Managing Complications of Fillers - Rare and Not-So-Rare - PMC

01/08/2022, 20:07 Managing Complications of Fillers: Rare and Not-So-Rare - PMC
J Cutan Aesthet Surg. 2015 Oct-Dec; 8(4): 198–210. PMCID: PMC4728901

doi: 10.4103/0974-2077.172191: 10.4103/0974-2077.172191 PMID: 26865784
Managing Complications of Fillers: Rare and Not-So-Rare

Eckart Haneke1,2,3,4
1
Department of Dermatology, Inselspital, University of Bern, Bern, Switzerland, Europe
2
Department of Dermatology, Clinic Dermaticum, Freiburg, Germany, Europe
3
Centro de Dermatología Epidermis, Inst CUF, Porto, Portugal, Europe
4
Department of Dermatology, Ghent University Hospital, Gent, Belgium, Europe
Address for correspondence: Dr. Eckart Haneke, Schlippehof 5, Freiburg - 79110, Germany. E-mail:
[email protected]
Copyright : © Journal of Cutaneous and Aesthetic Surgery
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-
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Abstract
Fillers belong to the most frequently used beautifying products. They are generally well tolerated, but
any one of them may occasionally produce adverse side effects. Adverse effects usually last as long as
the filler is in the skin, which means that short-lived fillers have short-term side effects and permanent
fillers may induce life-long adverse effects. The main goal is to prevent them, however, this is not al‐
ways possible. Utmost care has to be given to the prevention of infections and the injection technique
has to be perfect. Treatment of adverse effects is often with hyaluronidase or steroid injections and in
some cases together with 5-fluorouracil plus allopurinol orally. Histological examination of biopsy
specimens often helps to identify the responsible filler allowing a specific treatment to be adapted.
KEYWORDS: Complications, fillers, hyaluronic acid, blindness
INTRODUCTION
Volumetric rejuvenation of the face with fillers has gained popularity as the least invasive intervention.
However complications can occur. Some adverse effects are transient such as erythema and edema,
whereas some may persist such as granulomas. The management of complications depends on several
factors.
1. Severity of the adverse effect: Most of the immediate side effects are minor and disappear on their
own. Moderate side effects require treatment that is usually conservative. Severe adverse effects may
necessitate an immediate intervention.
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2. Duration of the adverse effect: Generally, adverse effects last as long as the desired filler effects.
This is true for most of the fillers. However, with collagen they may persist. A middle-aged woman
was seen developing stone-hard swellings at each point where she was injected with bovine
collagen, even at the test site, and despite all treatments these granulomas did not regress. Collagen
injections have a risk of approximately 6% to produce granulomatous reactions and usually respond
to corticosteroid injections within a few weeks. Adverse side effects to hyaluronic acid fillers were
frequently seen at the beginning of their use, probably due to the protein moiety that is part of the
biosynthetic production procedure. These swellings commonly remained at the site of injection and
disappeared with adequate treatment; however they are now infrequent. Clumping of a filler causes
lumps and bumps that usually have to be surgically removed. Permanent fillers cause permanent side
effects.
3. Time course of adverse filler effects: The time course is divided into reversible or temporary (caused
by collagen and hyaluronic acid); late and long-term (caused by poly-L-lactic acid (PLLA), calcium
hydroxylapatite, alginate, and dextranomer beads in hyaluronic acid); and delayed and permanent
(caused by vaseline, paraffin, silicone oil, hydroxyethyl methacrylate fragments,
polymethylmethacrylate beads, polyacrylamide, and polyalkylimide gels).
There is a general misconception that temporary fillers rarely provoke side effects; the frequency is
comparable to that induced by long-term and permanent fillers but their duration is shorter and hence,
they are less serious.
COMPLICATIONS
Early side effects include erythema, edema, and bruising; they are in fact a normal physiological reac‐
tion to the injection of a foreign substance and can often be mitigated by cooling the injected area. Pain
is reduced by slow injection and administration of local anesthetics in small volumes. Bruises are said
to be reduced by using arnica, aloe vera, or vitamin K creams. Allergies may occur within hours in cas‐
es where the patient has been sensitized before. Lumps and bumps occur when an unsuitable filler is
injected superficially or in the wrong location. These may occur immediately or develop from clumping
of the substance due to muscle activity. Vascular compromise becomes evident within a day in case of
arterial occlusion due to inadvertent intravascular injection or compression by the filler volume. Using
