How to prevent filler-related complications

To prevent filler-related complications, Dr. Cohen and his staff focus on understanding the anatomy of the skin and what lies beneath the areas that they’re injecting. Learn to practice safe principles for prepping the skin.

Dermal filler complications, ranging from product-related sensitivity to vascular compromise, continue to occur among aesthetic patients. Most are preventable and are related to inappropriate patient selection, sterility issue, filler placement, volume and injection technique, according to a paper published April 15, 2015 in Clinical, Cosmetic and Investigational Dermatology.

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Joel L. Cohen, M.D.Joel L. Cohen, M.D., a dermatologist whose studies on filler complications and how to manage them have been published in the literature since 2006, says dermatologists who inject fillers can significantly reduce the risk of even the most dangerous complication, vascular compromise, by having a good understanding of anatomy and recognizing and acting on early warning signs.

Dr. Cohen, director of AboutSkin Dermatology and Dermsurgery in Englewood and Lone Tree, Colo., and associate clinical professor of dermatology at the University of Colorado, recently presented on the topic and reviewed the full-spectrum of filler complications at the Orlando Dermatology Aesthetic and Clinical Conference (Orlando, Fla., January 2016).

Starting with what’s simpler

Complications that are relatively easy to avoid and fix include inappropriate or superficial placement of hyaluronic acid filler materials, which, if unable to mold-out by pushing down on it firmly, can usually be dissolved with hyaluronidase enzyme. If the HA-filler was placed a long time ago (such as over 18 to 24 months), then it might not work as well as the product may have been replaced by some neocollagenesis, according to Dr. Cohen.

“There are different formations of hyaluronidase,” he says. “There’s Vitrase [ovine hyaluronidase, Bausch and Lomb] and Hylenex [recombinant hyaluronidase human injection, Halozyme]. Hylenex is something you don’t have to skin test for. With Vitrase, we typically would do a skin test first for a non-urgent issue like a non-malleable lump of product or superficially-placed ridge of product.” 

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Rarely, filler patients might experience sensitivity to an FDA-approved filler, and derms usually can managed this complication with antiinflammatory agents. Should infection occur, it can often be managed successfully with antibiotics, depending on the clinical features, according to Dr. Cohen. But a culture can sometimes be helpful as some of these infectious processes have actually required months of antibiotics to resolve, he says. Dr. Cohen documented such cases in Dermatologic Surgery, March 2006.

The most concerning complication is vascular compromise.

“Vascular compromise is when the arterial circulation is compromised and leads to a dusky color or patchy purple to the area. It’s usually painful. That’s the important feature,” Dr. Cohen says.

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An ounce of prevention

To prevent filler-related complications, Dr. Cohen and his staff focus on understanding the anatomy of the skin and what lies beneath the areas that they’re injecting. They also practice safe principles for prepping the skin.

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“I think we’re paying a lot more attention in terms of prepping the skin these days, after people have reported some delayed sensitivities to some products,” Dr. Cohen says. “Folks in Europe and Canada and now in the U.S. discuss seeing people who have had some inflammatory or potential sensitivity reactions to products months after injection. Some people believe the complications coincided with a sinus infection or having their teeth cleaned. As a result, I think there are some specific considerations that we think further about.”

Dr. Cohen preps the skin in most areas, except around the eyes, with alcohol and chlorhexidine. Around the eyes, he uses alcohol and chloroxylenol.

“I [tell patients] to avoid applying makeup, or touch/manipulate the area subsequent to injection for at least a day,” he says.

While he usually uses a needle to inject fillers for most areas, he sometimes prefers a cannula - especially for injections below the eye, in the medial cheek and in the dorsal hands. He reported on the topic in a study published Jan. 2012 in the Journal of Drugs in Dermatology.

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 “Cannulas have been found in some studies to decrease pain and bruising. You don’t necessarily get less swelling with the cannula because you tend to be moving it around by fanning in multiple different direction,” Dr. Cohen says.

NEXT: Avoiding, managin vacular compromise


Avoiding, managing vascular compromise

Dermatologists injecting facial areas in the distribution of underlying large, named arteries run the risk of potentially pushing product into an artery and affecting the blood supply in that distribution of the artery. This could lead to skin necrosis, according to Dr. Cohen.

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“Necrosis can cause a dusky or reticulated discoloration to the area. And that’s something we want to know about when it occurs. So, if somebody calls and says they have some purple discoloration, we don’t want to reflexively say, that’s bruising, just put some ice on it. We want a better description,” Dr. Cohen says. “With vascular compromise, if you’re concerned about a patient, it’s good to take a look and see what’s going on. Talk with them about the symptoms such as pain as another feature of concern for vascular compromise.”

