Addressing Filler Complications

It is well known that complications data is lacking in the aesthetic sector, but anecdotally there are reports that they are rising. If a practitioner has been fortunate enough not to have been faced with an aesthetic correction, it’s likely they will at some point in the future. With this comes the complex issue of addressing concerns from another injector’s work.

In many circumstances consulting these patients can prove very difficult, being conflicting and distressing for both the practitioner and the patient. I have personally had many patients present to me from other clinics seeking my opinion on their outcomes.

In my experience, the most common complaint patients present with is related to lip fillers and product migration. Migration of dermal filler is where the product moves above or below a border where it is placed, causing, in some instances, a shadow outside of the lip border. The borders can become blurred and the vermilion border is no longer crisp. What was the philtrum and upper lip area is now one with the pink of the lip.^1,2

Other unsatisfactory results I am often approached about are lumps, asymmetry, lack of change, too much change, unnatural results or even too natural; all of which are undesired in the eyes of that patient. Rarely do I get presented with a vascular occlusion (VO) case.

This article aims to explore some of the challenges I have faced and provide my tips for overcoming them.

Initial consultations

When approached about a complication or unsatisfactory results, the questions I would initially ask the patient are:

• When were you last injected and in what area?
• How many times has the area of concern been injected?
• What product/s have been used and how much was injected?
• What was your desired outcome?
• What practitioner/clinic did the initial treatment?

When the patient was injected is extremely important. Each brand of dermal filler has a recommended timeline suggested before switching to a different brand. Teoxane, for example, strongly advises one year for its Teosyal products.³ This has been done to ensure that if an adverse reaction was to occur, the brand of dermal filler that’s more likely to be the cause is easily identifiable.

I then ask the patient to discuss what they feel the issue is. I think it’s important at this stage not to be vocal about your personal assessment before you listen. By first listening to the patient’s story, you fully understand their concerns from their eyes, which will help you to form your opinion and give significant, detailed and specific advice according to their presented complaint/area of concern.

Once the treatment history and desired outcome is obtained, I always ask who their original practitioner/clinic was and advise they discuss their concerns with their original practitioner. I do this as I feel that each injector should have the ability and opportunity to rectify or address their patient’s concerns, and because it’s commonly stated on insurance policies that once remedial work is carried out, the patient then fully becomes yours. Of course, insurance policies are always bespoke, so be sure to check with your own provider.

At this point, the patient sometimes feels more at ease because they may have felt their previous injector was incompetent; but this is not always the case. By taking the time to discuss the ‘problem’, the possible reasons why something has happened and talk though what to do next, the patient is often much more confident and less anxious about going back to their original practitioner.

In my experience, for those happy to return to their original practitioner, I would estimate that around 60% of previous practitioners will address the issue presented to them. However, around 30% will unfortunately suggest the fault lies with the patient and the remaining 10% ignore all forms of contact. It’s these 40% of patients that usually find their way back to me.

Alongside this, sometimes patients refuse to contact their previous injector due to the lack of faith in their ability even if the practitioner has offered to address the concern. In most cases, they have already approached the previous practitioner and unfortunately the advice given and/or rectification plan was not to their liking, and they felt they would still be left with their undesired result. On several occasions, I have also found that rather than being offered adequate rectification, where in some instances dissolving is required, further dermal filler is offered ‘for free’. Once I have been made aware of the particular injector that had carried out treatment, I will usually check their credentials and see if they have the ability to rectify a particular issue. On rare occasions, I have also found the previous practitioner is not competent to carry out corrections. This can be individuals who have not attended or had included in their training the use of hyaluronidase for instance, or are not a prescriber or have a prescriber, which makes the process lengthy and complex for them to address. On these occasions, I would take the person on as my patient without advising they return to their original practitioner and improve their situation to the best of my abilities.

Treatment consultations

If I decide to go ahead with treating the patient, I will always seek the medical history from the previous injector, where possible. I initially ask the patient to obtain this and typically, practitioners are accommodating. In instances where this is not possible, I personally send an email to the clinic asking for the information and include the patient in the email. If I am unable to acquire the information required, I collate as much evidence as possible, such as appointment confirmations, their previous before and after images with time stamps, and the previous practitioner’s possible product of choice, which can generally be found on their social media and/or website.

I will then, as usual, undertake a full medical history of my own using the medical model (comprehensive consultation, assessment with diagnosis and treatment plan aiming to treat aesthetic, medical and psychological concerns) and initiate a minimum cooling-off period of at least four to six weeks if not an emergency. This allows the patient time to heal adequately and to overcome the emotional aspects, as well as come to terms with a potential treatment plan.

I always ensure I ask what the patient has had done in the past and if all treatments were at the same clinic or various clinics. Unfortunately, many patients ‘clinic hop’ and are unsatisfied with every treatment they have had. Regrettably, with these particular patients, satisfaction is never gained, even with adequate consultation and management of expectations. Some of these patients may also have underlying Body Dysmorphic Disorder (BDD) that must be screened for and considered to cause ‘no harm’.⁴

The patient should be consented, with the risks of your treatment clearly explained, and I add on the consent form that they are aware that full resolution may not be achieved. They understand that I will get it as close to their desired outcome as possible, but they understand the difficulty when working to rectify, hence outcome is not a guarantee. Managing expectations is paramount and is advised by both the JCCP and CPSA in their ‘Guidance for Practitioners Who Provide Cosmetic Interventions’⁵ as well as recommended by the GMC in its guidance for doctors.⁶

Managing expectations

Complications such as VOs, migration, lumps and asymmetry, can be challenging and time-consuming to rectify. However, I find cases where a patient ‘didn’t get what they asked for’ much more challenging. With the rise of social media and celebrity influencers, patients commonly show images of other people’s lips asking for that exact look. However, what they do not always understand is that results can vary from patient to patient and the exact same result is unachievable. If this isn’t addressed in the consultation, an avoidable complication could occur as the patient may not be happy with the result.

