References

Dermal fillers. In: Goldberg DJ (ed). Basel: Karger; 2017
Kontis TC, Rivkin A. The history of injectable facial fillers. Facial Plast Surg. 2009; 25:67-72
Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013; 33:769-82 https://doi.org/10.1177/1090820X13495405
Department of Health. Review of the regulation of cosmetic interventions. 2013. https//tinyurl.com/3amac9ss (accessed July 2022)
Chiang YZ, Pierone G, Al-Niaimi F. Dermal fillers: pathophysiology, prevention and treatment of complications. J Eur Acad Dermatol Venereol. 2017; 31:405-413 https://doi.org/10.1111/jdv.13977
Sandoval SE, Cox JA, Koshy JC Facial fat compartments: a guide to filler placement. Semin Plast Surg. 2009; 23:283-287 https://doi.org/10.1055/s-0029-1242181
van Loghem JAJ, Humzah D, Kerscher M. Cannula versus sharp needle for placement of soft tissue fillers: an observational cadaver study. Aesthet Surg J. 2017; 38:73-88
Monheit GD, Rohrich RJ. The nature of long-term fillers and the risk of complications. Dermatol Surg. 2009; 35 Suppl 2:1598-1604
Chatrath V, Banerjee PS, Goodman GJ, Rahman E. Soft-tissue filler-associated blindness: a systematic review of case reports and case series. Plast Reconstr Surg Glob Open. 2019; 7
Colbert SD, Southorn BJ, Brennan PA, Ilankovan V. Perils of dermal fillers. Br Dent J. 2013; 214:339-340 https://doi.org/10.1038/sj.bdj.2013.326
Marusza W, Olszanski R, Sierdzinski J Treatment of late bacterial infections resulting from soft-tissue filler injections. Infect Drug Resist. 2019; 12:469-480
Lee JM, Kim YJ. Foreign body granulomas after the use of dermal fillers: pathophysiology, clinical appearance, histologic features, and treatment. Arch Plast Surg. 2015; 42:232-239
King M, Convery C, Davies E. This month's guideline: the use of hyaluronidase in aesthetic practice (v2.4). J Clin Aesthet Dermatol. 2018; 11:E61-E68

Background and complications of dermal fillers: the increasing use of non-surgical facial aesthetics in dental practice

From Volume 49, Issue 8, September 2022 | Pages 670-674

Authors

Tanya Ahmed

MFDS RCS

Dental Core Trainee, Royal Victoria Infirmary

Articles by Tanya Ahmed

Email Tanya Ahmed

SJ McCarthy

MFDS RCS, BMedSci (Hons), MFDS RCS

Dental Core Trainee, Royal Victoria Infirmary

Articles by SJ McCarthy

A Cartner

BDS

Dental Core Trainee, Royal Victoria Infirmary

Articles by A Cartner

RJJ Pilkington

FDS RCS OMFS

Registrar, Royal Victoria Infirmary

Articles by RJJ Pilkington

RS McCormick

FRCS OMFS, OMFS, FRCS OMFS

Consultant, Royal Victoria Infirmary, Newcastle upon Tyne

Articles by RS McCormick

Abstract

There has been a noticeable increase in the number of patients who present to oral and maxillofacial surgery (OMFS) departments for treatment of post-operative complications of dermal fillers and botulinum toxin. These complications are more likely when the treatments are performed by untrained persons or self-administered by patients. Occasionally, these adverse outcomes cannot be avoided, even when products are administered by medically trained professionals. This review includes two cases and discusses some of the key issues surrounding these products so that patients can be informed of the benefits and risks with these types of non-surgical aesthetic procedures and, where possible, reduce the risk of complications occurring.

CPD/Clinical Relevance: Appropriate knowledge of facial anatomy and different types of dermal fillers is necessary to reduce the risk of complications associated with injection of these products.

Article

Currently, members of the public can purchase and place most dermal fillers without the need for a prescription or a medical licence because the products are classified as medical devices and not as prescription-only medicines. There is no requirement to be registered to a regulatory body in order to administer fillers, and no minimum qualifications are required. Data are limited on the number of people who self-administer dermal fillers. The increase in reported complications and the lack of regulation are potentially burdens to both patients and health services. Non-surgical facial aesthetics include:

  • Injectable neuromodulators: botulinum toxin (BTX) of which serotypes BTX-A and BTX-B are used in facial aesthetics;
  • Dermal fillers;
  • Skin rejuvenation;
  • Non-ablative radiofrequency;
  • Chemical peels;
  • Laser skin resurfacing.
  • History of use