a blunt cannula instead of a sharp injection needle prevents inadvertent intravascular injection.[1] This
is particularly dangerous for the glabella, inner corner of the eye, and ala nasi, and is reported to cause
skin necrosis and even blindness.[2,3] A review of the world literature on eye complications from filler
injections identified 98 cases in English-language journals [Table 1]. Most cases were due to autolo‐
gous fat (n=47), hyaluronic acid (n=23) and collagen (n=8), whereas all other substances used as fillers
were below 5%. Fifty-nine cases were reported from South Korea where the data were collected from
the major retinal centres.[4] Whenever blanching is seen during the injection, it must be stopped imme‐
diately.[5] Hyaluronidase is injected around the vessel in order to prevent the side effects caused by
hyaluronic acid filler. Aggressive massage, warm compresses, and topical nitroglycerin are further sup‐
portive measures.[6,7,8]
Late complications are defined as those appearing after about 2-6 weeks. They comprise late allergic
reactions, chronic inflammation and infection, granulomas, filler migration, loss of function, telangiec‐
tasia, and hypertrophic scars. A detailed history may disclose a potential allergy. To avoid infection, the
injection site has to be thoroughly disinfected and defatted and the injection must not be done through
makeup.[9] Infection should be immediately treated with antibiotics and usually responds quickly.
Granuloma formation is unpredictable but depends on the material used. Particulate material is prone to
induce a macrophagic reaction, particularly the permanent fillers, but also poly-L-lactic acid (PLLA)
the particles of which have a crystalloid structure. The probability of granulomas increases with the
surface-to-volume relation of the filler particles and their shape with sharp edges. Homogenous fillers
rarely induce granulomas. Good quality hyaluronic acid fillers are virtually devoid of this effect. Sili‐
cone oil provokes a slightly different reaction called siliconoma with lymphocytic infiltrates. Permanent
fillers on the basis of acrylate gels appear homogenous but are, in fact, particulate.
Delayed reactions are those that occur 6 weeks after the filler injection. They are caused mainly due to
bacterial biofilms,[10] although this view has been vehemently disputed. They may induce granulomas
as well as the so-called cold abscesses. As biofilms are mostly bacterial in nature, they should not be
treated with steroid injections.[11]
Delayed side effects may develop months or years after the placement of the filler, and the patient often
does not remember which filler he/she had got and whether other fillers had also been used. Nonphysi‐
cian injectors are often ignorant of the side effects of the fillers they use, and they also neglect good
clinical practices such as disinfection and wearing of gloves.
ADVERSE EFFECTS ACCORDING TO TYPE OF FILLERS
Most adverse effects are not specific to a particular filler. They may be the result of volume augmenta‐
tion or due to technical faults such as wrong indication, placement site, wrong injection needle,[12] and
infection caused by contaminated ice or water.[13] Infections are differentiated from other nodules and
granulomas by radiolabeled leukocyte scintigraphy.[14] Inflammatory and immune-mediated adverse
effects often occur late. Persistent edema, granulomas,[15] sarcoid-like reactions, and panniculitis are
the most common side effects. Systemic granulomatous, autoimmune diseases and acute hypersensitivi‐
ty reactions are very rare.[16] Manipulation close to an injection site may lead to infection even years
after the placement of the filler.[17]
Autologous fat
Adherence to key principles, such as sterile technique and low-volume injection throughout layers of
tissue, is necessary for obtaining excellent results. Adverse outcomes are rare. However, early adoption
of surgical procedures by those without a sound understanding of the underlying principles and tech‐
niques can have disastrous consequences. Furthermore, physicians operating on any patient must under‐
stand the potential for complications and be able to manage these appropriately when they occur.[18]
Fat longevity is dependent upon methods of handling and preparation of the fat. Poor fat viability pro‐
duces an inadequate result. This has thus to be considered as a complication.[19]
On the other hand, poor aesthetic results due to significant weight gain as a result of corticosteroids,
oral contraception, and a change of lifestyle were seen in a patient with Romberg's syndrome.[20] Lipo‐
modelling of the breast was performed in 880 cases, approximately 140 mL of filler was injected for a
desired volume of 100 mL, which remained stable for 3-4 months. No radiological problems at mam‐
mography occurred after the procedure. Fat necrosis was observed in only 3% of the cases. Serious
complications included one case of infection at the harvest site, six cases of infection at the injection
