Background:
Although the safety profile of hyaluronic acid fillers is favorable, adverse reactions can occur. Clinicians and patients can benefit from ongoing guidance on adverse reactions to hyaluronic acid fillers and their management.

Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations.

American society for aesthetic plastic surgery

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. 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. 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. 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. 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
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Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations.

While rare, complications do occur with the esthetic use of dermal fillers. Careful attention to patient factors and technique can do much to avoid these complications, and a well-informed practitioner can mitigate problems when they do occur. Since cosmetic surgery is usually an elective process, requested by the patient, clinical trials are complex to organize and run. For this reason, an international group of practicing physicians in the field of esthetics came together to share knowledge and to try and produce some informed guidance for their colleagues, considering the literature and also pooling their own extensive clinical experience. This manuscript aims to summarize the crucial aspects of patient selection, including absolute contraindications as well as situations that warrant caution, and also covers important considerations for the pre- and posttreatment periods as well as during the procedure itself. Guidance is given on both immediate and long-term management of adverse reactions. The majority of complications are related to accepting patients inappropriate for treatment or issues of sterility, placement, volume, and injection technique. It is clear that esthetic practitioners need an in-depth knowledge of all aspects of treatment with dermal fillers to achieve optimal outcomes for their patients.

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Patient factors influencing dermal filler complications: prevention, assessment, and treatment

Dermal fillers are increasingly used for soft tissue augmentation of the face and hands. The widespread use of dermal fillers for rejuvenation has led to a rise in reports of associated complications. Although the majority of complications are mild and transient, serious and long-lasting complications have been observed. This article discusses the key complications including pigmentary changes, hypersensitivity reactions, infections, nodule formation, granulomatous reactions, vascular occlusion and migration of filler material. A thorough literature review was performed in addition to the combined extensive authors' (GP and FA) experience. Complications from fillers are increasingly being recognized and highlighted in the literature partly reflecting the growth in the market. This article provides a comprehensive overview of the filler complications with mechanisms of prevention and treatment per complication. A thorough understanding of the preventative and management strategies for the associated dermal filler complications will help the physician to prepare the patient well, and deal with complications that may arise effectively.

Dermal fillers: pathophysiology, prevention and treatment of complications

Background
The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.

/pdf/dermal-fillers-in-aesthetics-an-overview-of-adverse-events-4kzmt9ht4j.pdf

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

Background The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase. Objective To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance. Methods Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors' extensive experience, recommendations for avoiding and managing complications are provided. Results Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique. Conclusion For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.

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

Summary: Hyaluronic acid fillers are one of the most widely used and versatile fillers worldwide. Although traditionally regarded as immunologically inert, many currently available products have been substantially modified to improve longevity and to optimize properties for specific indications. Such modifications, either alone or in combination with other factors (such as the immune status of the patient, immune-triggering events, and bacterial contamination), may lead to the development of late-onset inflammatory nodules in some patients. This article discusses the clinical presentation of late-onset adverse inflammatory reactions to hyaluronic acid injections, describes their likely triggers, and presents the author’s treatment algorithm for successful resolution.

https://doi.org/10.1097/gox.0000000000004362

Treatment of Delayed-onset Inflammatory Reactions to Hyaluronic Acid Filler: An Algorithmic Approach

Sir: S et al1 have recently called into question the originality of an article I published in the June 2022 issue of PRS Global Open.2 The article was written at the request of former PRS Editor-in-Chief Rod Rohrich, based on a presentation of the same topic made at the American Society for Aesthetic Plastic Surgery Aesthetic Meeting 2021 (Miami, May 2021). Prior to this meeting and before the publication of the 2018 Snozzi et al article with a similar title, my protocol was presented at multiple continuing medical education (CME) and non-CME events in the United States, and to key opinion leaders and medical affairs staff at Allergan, at the time when delayed-onset nodules first became clinically relevant. The current article is true to the presentations given at these events and presents a treatment approach for delayed-onset inflammatory reactions. As clearly stated in the text, it is an update to broader guidance on dermal filler adverse events that I originally co-authored in 2013.3 If Snozzi et al came to similar conclusions in 2018,4 I can only assume that my initial guidance continues to be relevant. Snozzi et al subsequently report that since the publication of their 2018 article they have changed their approach, and now recommend injection of hyaluronidase as a first-line treatment for all delayed-onset inflammatory reactions, regardless of etiology. Their inference is that my algorithm overstates the importance of antibiotics. I would like to point out that the approach in my treatment algorithm is to target treatment based on suspected etiology.2 For example, if a patient presents with signs of an infective etiology, namely warmth, tenderness, erythema, induration, or edema, my recommendation for initial treatment would be broadspectrum antibiotic therapy. In contrast, if generalized edema or induration is present, my recommendation is to start the patient with oral steroids with concurrent injection of hyaluronidase. I recognize that it can be difficult to distinguish between inflammatory nodules that result from infectious processes versus those that are immune-mediated. The algorithm was developed over time, based on my experience as an adverse event consultant for Allergan, Revance, Galderma, and Merz: leading pharmaceutical companies in the aesthetic field. This algorithm has been successfully employed by me in this capacity and is based on my extensive experience. My aim is always rapid resolution of the offending area with minimal trauma for the patient. The algorithm presented has allowed me to achieve this in the majority of patients I have been asked to treat.

David Funt

Papers

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

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

Treatment of Delayed-onset Inflammatory Reactions to Hyaluronic Acid Filler: An Algorithmic Approach

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