuvenation. Curr Opin Ophthalmol 2012; 23:443.
14. Muhn C et al. The evolving role of hyaluronic acid fillers for facial volume restoration and contouring: a Canadian overview. Clin Cosmet Invest Dermatol 2012; 5:147.
15. Niamtu J. Complications in Fillers and Botox. Oral Maxillofac Surg Clin North Am 2009; 21:13.
16. Palm MD. Filler frontier: what’s new and heading west to the US market. Semin Cutan Med Surg 2014; 33:157.
17. Sandashivaiah AB, Mysore V. Biofilms: their role in dermal fillers. J Cutan Aesthet Surg 2010; 3:20.
18. Sharad J. Dermal fillers for the treatment of tear trough deformity: A review of anatomy, treatment techniques, and their outcomes. J Cutan Aesthet Surg 2012; 5:229.
19. Sundaram H, Voights B, Beer K, Meland M. Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxyl apatite and hyaluronic acid. Dermatol Surg 2010; 35:1859.
20. Wang F et al. In Vivo Stimulation of De Novo Collagen Production Caused by Cross-linked Hyaluronic Acid Dermal Filler Injections in Photodamaged Human Skin. Arch Dermatol. 2007;143(2):155-163.
21. Woerle B, Hanke CW, Sattler G. Poly-L-Lactic Acid: A temporary filler for soft tissue augmentation. J Drugs Dermatol 2004; 3:385.