site, and one case of intraoperative pneumothorax.[21] Abscess formation, life-threatening sepsis, and
residual deformity have also been reported.[18]
A recent review of the English-language literature revealed 98 cases of vision change due to filler injec‐
tions, of which 47 were due to autologous fat injection; one patient experienced necrosis of her left eye
after 2 days and died after 4 days.[4] Neurological complications after fat injection comprised 2 patients
with unilateral loss of vision after fat injection in glabella,[22] 2 patients with sudden loss of vision,
aphasia and hemiparesis[23] and 1 patient with sensorimotor hemiparesis after infarction of the middle
cerebral artery.[24] Three preconditions that predispose to intravascular fat embolism include well-vas‐
cularized tissue, a sudden local increase in pressure in the injected tissue and fragmentation of
parenchyma.[25] It is assumed that fragments of fatty tissue reach ocular and cerebral arteries by re‐
versed flow through branches of the carotid arteries from the facial vessels. Complication of fat em‐
bolism can appear either immediately after the fat injection or after a latency period. It may remain sub‐
clinical and may not be recognized, or the clinical features may be misinterpreted.[25] To minimize the
risk of such a major complication, it is essential that fat injections should be performed slowly, with the
least possible force. Routine funduscopic examination after fat injections into the face may be useful.
[25]
Human collagen
Autologous human collagen is well-tolerated, both when derived from cultured fibroblasts and autolo‐
gous injectable dermis.[26] Human allogeneic collagen was found to elicit acute-to-subacute inflamma‐
tory reactions,[27] but no serious long-term side effects were reported. The cosmetic effect lasts 4-7
months.
Nonhuman collagens
Nonhuman collagens are foreign proteins that exhibit a risk of allergies and granulomas, particularly
bovine collagen, although porcine collagen is better tolerated. The side effects are mostly temporary un‐
til all collagen has been degraded but one case was observed with stone-hard granulomas not disappear‐
ing with any treatment over more than a decade.[28] Most granulomas are palisaded around amorphous
eosinophilic material representing bovine collagen. This is characterized by structureless deposits, lack
of birefringence, and pale gray-violet staining with Masson's trichrome stain.[29] Whether the injection
of collagenase[30] would be successful has not been examined. About 4-6% of the patients developed
temporary granulomas at the injection site. Testing and double testing before treatment were recom‐
mended, and in both cases granulomas were found to occur.
Presently, collagen fillers are used less frequently, and as a result adverse effects are expected to be rare.
Hyaluronic acid
Hyaluronic acid (HA) is universally present in all animal species. It is not species-specific; however,
hyaluronans are linked to proteins that are species-specific. Good preparations are (almost) free from
foreign proteins. They have a low propensity to induce granulomas, but show a variety of transitory side
effects such as rare granulomas and infection.[31,32] Presently, approximately 200 HA preparations are
on the market. To prevent untoward adverse effects, high-quality brands with a low rate of problems are
preferred as their complication rate is much lower.
Untested cheap products should not be used at all.
HA is currently the most widely used filler. It has a longevity of approximately 6 months, but this de‐
pends on the molecular size, method of cross-linking, and the region of injection. There are differences
among HA fillers concerning the size of the molecule, the protein content, the chemical bonding, the
fluidity, whether they are monophasic or biphasic, injection pain, and longevity.[33] A good preparation
does not clump as this may give rise to granulomas. They were not rare in the beginning of the nonani‐
mal-derived synthetic HAs (NASHAs) but are now very rare, except for new, cheap, untested products,
particularly bought online through the internet.
In the early period of HA filler use, reactions were assumed to be caused due to hypersensitivity.[34,35]
Erythematous multiform rashes and systemic anaphylactoid reactions are very rare side effects[36,37]
that occur after intra-articular injection of HA,[29] with native HA having a lower sensitizing potential.
[31]
Side effects due to the substance are usually short-lived and can instantaneously be treated by injecting
hyaluronidase. The dose depends on the specific drug and also varies according to the HA used and its
degree of cross-linking. Hyaluronidase cleaves both natural and cross-linked HA. Bovine, ovine, and
recombinant hyaluronidase are available. As they are foreign proteins, they have the potential of caus‐
ing an anaphylactic shock in sensitized individuals. It is, therefore, necessary to question the patient