A derm’s discussion with a patient about vascular compromise should include differentiating vascular compromise and bruising. A purple and kind of dusky gray and patchy appearances suggests vascular compromise, versus purple discoloration in a specific spot, which is more likely a bruise.

“Then, if it’s painful, that more points to vascular compromise, with the skin struggling for survival,” he says.

Dr. Cohen was the lead author of a paper published last year reflecting consensus recommendations regarding the treatment of injection-induced necrosis. In it, the authors write that the first step is to promptly (ideally within 24 hours) diagnose the condition and treat it immediately with at least 200 U of hyaluronidase and often more. Clinicians involved in the consensus say it isn’t necessary to do a skin test in cases of impending necrosis.

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“Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage may potentially even help to try to [mechanically] break-up impingement of the vessel. Some experts advocate the use of nitroglycerin paste as some studies indicate that nitroglycerine can vasodilate low-resistance arterioles, although this topic is a bit controversial. Introducing an oral aspirin regimen can help prevent further clot formation due to vascular compromise,” according to the paper’s abstract in the September 2015 Aesthetic Surgery Journal.

There are reports of blindness due to vascular occlusion affecting orbital vessels and their anastomoses, especially the central retinal artery, according to Dr. Cohen.

“There have been some newer reports of blindness from fillers in Korea,” Dr. Cohen says. “The glabellar area is where the dorsal nasal artery and the supratrochlear artery back up to the ophthalmic artery, which backs up to the central retinal artery. As a result, you can get product into a vessel that connects to other arteries that affect vision.”

NEXT: Avoiding complications when treating scars


Avoiding complications when treating scars

While Dr. Cohen uses fillers to restore depressed surgical scars on the helical rim, as well as on the cheek, he often uses a different approach to treat depressed scars on the nasal tip.

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“When treating the tip of the nose, I try to be very conservative. If I’m going to use filler, I just use a tiny bit. The concern is the blood vessels and getting into a blood vessel or pinching off a blood supply to the tip of the nose,” he says.

In most cases of depressed surgical scars at the tip of the nose, Dr. Cohen says he uses a dermal graft, which he published in a study in Dermatologic Surgery in October 2014. In essence, he takes skin from behind the ear or elsewhere with a punch biopsy. He’ll then put a little of the dermis of the skin from the biopsy under the area that’s depressed to lift it. He adds that he simply removes the epidermis with an 11-blade. The dermal graft is, in some cases, permanent, he says.

Filler wisdom

Dr. Cohen’s tips for avoiding and managing complications:

·       learn the anatomy

·       learn how to use the product

·       understand the importance of prepping the skin

·       understand what outcomes are normal versus not quite right

Disclosure: Dr. Cohen consults and participates in clinical trials for Allergan, Galderma, Merz.

NEXT: Select papers by Dr. Cohen on complications


Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg. 2006 Feb;32(2):276-81. Review.

Clinical conference: management of rare events following dermal fillers--focal necrosis and angry red bumps.

Narins RS, Jewell M, Rubin M, Cohen J, Strobos J. Clinical conference: management of rare events following dermal fillers--focal necrosis and angry red bumps. Dermatol Surg. 2006 Mar;32(3):426-34.

Understanding, avoiding, and managing dermal filler complications.

Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. 2008 Jun;34 Suppl 1:S92-9.

Etiology, prevention, and treatment of dermal filler complications.

Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011 Jan;31(1):110-21.

Nitroglycerin: a review of its use in the treatment of vascular occlusion after soft tissue augmentation.

Kleydman K, Cohen JL, Marmur E. Nitroglycerin: a review of its use in the treatment of vascular occlusion after soft tissue augmentation. Dermatol Surg. 2012 Dec;38(12):1889-97.

Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations.

Cohen JL, Biesman BS, Dayan SH, DeLorenzi C, Lambros VS, Nestor MS, Sadick N, Sykes J. Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis with Hyaluronidase: Consensus Recommendations. Aesthet Surg J. 2015 Sep;35(7):844-9.

An additional reference on dermal filler injections resulting in blindness:

Description of a novel anatomic venous structure in the nasoglabellar area.

Lee HJ, Kang IW, Won SY, Lee JG, Hu KS, Tansatit T, Kim HJ. Description of a novel anatomic venous structure in the nasoglabellar area. J Craniofac Surg. 2014 Mar;25(2):633-5.

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