Dr Beatriz Molina presents a lip filler complication and discusses the management of the patient
Managing complications is a difficult task. However, it is even harder when a patient presents to clinic with a complication from another practitioner, as most patients do not know what product they had or where the product was exactly injected. In this circumstance, what do you do? The easiest thing is to ask the patient to return to the practitioner who treated them. This, I believe, is best practice as the original practitioner should have all the necessary clinical data to correct the complication. But, sometimes this is not an option because the patient may have lost their trust in the practitioner and does not wish to be treated by them again. Other times, we get referrals from practitioners who are not sure how to handle a complication, or the patient is not listening to their advice. At least in these cases, a referral means that we get a full medical history and we know exactly what products were used and in what way.
The following case study will discuss the patient journey of a young female who was referred to me from another aesthetic doctor after the patient experienced a filler complication in the lips. Please note that the below information is from the patient’s testimony only, not from the various practitioners involved.
A 28-year-old female patient was recently referred to me from one of my colleagues and friends who is an aesthetic doctor.
The patient was firstly injected by this practitioner with 1ml of a well-known hyaluronic acid (HA) dermal filler in May 2016. It was injected into the body of the lips with a cannula in an anterograde technique and there were no adverse events reported.
A following treatment was performed by the same practitioner five months later, on October 28, where 1ml of a different HA filler was injected in the same area.
As expected, following these second injections, the patient experienced slight swelling and bruising, but this went down after three days. At this stage, it seemed that there were no concerns following the treatment and the patient was pleased with the results (Figure 2).
However, after day three, the patient’s lips were becoming very swollen. This was causing her difficulty in speaking and eating as her lips would split easily, even from a soft touch (Figure 3). The skin on the lips became increasingly sensitive and raw.
She soon developed flaky brown crusts and patches of dryness on the underside of her top and bottom lips (Figure 4). She was concerned as it was not something she had previously experienced after her filler treatment five months ago. Seven days after her initial treatment she went back to see her original practitioner.
The practitioner was not concerned with the patient’s symptoms and advised her that the symptoms she was experiencing might have been the result of dryness or transient sensitivity. A transient reaction to the filler would mean that it should settle after a couple of weeks.1
Straight after this consultation, the patient emailed a plastic surgeon she found through a Google search to get a second opinion. The surgeon advised her that the problem could have arisen because the lips were potentially overfilled. They said this could be causing the mucosa, (wet part of the lips) which would otherwise be inside the mouth, to be exposed to the surrounding air, drying them out. They advised her to use a 100% petroleum ointment (Vaseline) to resolve this. The patient had already been using Aquaphor, a skin ointment containing petroleum (plus other ingredients) to keep her lips moisturised prior to the development of this crust.2 She had used Aquaphor for at least five years intermittently, with no side effects from it. Following the advice of the plastic surgeon, she started to use more Aquaphor and kept a thin layer of it on her lips constantly.
However, she continued to experience problems; layers of the skin peeled off, bit by bit, and her lips became increasingly raw. Two weeks’ post treatment, she saw her original practitioner again. They reassured her that she was experiencing some normal skin sensitivity issues following treatment and things should clear up soon.
To be on the safe side, the practitioner suggested to have the filler removed with hyaluronidase. It is unknown why the patient didn’t agree to this, or why the practitioner didn’t insist upon it. At this stage, the patient was feeling as though her situation was not normal, but the patient said that the practitioner advised her that it was. The patient raised the possibility that she might be experiencing a hypersensitivity reaction to the product, as it was a different one used to her previous treatment, but the practitioner did not believe that this was a concern at this stage.
As the skin on the patient’s lips became increasingly sensitive, fragile and seemed to rub off when she touched them (Figure 6), she arranged an appointment with the plastic surgeon that she had emailed previously on November 27. The surgeon advised her that she was experiencing either an inflammatory reaction, or a herpes outbreak. They therefore prescribed oral antiviral medication – acyclovir 800mg five times a day for seven days – suggesting that treating the herpes should be a first line of action before having the filler removed.
However, her skin got progressively and rapidly worse. The surgeon contacted the patient’s original practitioner via email to discuss their concerns, and again suggested that the patient was experiencing a herpes outbreak.
After taking the course of acyclovir, the patient’s skin became even more raw, so she sought the advice of her GP, who advised that she was experiencing inflammatory issues in response to the filler treatment. She was prescribed topical steroid medication and Epaderm emollient cream and was told to keep using Aquaphor. As her symptoms continued, the patient went back to the GP several days after. They prescribed oral steroid medication – prednisolone 30mg a day for one week.