about possible allergies. Hyaluronidase can also be used to treat HA granulomas.[38]
Technique-related side effects occur as with other fillers as well. HA injected too superficially may
shine through with a bluish-grayish color, due to the Tyndall effect [Figure 1]. It has to be used with
care in the eyelids as it may cause swelling due to its ability to attract water. Accidental intracapillary
injection may cause livedo reticularis.[39]
The histopathology of grayish-glassy nodules after superficial injection shows HA deposits without any
inflammatory changes. Granulomas exhibit a very dense lymphocytic infiltrate with abundant
eosinophils and many foreign body giant cells containing basophilic amorphous material that corre‐
sponds to HA [Figures 2–5]. Autoinjected diluted HA cream resulted in a dense inflammatory and
granulomatous infiltrate to the abused cream vehicle.[40] It was successfully treated with systemic an‐
tibiotics and intralesional steroid injections.
Alginate
In an attempt to develop a new biological filler with a longer duration, an alginate derived filler (Nov‐
abel®) was marketed. Very shortly after its launch, the side effects of granulomas were observed;[41]
hence, it had to be withdrawn from the market. The granulomas started with erythema and swelling un‐
til hard nodules formed 2-5 months after the injection. Ultrasound showed hypoechoic structures with a
hyperechoic rim. Histopathology revealed spherical basophil structures of 100-120 μm diameter sur‐
rounded by a rim of giant cells. Around the granulomas, a distinct hyaline collagen capsule was seen.
Hyaluronic acid plus dextranomer microspheres
Dextranomer beads were incorporated in HA to improve the longevity of the filler. They consist of
cross-linked dextran molecules with a positive surface charge and a diameter of 80–120 μm. The beads
attract macrophages that release tumor growth factor-β and interleukins stimulating collagen deposition
around the detranomer beads, maintaining the volume correction effect after the resorption of HA.[42]
The material is well tolerated with only three reports of a granulomas, one of which was
suppurative[35] and the other ones were rich in foreign body giant cells.[43,44] The histopathology
shows dark bluish or purplish dextranomer beads, or may exhibit empty spaces giving a “Swiss-cheese”
aspect. Incision of the nodules and treatment with cephalexin and methylprednisolone aceponate led to
complete resolution in one case.[45]
Poly-L-lactic acid (PLLA)
This substance has been used for decades in medicine and surgery and is well-tolerated. In contrast,
PLLA as a filler comes as a powder of crystalloid particles that has to be reconstituted before injection.
Subcutaneous nodules are either fibrotic or granulomas. They can form because of insufficient time dur‐
ing reconstitution of the material, inadequate dilution, overcorrection, superficial injection techniques,
or inappropriate concentration of PLLA molecules secondary to muscle movement. Granulomas are
thought to be due to allergic or inflammatory host responses.[1] In the early years, a volume of 3 mL of
filler was recommended: This was found to cause granulomas and it also clogged the injection needle.
Now, most physicians use 10 mL or more of physiologic saline, often with some lidocaine. After injec‐
tion, the water is resorbed and the PLLA particles induce a fibroblastic reaction lasting for 24 months or
longer. This may cause fibrotic nodules around the eyes and in the hands,[46] and the substance may
clump in the lips; these are adverse effects of a faulty technique. PLL granulomas are classical giant
cell granulomas with many epithelioid cells and relatively few lymphocytes. The PLL particles are oval,
fusiform, or spiky, and seen in epithelioid and giant cells as well as in between. They show birefrin‐
gence in polarized light.[47] The granulomas last for at least 18 months, which approximately repre‐
sents the time needed to hydrolyze the crystalloid particles.[48]
Calcium hydroxyl apatite
Calcium hydroxyl apatite (CAH) is an inorganic material that has been used successfully as bone ce‐
ment for decades. The material currently used as a cosmetic filler is Radiesse® (Merz Pharmaceuticals,
Frankfurt am Main, Germany). It consists of microspheres (30%) of 25-45 mm diameter suspended in
carboxymethyl cellulose (70%) gel. It is biochemically inert and nonantigenic but stimulates collagen
production. When injected as a suspension for soft tissue augmentation, it is very well-tolerated. Its fill‐
ing effect lasts 9-12 months[49] and sometimes longer. Adverse effects are rare and caused mostly due
to technical faults. Postinjection cellulitis was reported at a frequency of 1.7% in one study.[50] It must
not be injected into the lips as it tends to clump and produce palpable nodules.[51] In elderly women,
granulomas were observed that consist of tightly packed dark bluish microspheres of 25-40 μm diame‐