    The use of paraffin and Vaseline injections to augment the face dates back to the 1800s. Their use was associated with many complications and so the search for safer, more reliable and biocompatible materials began. In 1893, autologous fat injections were used to correct facial defects, the success of which was variable, relying heavily on adequate training, sterile technique and storage. Silicone use as a permanent facial filler remains controversial owing to the material's ability to migrate and form fistulas. In 1981, bovine collagen was the first agent to be approved for cosmetic injection by the US Food and Drug Administration (FDA). Recently hyaluronic acid use has increased in popularity1 due to its skin smoothing and volume-producing effects that can generally last between 6 and 18 months.2

    The ageing face

    The skin acts as a mechanical barrier to the outside world. The face is divided into superficial and deep fat compartments by various retaining ligaments and their septa, the muscles of facial expression are in between the compartments. This network of retaining ligaments arises from the deep fascia penetrating the superficial muscular aponeurotic system (SMAS). This is a continuation of the platysma/superficial cervical fascia in the neck and the temporoparietal fascia in the temple region and extends into the galeal aponeurotic layer in the scalp. When these various compartments weaken at their various supporting ligaments/septi, the face starts to lose its youthful appearance. Through these various weakened degenerated compartments, fat migrates and the characteristic features of ageing appear (Figure 1, Table 1).3

    Figure 1. Facial components, fat compartment and retaining ligament, respectively.

    Age (years) Changes
    >30 Redundant eyelid skin, crow's feet
    >40 Prominence of nasolabial folds, forehead furrows
    Loss of cupids bow (lip) fullness
    >50 Neck rhytids, jowls
    >60 Skin atrophy, increasing wrinkles

    Types of dermal filler

    Fillers can be classified as permanent, semi-permanent and temporary. Permanent fillers, such as silicone, can often lead to more severe, chronic complications, which are more difficult to treat. The most common type of complication associated with permanent fillers is granuloma formation, which may necessitate treatment with immunosuppressive drugs and repeated surgery.

    Semi-permanent fillers, such as poly-lactic acid and calcium hydroxyapatite may be associated with granuloma formation and occasional nodule formations. The desired effect may be very short lived because its use is dependent on tissue response.

    Temporary fillers, such as hyaluronic acid, may be associated with allergic reactions and an optical phenomenon known as the Tyndall effect, where a blue discolouration can form after filler injection. Some temporary fillers can stimulate fibrous tissue formation and rarely, but still quoted in literature, these types of fillers, if combined with lignocaine, can lead to anaphylaxis and death.4 This is a very rare complication associated with lignocaine, rather than the filler. Table 2 highlights the types of filler, material, longevity and advantages and disadvantages of each.


    Types of filler Material Longevity Advantages Disadvantages
    Temporary Fat 3–4 months, up to 3 years Autologous Atrophy with timeDonor site morbidityResorbs with timeIf injected intra-vascularly, can cause vascular occlusion (VO) leading to tissue necrosis +/- blindness
    Collagen 3–6 months Can achieve good aesthetic results with combination of other fillers Allergic reactionAnimal- and human-based productsResorbs with timeAllergy testing requiredIf injected intra-vascularly, can lead to tissue necrosis +/- blindness
    Hyaluronic acid 6–18 months Good volumeNon allergenicStimulates collagen formationSafest choiceCan be removed with hyaluronidase Resorbs with timeIf injected intra-vascularly, can lead to tissue necrosis +/- blindness
    Semi-permanent Poly-L-lactic acid 24 months Good for deep wrinklesTemple, marionette and nasolabial lines, lipoatrophy in persons living with HIV Several weeks to see desired effectNeed for reconstitution, may need 2–3 visits, 4 weeks apart to get desired effectCan cause nodulesIf injected intra-vascularly, can lead to tissue necrosis +/- blindnessHigher risk of migration5
    Calcium hydroxyapatite 1–3 years Easy to mouldUseful in moderate to deep wrinkles Not suitable for lip augmentationSuperficial injection can lead to skin blanched appearanceCan cause nodulesIf injected intra-vascularly, can lead to tissue necrosis +/- blindnessHigher risk of migration 5
    Permanent Silicone Permanent Nasal tipProjection, acne scarringPhoto-ageingContour defectsNot suitable for lip augmentation If injected intra-vascularly, can cause VO leading to tissue necrosis +/- blindnessChronic inflammationHigher risk of migration5Difficult to remove if it migrates
    Polyacrylamide Permanent Good at restoring lost volume areasUseful in cheek remodelling, lip augmentation, peri-oral augmentation No use in fine wrinklesDifficult to remove, aspiration removal technically difficultGranuloma formation and migration of fillerIf injected intra-vascularly, can lead to tissue necrosis +/- blindness
    Polyalkylimide Permanent Good at restoring lost volume areasLipodystrophy and lipoatrophy Aspiration removal technically difficultNo use in thin wrinkle removalIncreased risk of infection and migration5If injected intra-vascularly, can lead to tissue necrosis +/- blindness
    Polymethylmethacrylate (PMMA) 5 years+ Good volume replacement Used with collagen, risk of allergic reactionOverfilling/difficult to mouldBest results done by incremental injectionsHigher risk of migration 5If injected intra-vascularly, can lead to tissue necrosis +/- blindness

