Complications after injection of fillers

Excerpt from a book:

Complications after injection of fillers. Hypersensitivity reactions, granuloma, necrosis and blindness, Ik Soo Ko, Won Lee

Skin necrosis after filler injections

Skin necrosis after filler injections worries patients, and doctors are horrified by the results of a procedure they thought was safe. Subsequently, even permanent scars may form.

Surprisingly, it is usually not beginners, but experienced doctors who encounter skin necrosis. Novice doctors inject very carefully, while experienced doctors often inject large amounts of filler into several areas. A common mistake experienced doctors make is creating their own injection method without scientific evidence and thinking of the injection of fillers as a very simple procedure. Therefore, evidence-based information on skin necrosis is needed.

This chapter discusses the mechanism of occurrence, classification, diagnosis and treatment of skin necrosis after filler injections.

5.1. Definition and mechanism of skin necrosis

5.1.1. Definition of skin necrosis

Necrosis is irreversible tissue damage caused by ischemia and subsequent breakdown of natural protective mechanisms. With infectious necrosis, tissue destruction over a wide area is possible.

Necrosis begins due to disruption of the blood supply due to occlusion or compression of the vessel. After filler injections, necrosis usually develops due to strong compression, and not due to puncture of the vessel with a needle.

Risk factors for skin necrosis:

• Superficial injection of filler.
• Thick skin.
• Rough skin.
• Thick skin.
• Excessive volume of filler.
• Extensive swelling.
• Small needle diameter.

5.2. Classification of skin necrosis

Skin necrosis can be divided into local and extensive. Local necrosis develops at the injection site, extensive necrosis spreads to the area where the vessel branches (Fig. 5.2). The most serious complications of extensive necrosis are blindness and ischemic stroke.

5.3. Local skin necrosis

In the dermis and subcutaneous fatty tissue there is a network of small vessels. When injected into these layers, filler can compress blood vessels, leading to skin necrosis because the pressure is not distributed into the tissue. Due to poor circulation, the skin turns pale.

Within 30 minutes the skin remains pale and then due to local damage within 48 hours the skin color changes to dark pink and pustules appear. After this, infectious necrosis usually develops.

Minor compression of the vessel, indicated by the appearance of a small pustule and pinkish skin color, may not require treatment. However, with severe compression, the skin color turns dark red and a pustule forms on each sebaceous gland. In the subcutaneous layer, like groundwater, the pustules merge and extensive infectious necrosis occurs. Tissue necrosis gradually increases, resulting in the formation of an atrophic scar. If treated incorrectly, the exudate turns into scabs covering the area of necrosis. If a dense scab forms, the infection progresses further, leading to further destruction of the subcutaneous tissue. To choose the right treatment method, it is necessary to understand the process of necrosis development.

5.3.1. Treatment

5.3.1.1. Decompression

If the skin becomes pale after the filler injection, decompression should be performed immediately. Hyaluronidase is used to break down hyaluronic acid (HA) filler. We prefer to dilute one bottle of hyaluronidase (1500 IU) in ml of saline and after injection, gently massage the injection site. There are no exact recommendations for hyaluronidase injections, but we prefer to inject a larger dose. If any filler remains, hyaluronidase should be reinjected, but since ischemia causes the tissue to become very loose, it is recommended that all filler be removed at once. If permanent or calcium hydroxyapatite filler is injected, it should be removed as soon as possible by aspiration with a large-diameter needle (18 G).

The day after the injection, you should call the patient to find out if there are any changes in skin color or characteristic symptoms. If there are unusual phenomena, ask the patient to send a photograph. Most likely, after 2 days the patient will contact the clinic about pustules. Thus, if decompression is performed as soon as possible, the patient's condition should be checked every other day.

Usually, pustules appear within 2 days after the injection, so patients usually go to the clinic themselves. Patients who often describe symptoms as minor should be assessed by photograph or in person.

5.3.1 H. Removal of pustules

In the absence of decompression or severe compression of the vessels within 48 hours, pustules form. If pustules appear in less than 48 hours, intensive treatment should be started, otherwise severe necrosis may develop.

Pustules must be removed very carefully, since due to the anastomosis of the facial vein and cavernous sinus, the area of the nose and maxilla is considered a “dangerous triangle”. Retrograde infection can spread to the brain and lead to cavernous sinus thrombosis or meningitis.

Drainage of pustules can be combined with the use of oral medications.

The number of pustules increases within 48-72 hours, decreases after 4 days, and the pustules disappear 6 days after injection. Thus, pustules should be removed 2 times a day 2-4 days after the injection. It is very important to prevent the development of infection and the formation of atrophic scars if possible. After the acute stage of infection, small pustules may appear, but these are easy to treat.

The book examines the rheological properties of fillers, provides information about the anatomy, describes the types of complications after procedures, and also provides recommendations for their prevention. The publication is well illustrated and will be useful to all specialists in aesthetic medicine.

Buy the book: Complications after injection of fillers. Hypersensitivity reactions, granuloma, necrosis and blindness • Ik Soo Ko, Won Lee