ter and giant cells.[52] The nodules were effectively treated by fractional CO2 laser.[53] A grade 3 sys‐
temic reaction developed 30 min after the injection of cyclohexyladenosine (CHA) vocal cord filler
prompting the authors to recommend a 30-min postprocedure observation period.[54]
Acrylic hydrogel
Suspension of ethyl methacrylate and hydroxyethylmethacrylate particles in hyaluronic acid was mar‐
keted as DermaLive® and DermaDeep®. Initial reports claimed good tolerance level[55] but soon it be‐
came evident that this biphasic filler caused late granulomas in a very high percentage of
cases[56,57,58] and it had to be withdrawn from the market. However, granulomas still occur.[59] They
present as palpable and then often visible nodules [Figures 6 and 7]. Fistulation may develop with time,
and occasionally a keratoacanthoma-like appearance is seen.[60] The granulomas are well-delimited
and easy to dissect surgically [Figure 8]; however, new granulomas develop until all material has been
removed. Other treatment options are intralesional corticosteroids, allopurinol, and 5-fluorouracil. An‐
tibiotics are given immediately if an infection is suspected.[61] The histopathology shows a dense gran‐
uloma with a fibrous pseudocapsule containing masses of crystalloid acrylate particles. The granulomas
are made up of epithelioid and foreign body giant cells that engulf the particles. Some areas become
necrotic and contain cholesterol clefts. Epidermal ridges may grow down and try to surround the for‐
eign material giving rise to fistule formation. Some granulomas may become sclerotic with time [Fig‐
ures 9–12]. Acrylic hydrogel is probably the product with the highest risk of complications.
Polyacrylamide gel
Polyacrylamide gel (PAAG) is a suspension of 2.5-5% PAAG in sterile water. It is a large volume filler
and can hold 300 to 400 times its weight in water. It is marketed under many different names: PAAG
(Sinocos Eastcos, Hong Kong, China); Amazing gel, Aqualift, Aquamid (Contura International,
Söborg, Capital Region of Denmark, Denmark); Argiform, Bioformacryl, Formacryl, and Outline, each
of which contain slightly different additional components.[1] The material is widely resistant to enzy‐
matic degradation and phagocytosis and hence, it is considered a permanent filler. The particles can
harbor bacteria on their surface and give rise to late infections, biofilms, and abscesses.[62] It does not
induce allergic reactions. It is mainly used in breast augmentation surgeries, especially in Eastern Eu‐
rope and Asia. Although the results are immediate, overcorrection is necessary. It remains soft and pli‐
able after injection, which is a major advantage of this filler over other substances.[63] PAAG should
not be injected over other products. It is generally well-tolerated; however, severe adverse effects, such
as swelling, lumps, abscesses, facial disfigurement, gel dislocation, and respiratory distress, have been
known to occur.[64] Other series reported breast deformity, lumpiness, intermittent swelling, pain, and
gel extrusion.[64,65,66,67] The gel is exceedingly biocompatible, making it an excellent medium for
bacteria.[68] The main risk is infection that often develops after 8-12 months or even later. Cultures fre‐
quently remain negative and only PCR can identify bacteria, such as Propionibacterium acnes,
Streptococcus oralis, Streptococcus mirabilis, and Staphylococcus aureus, which are normally not
pathogenic and some atypical mycobacteria hinting at the importance of preinjection site disinfection.
Histopathology shows neutrophils, karyorrhexis, numerous macrophages, and foreign body giant cells
around a gel that appears to be morphologically similar to hyaluronic acid. Giant cells often contain
vesicles full of PAAG, and the material frequently shows small blebs in the material are seen both when
it is in giant cells as well as in large lakes in the tissue. PAAG is not birefringent but positive with Al‐
cian blue.
Polyalkylimide gel
Polyalkylimide gel 4% in water (Bio-Alcamid, Polymekon, Milan, Lombardy, Italy) is also a large-vol‐
ume filler. It is injected into the deep dermis or hypodermis. It develops a thin collagen capsule around
the site of injection preventing migration and keeping it apart from the surrounding tissue. An advan‐
tage is that aspiration or punching a small hole over it permits its removal. Side effects are edema,
bruising, nodules, infections, severe inflammatory reactions, unsatisfactory appearance, and late-ap‐
pearing abscesses. Migration despite the fibrosis around it is a rare event.[69] Histopathology shows
basophilic amorphous material surrounded by neutrophils and erythrocytes. Gram stain may reveal bac‐
teria. Infections are very difficult to treat and require long-term high-dose antibiosis, incision, drainage,
and irrigation.[70.71]
Polyvinylhydroxide microspheres in polyacrylamide gel
It is a suspension of 6% polyvinyl hydroxide microspheres in 25% PAAG hydrogel (Evolution®, Pro‐