    Dermal fillers may be used alone or in combination with other agents, such as neuromodulators, to achieve the best aesthetic result. In the placement of these agents, appreciation of the regional anatomy is essential. This is necessary to avoid inadvertent injection of these products into vital structures (eg neural and vascular), which could result in serious complications for the patient. Secondly, to gain the optimum cosmetic result, a complete understanding of anatomical compartments is required. An example is the commonly ‘overfilled’ appearance of the lips if dermal filler is injected in a vertical direction at the vermillion-cutaneous border. This can lead to inadvertent injection into the superficial compartment of the lip (anterior to orbicularis oris) rather than the intended deep compartment (by injecting posterior to the orbicularis oris). Correct injection can lead to a more youthful appearance secondary to lip eversion.6

    Dermal fillers may be administered with a needle or a cannula: the latter often enables more precise injection of product in the desired facial plane and has a lower risk of intra-arterial injection.7 There are several techniques that the practitioner may use for administration:

    Linear threading technique: full length of needle is inserted along centre of wrinkle and injected as the needle is withdrawn.

    Serial puncture technique: multiple injections of the filler along the wrinkle length, so small deposits of the filler combine to form a smooth continuous line lifting up the skin.

    Fan technique: multiple passes of the linear threading technique. Needle passes into the centre from different peripheral points.

    Cross hatching technique: filler injected as regular parallel lines using the linear threading technique, then repeated at right angles.

    Sandwich technique: filler injected one above another.

    Dental clinicians should also bear in mind the importance of oral rehabilitation and the restoration of a full dentition as important contributory factors in leading to a more aesthetically pleasing facial profile.

    Current legislation

    Dermal fillers currently placed on the UK market with a medical purpose are classified under the medical devices legislation and therefore require a CE mark. The current stance from the Medicines and Healthcare Products Regulatory Agency (MHRA) is that medical devices from May 2020 will be regulated under the European Regulations EU2017/745. All dermal fillers are incorporated into this category. However, there are two main issues. First, these recommendations may not apply in the UK post-Brexit as this is an EU regulation. Secondly, no prescription is required for dermal fillers (unlike botulinum toxin) and, therefore, untrained persons can continue to administer these products, increasing the risk of post-operative complications.

    An independent review of the cosmetic procedures industry in the UK recommends all practitioners to be properly qualified and an Ombudsman to be instated to oversee private healthcare complications. Enlisting onto formal registers (although not a legal requirement) may help the public form more informed decisions about cosmetic treatment. ‘Unfortunately, since the release of this report the government has failed to sufficiently respond to the recommendations set. In part, this is due to their belief that they shouldn't have to fund a register for commercial cosmetic elective procedures’.4

    Complications

    All surgical procedures carry a risk of post-operative complications and the injection of dermal fillers is no different. The nature of complications varies widely depending on the type of filler used. Up to 80% of patients who receive a temporary filler experience complications, viz, erythema from the injection site, swelling, bruising.8 These are generally classified as early or late complications.

    Early complications, occurring 0–14 days post-injection, include infection, immediate tissue necrosis due to vascular occlusion (VO), dysaesthesia, under/over correction of the filler, Tyndall effect, temporary and permanent visual loss due to VO (very rare),9 herpes simplex reactivation causing cold sores, and temporary swellings that resolve early. Late complications can occur 1 year post-operatively and are often more difficult to manage. These complications include recurrent infections due to biofilm formation, formation of chronic sinuses and granulomas.10

    Typically in biofilm-related infections, there is history of a condition predisposing the patient to biofilm growth. Following implantation of a foreign body, the patient may experience pain, swelling, erythema, induration and loss of function. Symptoms of infection last more than 7 days and may resolve during antibiotic treatment, but recur later. Antibiotic treatment alone can prove ineffective.11

    Figures suggest that granuloma formation occurs in 0.02–0.4% of cases when hyaluronic acid fillers are used.12 Skin necrosis is a particularly physically apparent complication, occurring where filler has been incorrectly injected into a vessel or injected in significant volume next to a vessel causing compression, leading to VO. Fortunately, hyaluronic acid can be dissolved quickly and efficiently with hyaluronidase, which can diffuse across vessel walls and can therefore penetrate intra-vascularly.13

    We describe two cases recently treated in our department that highlight some of the complications previously discussed.

