Etiology, Prevention, and Management of Infectious Complications of Dermal Fillers

Abstract

The demand for aesthetic augmentation with soft tissue fillers has greatly increased in recent years and has led to an expansion in the number of products available. Unfortunately, an increase in adverse events has followed. These can be categorized into early, late, and delayed. Early infectious complications generally present as a localized skin infection, cellulitis, or abscess. Fillers can also serve as a focus for chronic infection, which is associated with the development of foreign body granulomas, a late complication. Bacterial colonization and indolent infections of the filler site can lead to biofilms that are extremely difficult to treat. Therefore, it is important to focus on prevention through eliciting a thorough patient history including an injection history, practicing sterile technique, and minimizing tissue trauma. Looking forward, much can be done to curtail complication rates. Early teaching and training, a central recording registry for complications, and a standardized filler passport for patients are suggested.

Delayed sclerosing granulomatous reaction to dermal filler injection of poly‐hydroxyethyl‐methacrylate suspended in hyaluronic acid: Histochemical and confocal laser scanning microscopical analysis

“…Hyaluronic acid (HA) fillers in cosmetic medicine are widely used and considered relatively safe, though not all the fillers used in European countries and throughout the world have been approved by the Regulatory Agencies . Nevertheless, a wide range of medical compounds has been authorized as fillers for HA injections .…”

“…Filler adverse effects can be classified according to the technical procedure, onset (early or late), filler type, and host factors . Technical errors may be due to too much or too little volume injection, incorrect depth or wrong localization of filler placement, and inappropriate product choice, the latter possibly being the most relevant topic.…”

“…Many possible causes may lead to early and late granuloma formation, such as the volume of injected dermal fillers, impurities within the filler substance with biofilm formation, local infection unrelated to the filler site, and severe systemic infections with subsequent immunologic alterations . Surely, the presence of impurities may facilitate late granuloma formation, especially when including particles <20 µm in size, as phagocytosis and immunologic memory are more efficiently stimulated by smaller particles than by larger ones .…”

“…On the basis of manufacturers' and some authors' claims, all commonly used injection materials for esthetic correction and different formulations of hyaluronic acid (HA), with or without adjunctive substances, result in no immunogenic reactions or other complications; nevertheless, unexpected, late, or early adverse reactions have been reported . Overall, poly‐hydroxyethyl‐methacrylate (HEMA) suspended in HA can promote the formation of late foreign body granulomas (FBGs) .…”

“…Also, it was postulated that macrophages would incorporate foreign particles, thus keeping the foreign particles in a latent stage. Subsequently, additional priming events (eg, supervening infections) would be needed to re‐activate macrophages, lead to multinucleated giant cell accumulation, and, finally, to fully developed granulomatous reaction . Such pathogenetic mechanism may explain the prolonged course of the disease, with only late development of clinically detectable nodular lesions.…”