Cytech SA location details not given). It is reportedly well-tolerated but is not used very often.[53,72]
Polymethylmethacrylate (PMMA)
Polymethylmethacrylate (PMMA) beads suspended in bovine collagen were marketed as Artecoll®, lat‐
er Artefill® and Artesense®. The products require testing of bovine collagen before use to avoid an im‐
mune reaction. Patients with keloids should not be treated with this.[73] Around 3 weeks after injec‐
tion, collagen is deposited around the microspheres virtually encapsulating them. Overcorrection is not
performed. Artefill® polishes microbeads and attracts fewer impurities with less risk of inducing granu‐
lomas.[74] Metacrill and Metrex are also PMMA particles but they are not round and polished. Granu‐
lomas are a rare side effect with an incidence rate of 0.01%[75,76] but are difficult to treat.[77] Lumps
are frequent, particularly in the lips but most are only palpable and not visible. Granulomas develop
even several years after the injection[78] and occur after treatment with interferon for hepatitis C[79] or
after laser skin resurfacing (D Vochelle, personal communication). Sudden onset of induration,
swelling, tenderness, and erythema indicates granuloma. The histopathology reveals a typical granulo‐
ma with round empty-appearing clear spaces in a fibrotic tissue. Therapy constitutes intralesional corti‐
costeroids and 5-fluorouracil[80] as well as allopurinol and surgery. Metacrill granulomas are melted
with high frequency endocoagulation that leaves a residue of burnt plastic with a characteristic smell.
[81] Intralesional laser treatment is another option.
Mineral oils, paraffin, and other lipid derivatives
Vaseline was the first substance to replace a testicle more than 120 years ago. Other crude substances
such as paraffin, lanolin, cod liver oil, or beeswax were also used in the late nineteenth and early twenti‐
eth centuries. The initial results were satisfying but the long-term results were appalling with skin hard‐
ening, swelling, granuloma formation, ulceration and fistulation, infections, abscesses, and even cancer
development.[1]
The side effects of paraffin are irreversible and hence, it is no longer legally used as a filler. Highly in‐
flammatory granulomas after fraudulent use of paraffin or other oils containing vitamin E, sometimes
also D and A, are still seen.[82] Injection of paraffin into the penis caused sclerosing lipogranuloma
characterized by fibrosis and deformation.[83] Vaseline and other mineral oils cause a very similar re‐
action.[84,85,86,87]
Histopathologically the deep reticular dermis and subcutaneous fat are involved with a predominantly
lobular panniculitis with a Swiss-cheese appearance. The cystic spaces are surrounded by foamy histio‐
cytes and giant cells. The collagen bundles in-between are sclerotic.
Whether ultrasound liquefaction of the fat where the inappropriate substance had been injected, and
subsequent extraction by a suction cannula helps to eliminate this material remains to be seen.[88,89]
Silicone
Silicone is a filler with irreversible side effects. It is a highly polymerized hydrophobic oil (Silikon
1000, Adatosil 5000, Biopolimero), gel (MDX 4-4011), or solid rubber consisting of dimethylsiloxane
units. It is well-tolerated but the occasional side effects are dramatic and irreversible; therefore, it is
banned for cosmetic use in the European Union and the United States. Those who still use silicone off-
label claim that pure silicone[90] and proper microdroplet technique prevent adverse effects but this
view is disputed. Medical grade silicone oil is pure and sterile. The secret of good results is the injec‐
tion of truly minute amounts.[91,92,93] A mixture of silicone with hyaluronic acid was recently de‐
scribed as “the optimal filler.”[94]
Side effects are local and systemic. Small nodules are minor complications that occur within a year af‐
ter injection. They occur due to injection of too much substance. Indurations and erythema with
swelling are silicone granulomas that frequently appear 2-12 years after injection. Some authors differ‐
entiate between siliconoma, which consists almost exclusively of macrophages containing small
droplets of silicone oil and contains virtually no inflammatory cells, and silicone granuloma, with sili‐
cone containing macrophages, lymphocytes [Figures 13 and 14], and few giant cells that are somewhat
artificial. Both respond to intralesional corticosteroids in most cases. Major complications are systemic
with pneumonitis, acute respiratory distress syndrome, sudden death after intravascular injection, mi‐
gration of large volumes of low-viscosity silicone oil, erysipelas-like reactions, blindness, loss of neuro‐
logic functions, and death after silicone oil was inadvertently injected into the ophthalmic or meningeal
vessels.
Silicone elastomer particles
Silicone elastomer particles (SEP) suspended in polyvinylpyrrolidone plasdone hydrogel