    Case 1

    A fit and well 46-year-old female presented to OMFS via the emergency department regarding a left-sided facial swelling. She described a 2-month history of refractory swelling in the left cheek that had occurred following placement of hyaluronic acid dermal filler.

    Prior to her initial presentation to our department, she had been treated with multiple courses of antibiotics and steroids, which all had proved ineffective. Further to this, aspiration of fluid from the collection and four attempts to dissolve the filler using hyaluronidase had also proved unsuccessful.

    On examination, a left buccal swelling with associated fluctuance of approximately two 1.5-cm swellings (probably due to biofilm formation) was noted in the area of placement of the dermal fillers with no associated neurosensory deficit. Repeated aspiration of the swellings cultured Streptococcus intermedius (sensitive to amoxicillin). She subsequently developed hollowing of the left cheek that was thought to be due to necrosis of the buccal fat, and an MRI was arranged.

    The MRI revealed a buccal and labial collection in the cheek associated with innumerable small, relatively well-defined nodules in the subcutaneous tissues (Figure 2). Over the course of the following months, the patient had numerous incision and drainage procedures to wash out the recollection as well as a prolonged course of IV amoxicillin and clindamycin, after microbiology advice. The persistent recollection was thought to be related to the diffuse nature of residual filler in the soft tissues that acted as foreign body and was difficult to fully debride without causing further loss of buccal fat, damage to the buccal branch of the facial nerve or perforating the skin. This was a significant risk in relation to the patient's aesthetic concerns.

    Figure 2. (a) Axial and (b) coronal views of MRI scans taken after repeated attempts to treat with hyaluronidase and aspiration, showing refractory left buccal and labial collections most likely to have been caused by diffuse residual filler.

    The eventual resolution of the infection was confirmed at subsequent outpatient review, where hollowing of the left cheek was noted due to fat necrosis. At this juncture, the patient was still actively seeking further filler treatment against which she was cautioned.

    Case 2

    A fit and well 48-year old female attended the emergency department complaining of a bilateral peri-orbital cellulitis 6 days following a course of botulinum toxin (BTX) as part of non-surgical aesthetic facial rejuvenation treatment. The BTX was administered to the glabella region and bilateral crow's feet area. The patient described two previous identical courses of BTX with the same practitioner without complication.

    Initially the patient had noticed swelling 3 days post-administration, which spread bilaterally over the zygoma region and extended to the cervical region on the right-hand side (Figure 3).

    Figure 3. (a–e) Bilateral swelling over the zygoma region, extending to the cervical region on the right-hand side.

    On examination the patient was pyrexic, with a general feeling of malaise. Ophthalmological review and CT scan imaging confirmed a pre-septal cellulitis with no drainage collection involving the orbital/sinus structures (Table 3).


    Stage 1 Pre-septal cellulitis
    Stage 2 Post-septal cellulitis (orbital cellulitis)
    Stage 3 Sub-periosteal abscess
    Stage 4 Orbital abscess
    Stage 5 Cavernous sinus thrombosis

    The patient was subsequently admitted for IV flucloxacillin and benzylpenicillin for 2 days and discharged with an oral course of flucloxacillin. At review 2 weeks later, the patient's symptoms were fully resolved with no residual deficit. The patient expressed reluctance for any further aesthetic treatment in the future.

    Discussion

    The reporting of complications is inconsistent, due to the loose regulations around the use of dermal fillers, and the lack of professional follow up. Similarly, minor complications are unlikely to be reported to professional authorities, as they require little intervention and can often be managed by non-professionals. Complications that require professional intervention tend to be those with a higher associated comorbidity, and as such, the reporting will be skewed.

    In 2013, Sir Bruce Keogh KBE published guidance from the Department of Health for dermal fillers to have tighter post-market surveillance, with a need for an interspecialty committee of cosmetic surgery to be developed. He also called for dermal fillers to be classed as a prescription-only medicine. This would allow for complications to be thoroughly reported, investigated, and policies made to streamline investigations and treatment.

    Conclusion

    As the popularity of non-surgical aesthetic treatments increases, the risks cannot be ignored and proper knowledge and training is a necessity.