Case study – vascular occlusion

A 48-year-old female presented to me a year following injection of 1ml of dermal filler to her lips at another clinic (Patient 1). She was concerned with scaring and unevenness she had been left with, which affected her physically and psychologically and had images to demonstrate the result (Figure 1).

She said that immediately post injection she had unbearable pain but was told by her practitioner not to worry and that it was normal. She contacted the practitioner a few hours later with her concerns, but was informed it was ‘simply an allergic reaction to the dental block’, and was advised to take antihistamines. A few days later, despite having immediate severe pain, discoloration and ulceration at the site of injection, the practitioner denied the patient a face-to-face review. Several days later, the tissue had become black (tissue necrosis) and parts of her lip were ‘falling off’. She had to self-manage at home with over-the-counter pain relief, massaging (as she felt the area had ‘a lump’) and watchful waiting. She had contacted her GP, seven days after, who misdiagnosed and prescribed treatment for impetigo, prescribing topical fusidic acid, and then flucloxacillin as second line. Although this may have not been the relevant treatment plan, indirectly with watchful waiting, massaging and pain management, her symptoms started to slowly ‘resolve’ to a more bearable state.

To me, the images and description of the patient’s experience demonstrated an obvious VO and impending necrosis. Unfortunately, this was never suggested to her and she was never even consulted about complication risks or signs to look out for.⁷ This mismanagement caused great loss of lip tissue and scarring, leaving the indentation she presented with in the body of her bottom lip (Figure 2).

Circumstances like this are very difficult to manage, as the patient had no trust in their previous practitioner and they were greatly against going back to them. I therefore decided to help and was able to add volume and definition to her lip to become close to her natural lip shape, however, I could not rectify her scars. In fact, I had to be very careful around the scared area as deep tissue scars can fix arteries in place and make them easier to penetrate (Figure 3).¹ I advised that microneedling and platelet-rich plasma treatment might help with her remaining evident scaring.

Case study – undesired aesthetic result

A 26-year-old lady approached me 18 months after lip augmentation elsewhere because she was concerned about the lumps she had in the underside of her lips (Figure 4). These lumps were present two weeks after her treatment, but increased in size over the following months. She approached her previous injector, but was not offered a face-to-face consultation and was told to massage them to resolve. However, the lumps remained, and she was still refused a face-to-face consultation. The patient explained that initially the lumps were not something that were of great concern and she explained they were ‘bearable’. She finally came to see me as they had eventually become a topic of anxiety for her.

The patient had been told that her lips were normal when to me they clearly weren’t; so in the consultation I detailed what is generally accepted as ‘normal’ and ‘not normal’ in the perioral region. Upon examination, I observed numerous lumps in the body of the lip and within the oral mucosa. The larger lumps had caused incompetent lips where the interlabial gap was visible on resting. As well as this, she had severe migration above her vermillion border and her philtrum was distorted.

I initially advised the patient to approach her previous injector, however she refused as she had already tried on several occasions and was turned away and made to feel as if ‘she was bothering the practitioner’. Given her anxiety, and how sensitive she was with any discussion regarding her lips, I came up with a treatment plan to suit her. Her main concern was the fear of going back to her natural lip, but with an added deformed appearance. She required in-depth discussions with what each stage of treatment set out to achieve and the timeline of results, highlighting the potential outcomes and managing her expectations.

She did not want to be treated with hyaluronidase as she had watched many videos online; some showing extreme pain, tremendous swelling and bruising, causing her great anxiety. I advised that we could first try to manually remove/lance some of her larger lumps8 to see if the outcome was an aesthetically pleasing result she would be happy to ‘live with’ until she was ready to be treated with hyaluronidase. Some were very superficial so were easy to remove.

I reviewed her again 14 days later. The lancing had improved the overall appearance by around 30%, which was expected and explained to her prior to treatment. We had another consultation and again discussed her options. At this point I had built her confidence, not only in me as her practitioner but also in her ability to visualise and accept the journey required to get her to where she wanted her lips to be. We finally treated her lips with hyaluronidase, and refilled once the lips had healed over a further 14 days. The Patient was much less nervous in her dissolving session due to the results she had seen up until this point and the trust we had built between patient and clinician. She was happy with the results post treatment; she was able to close her lips with no protrusion of lumps; her borders were defined and there was no migration or blurred borders/philtrum (Figure 4).

Take special care with managing these patients

The aesthetic specialty is thriving and with that we can assume there will be increased complications presented to us from other practitioners. We as medical professionals should learn to address these concerns in a manner that is holistic in its approach. If a patient presents from another clinic, I believe practitioners should take care in the consultation and encourage them to return to their treating practitioner. If this is not possible, as with many cases I have seen, we should clearly give them the options available and allow them to reflect on the information given.