(Bioplastique®) were used in urology and for vocal cord augmentation. It causes some lumps and gran‐
ulomas.[95,96]
GENERAL CONSIDERATION ON THE HISTOPATHOLOGY OF ADVERSE FILLER

EFFECTS
Many fillers display a specific morphology and/or staining pattern in the skin.[52] This is both true for
acute reactions when the filler is still visible as well as for late reactions such as granulomas and infec‐
tions with abscesses.
Bovine collagen is seen as a dense eosinophilic mass in the skin. It is not birefringent like human colla‐
gen fibers. Early “allergic” reactions show a lymphocytic infiltrate that may turn into a granuloma with
many epithelioid cells and some intermingled giant cells.
HA is sometimes seen in the skin as a structureless basophilic substance, corresponding to the Tyndall
effect when localized very superficially. Granulomas were seen in the early times of manufacturing of
streptococcal HA, most probably due to the content of bacterial protein. This is extremely rare with this
product. Another brand new filler caused many granulomas and abscesses with a dense lymphocytic
infiltrate, many giant cells, often of excessive size, and abundant eosinophils around basophilic HA. In
case of abscesses and fistulation, the foci of neutrophils are seen.
Matridex demonstrates both hyaluronic acid as well as dextranomer beads in a cell-rich granuloma. The
microspheres are perfectly round and darkly basophilic or purple allowing the product to be identified.
PLLA is seen as crystalloid material in epithelioid cell granulomas with giant cells often surrounded by
fibrosis. The material is birefringent permitting its exact identification.
Acrylic hydrogel mainly causes late granulomas and no HA is seen any more. The acrylic particles are
polyedric and seen in a dense granuloma with giant cells, many of which try to phagocytose the foreign
bodies. Necrotic areas are frequent and contain cholesterol clefts. Clinically visible fistulae correspond
to epidermal ingrowths trying to engulf and transepidermally eliminate filler materials.
PMMA (Artecoll, Artefill) is seen as round empty-appearing spaces in a fibrotic tissue. Although ap‐
pearing to be of relatively uniform size, this depends on the section plane of the beads. Epithelioid and
giant cells are seen in granulomas.
PAAG is biologically well-tolerated. The main risk is infection that may cause abscesses and necroses.
Granulomas contain epithelioid and giant cells. The material is basophilic and does not exhibit a wavy
structure often seen with hyaluronic acid.
Silicone oil causes granulomas with droplets of varying size, some of which are seen in epithelioid
cells. Giant cells are rare as there are no particles. Dense lymphocytic infiltrates are mainly seen in
perivascular localization.
Sclerosing lipogranuloma is a characteristic feature of paraffin and vaseline injections, mainly in the pe‐
nis to increase its girth. It is characterized by a Swiss-cheese-like aspect in a fibrotic tissue with lym‐
phocytes, epithelioid, and giant cells. The empty spaces are of variable size.
The injection of vitamin E in different oils gives a similar histopathological picture but as these injec‐
tions are now mainly used in the face, particularly in the lips, by nonmedical persons the changes are
much more acute and the inflammatory component is more obvious in these cases.
IMAGING TECHNIQUES
Imaging techniques were introduced in the diagnosis of filler complications, particularly for suspected
abscesses. Other indications are overfilling, migration, foreign-body granulomas, and scarring.[97]
High-frequency ultrasound complemented with magnetic resonance imaging and white blood cell
scintigraphy permitted the distinction between infections, fibrosis, granulomatous inflammation, and
product migration.[98] Calcium hydroxylapatite is radio-opaque, and can be seen in normal radi‐
ographs.[99] Its injection may cause local hypermetabolism, and it can be a source of false-positive
findings in positron emission tomography (PET) scans.[100,101] Using conventional x-ray films and
computed tomography (CT) and magnetic resonance imaging (MRI) techniques, a distinction of differ‐
ent materials is often possible.[102]
GENERAL TREATMENT REMARKS
Prevention is always better and easier than treatment. After identifying the filler substance and the exact
nature of the adverse side effect, the appropriate therapy is chosen. Early side effects such as injection
pain, immediate swelling, and edema usually do not require specific treatment. Cooling is sufficient to
alleviate the immediate postinjection pain; however, this is rare after the addition of lidocaine as a local
anesthetic. Swelling may respond to acetylsalicylic acid or another nonsteroidal anti-inflammatory
drug. Placement of too much material or in the wrong area requires immediate massage or removal, if
possible. Lump formation after CAH injection in the lip is a technical fault as well as too superficial an
injection. Proper training for injecting this substance is mandatory.
Blanching extending beyond the immediate area of the injection volume may be a sign of vascular oc‐
clusion. Nitroglycerin cream and warming may be sufficient in mild cases.[14]
HA can be rapidly dissolved with hyaluronidase. Most of these enzyme preparations are of animal ori‐
gin and there is the theoretical possibility of a sensitization. It is wise to use one preparation to get ex‐
perience with it as the dosage may vary among the different drugs. The effect is usually seen within
hours, and reinjection is possible after 24 h; so small doses are recommended in the beginning.
The treatment of late and delayed adverse effects is challenging. First, the responsible substance has to
be identified. This is often difficult as the patients do not know, or are reluctant to disclose, which filler
was injected. Once a granuloma developed, it is to be assumed that more granulomas will continue to
develop as long as the foreign material is in the skin. It is not evident whether fillers can be reliably
identified on attenuated total reflectance/Fourier transform infrared analysis spectroscopy.[103] Another
validated method is the histological examination of sections, which yield quite specific changes with
most different fillers.[64,104]
The differentiation of infection from noninfectious granulomas is possible with radioactive labeled
leukocytes. In case of infection, antibiotics have to be given for a long period and in doses capable of
preventing the infection. Staphylococcus-fast antibiotics, such as cephalosporins, are given intravenous‐
ly.[105] Vancomycin is used against Staphylococcus epidermidis.
Granulomas often respond to intralesional injection of a mixture of 5-fluorouracil (250 mg/mL), triam‐
cinolone acetonide (10 mg/mL) plus mepivacaine (1 mL), which is given first twice a week and then
once a week;[106] in addition to allopurinol given in a dose of 300-600 mg/day.[107] TNF-α inhibitors
have not yet gained much acceptance in the treatment of granulomas.
CONCLUSION
Fillers are the most frequently used substances in aesthetic medicine. The “consumers” are not sick in‐
dividuals, but healthy persons expecting to look better after the procedure. Any adverse effect is a cata‐
strophe for them and for the treating physician. The following measures have to be taken to avoid the
adverse effects: The physician must be well-trained, the best product must be used, and indications,
contraindications, proper aseptic injection techniques, and adequate localization for each specific filler
to be injected should be respected. The client has to follow the physician's recommendations after treat‐
ment. The best would be to give a “filler pass” to the patient that notes which filler was injected when
and where. Despite all precautions, adverse effects may occur. The physician should take these adverse
effects very seriously and never dismiss a patient's concerns. The treatment should be instituted as soon
as possible.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the pa‐
tient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be
reported in the journal. The patients understand that their names and initials will not be published and
due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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106. Wiest LG, Stolz W, Schroeder JA. Electron microscopic documentation of late changes in permanent fillers and clinical
management of granulomas in affected patients. Dermatol Surg. 2009;35(Suppl 2):1681–8. [PubMed: 19807764]
107. Reisberger EM, Landthaler M, Wiest L, Schröder J, Stolz W. Foreign body granulomas caused by polymethylmethacrylate
microspheres: Successful treatment with allopurinol. Arch Dermatol. 2003;139:17–20. [PubMed: 12533157]
Figures and Tables
Table 1
Eye complications from fillers (adapted from Beleznay et al.[3])
Figure 1
Over correction Tyndall effect hyaluronic acid (Courtesy Dr. M Cantisano-Zilkha)
Figure 2
Reaction after injection of a new hyaluronic acid filler (Hylacorp®)

