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Managing Filler Complications

By: Steven H. Dayan, MD, FACS
Posted: September 1, 2010, from the September 2010 issue of
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page 2 of 4

My current protocol for treating impending necrosis includes:

  1. Hyaluronidase (Vitrasea), 10–30 units diluted 1:1 with saline, at the first recognition of vascular compromise, regardless of the filler used.
  2. Nitropaste, such as Nitro-Bidb (nitroglycerin ointment, 2%), applied to the affected area, with the amount dependent on the size and area of the impending necrosis.
  3. Aspirin, 325 mg each day.
  4. Warm compresses and massage.
  5. Topical Dermacytec, an oxygen cosmeceutical applied to the affected area q.i.d.
  6. See the patient daily. If there is no improvement, repeat the regimen and add a Medrold dose pack.

Hypersensitivity reactions—immunogenic or infectious?

After a recent trip abroad, I discovered many Asian and European medical aesthetic physicians are familiar with low-grade, locally persistent infectious complications following permanent filler treatments secondary to biofilms. Biofilms are complex communities where bacteria live and survive with little energy expended. Characteristics of biofilms include the secretion of an extracellular matrix, walling the biofilms off from the outside; living in clusters; irreversibly attaching themselves to a living or inert surface; reduced metabolism; changing their DNA; being highly resistant to antibiotics; and often being culture negative.

Biofilms may cause sepsis, which can be successfully treated, but then they may serve as a reservoir for further infections. The infections can get worse and progress with steroid and NSAID treatments. Biofilms are commonly linked with endocarditis, in-dwelling catheters, contact lens cases and solid implants. While there are no known confirmed biofilm reactions reported with the non-permanent fillers that are approved in the United States, they have been confirmed with fluorescent in situ hybridization (FISH) analysis following permanent filler treatments common in Europe and Asia.

Up to now, the perception has been that hypersensitivity reactions following filler treatments are immunogenic in nature. However, after reviewing all the non-permanent filler hypersensitivity reactions reported, a pattern suggesting an infectious origin emerges. Additionally, after reviewing cases of hypersensitivity reactions, they all seem to follow a pattern of infectious rather than allergic. Recently, I successfully treated four patients referred to me with persistent induration and erythema months after a filler treatment. While this is not confirmation of a biofilm reaction, the success I had with new hypersensitivity treatment protocols prompted me to share this information and help initiate a conversation among aesthetic physicians on the topic.

To prevent infectious complications, I use this protocol:

  1. Cleanse the face thoroughly of all makeup before injection.
  2. Use a benzalkonium chloride wash or betadine swab to prepare the face just before the treatment.
  3. Use as few injection sites as possible.
  4. Avoid bolus injections.
  5. Avoid injecting into previously placed fillers or through infected tissue.
  6. Also avoid injecting through oral or nasal mucosa.
  7. Consider using prophylactic antibiotics before a dental procedure or if a facial infection occurs within two weeks of a filler treatment.