Figure 3
Scanning microscopy of the excision specimen of the patient shown in Figure 2
Figure 4
Medium paower histopathology photograph of the hyaluronic acid injection specimen showing clumps of basophilic hyaluronan,
giant cells and huge masses of eosinophils
Figure 5
Close-up photograph of the hyaluronan granuloma with multinucleated giant cells engulfing the material as well as many
eosinophils.
Figure 6
Female patient after injection of acrylic gel (Dermalive)
Figure 7
Stretching out the skin makes the granulomas more visible.
Figure 8
Some of the extirpated acrylic gel granulomas
Figure 9
Scanning microscopy of the acrylic gel granulomas
Figure 10
High magnification of an area in the granuloma showing long slender so-called cholesterol clefts in a necrotic tissue as well as
smaller polyedric acrylic particles
Figure 11
Area of the granuloma with multiple acrylic gel particles
Figure 12
Mainly epithelioid cell granuloma with some giant cells and acrylic gel particles
Figure 13
Dense lymphocytic infiltrates around vessels and small silicone droplets (lower margin) reminiscent of small fat cells
Figure 14
Adverse reaction to silicone displaying small silicone droplets

Managing Complications of Fillers - Rare and Not-So-Rare - PMC

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01/08/2022, 20:07 Managing Complications of Fillers: Rare and Not-So-Rare - PMC

J Cutan Aesthet Surg. 2015 Oct-Dec; 8(4): 198–210. PMCID: PMC4728901

Managing Complications of Fillers: Rare and Not-So-Rare

Copyright : © Journal of Cutaneous and Aesthetic Surgery

KEYWORDS: Complications, fillers, hyaluronic acid, blindness

ADVERSE EFFECTS ACCORDING TO TYPE OF FILLERS

Untested cheap products should not be used at all.

Hyaluronic acid plus dextranomer microspheres

Poly-L-lactic acid (PLLA)

Calcium hydroxyl apatite

Polyvinylhydroxide microspheres in polyacrylamide gel

It is a suspension of 6% polyvinyl hydroxide microspheres in 25% PAAG hydrogel (Evolution®, Pro‐

Mineral oils, paraffin, and other lipid derivatives

Silicone elastomer particles

Silicone elastomer particles (SEP) suspended in polyvinylpyrrolidone plasdone hydrogel

GENERAL CONSIDERATION ON THE HISTOPATHOLOGY OF ADVERSE FILLER

GENERAL TREATMENT REMARKS

Declaration of patient consent

Financial support and sponsorship

There are no conflicts of interest.

28. De Coninck A. Personal Communication. 2008

Figures and Tables

Eye complications from fillers (adapted from Beleznay et al.[3])

Over correction Tyndall effect hyaluronic acid (Courtesy Dr. M Cantisano-Zilkha)

Reaction after injection of a new hyaluronic acid filler (Hylacorp®)

Scanning microscopy of the excision specimen of the patient shown in Figure 2

Female patient after injection of acrylic gel (Dermalive)

Stretching out the skin makes the granulomas more visible.

Some of the extirpated acrylic gel granulomas

Scanning microscopy of the acrylic gel granulomas

Area of the granuloma with multiple acrylic gel particles

Adverse reaction to silicone displaying small silicone droplets

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