At this point, the patient described, “It was as if the whole top layer of my lip skin had fallen away, exposing the raw layer underneath. I also developed small blisters. Smiling could cause small tears and abrasions in the skin. I was having a difficult time eating and speaking, and I was drinking everything through a straw. There were times when the skin on my lips looked white or pale."
She had been applying Aquaphor to her lips constantly for two weeks at this point, and she assumed that after seeing several different practitioners of different experiences that keeping the lips well moisturised was a reasonable strategy to protect her skin.
However, she did eventually notice that the Aquaphor packaging also states to ‘use as often as required’ and provides no further information regarding adverse reactions. The patient said, “However, at this point I felt perhaps my use of Aquaphor had been excessive and I discontinued using it as I felt it may have been contributing to the problem.”
After discontinuing the use of Aquaphor, the skin did seem to clear up quite substantially thereafter, with a noticeable improvement after just the first day. However, she gradually developed a very thick, dry crusting on her lips and was still unable to eat or speak normally as a result of this. She was only consuming liquid food through a straw. Unfortunately, she decided to apply gentian violet to her lips as an antiseptic on December 10. Gentian violet is an antiseptic dye used to treat fungal infections of the skin. She stated, “I didn’t realise that it would stain my lips so severely and that it would be impossible to get off due to the fragility of my skin.”
At this point, the patient used the mobile app HealthTap and arranged a virtual consultation using Skype with a board-certified American dermatologist. Their diagnosis was desquamation of the lip and they said that she was likely experiencing hypersensitivity issues due to the filler. They advised her to apply a topical steroid medication and to seek to have the filler dissolved if it didn’t clear up. Subsequently the patient developed small cracks at the corners of her mouth. The skin that healed in the area also started to have a white appearance again and formed crusts.
I concluded that there was a compression to the vascular supply to the lower lip; she aggravated things by using Aquaphor, as this was acting as an occlusion
The patient had been doing a lot of her own research online since having issues with her lips and was still concerned that the problem with her skin desquamation, diagnosed by the dermatologist, was partially due to an over application of Aquaphor. She thought this could potentially be due to maceration of her lip skin. She asked the dermatologist on HealthTap explicitly about this, but they suggested that the problem was more likely to be an inflammatory reaction to the filler material. They also stated that it could be due to an Aquaphor allergy. However, the patient researched the potential side effects of Aquaphor on WebMD and found that ‘turning white, wet and soggy from too much wetness’ were possible adverse reactions.2 She stated, “When my lips were at their worst, the skin did indeed look white and soggy.” However, she did not feel that this explained the other issues with her lips.
On December 19, the patient came to see me after being referred by her original practitioner.
Her lower lip was stained with the gentian violet that she has used previously. The patient refused to let me examine the lips, as she said they were too painful. She was also very upset as her condition had not improved after two months following her filler treatment, despite seeking advice from several practitioners.
After carefully looking through her medical record, her photographs and considering the events related above, I concluded that there was a compression to the vascular supply to the lower lip; she aggravated things by using Aquaphor, as this was acting as an occlusion. This explained the blistering and the desquamation of the lip and why symptoms were not immediately resolved post treatment.3
I knew that the only solution to resolve this was to dissolve the filler. If there is a problem with vascular supply to the tissue, it starts to die. The patient did not get necrosis, likely because there was only a partial vascular compromise, not a full compromise; adding an emollient made things worse.1,4-11 The patient was concerned that having the filler dissolved at this point would cause trauma to her lip, due to the fragility of her skin. I explained, in length, the risks associated with dissolving the filler (allergic reaction, anaphylactic reaction, bruising, swelling) and the pros and cons of using the hyaluronidase, such as the fact that the filler would go, making her lips go back to how they were before any filler treatment.
I then asked her to seriously consider the treatment and think about going ahead with it. Following this, I referred her back to her original practitioner. I got in touch with the practitioner and advised them to dissolve the filler using hyaluronidase 1500 units in 10ml of sodium chloride. I also said that if there were concerns of excessive inflammation and swelling in the lips, so to not aggravate the problem, they could start the patient on prednisolone 30mg for five days. After two or three days, the patient would likely be ready for their hyaluronidase treatment. Following this treatment, the original practitioner reported that the patient made a full recovery.
In my opinion, this patient probably experienced these symptoms as filler was likely injected too deeply, causing the compression. Alternatively, it could have been that too much product was injected in the area. Sometimes I find that practitioners who use cannulas inject deeper than they believe they are, which can cause issues. In my opinion, the original practitioner should have listened to their patient’s concerns and understood that it is not normal to develop new symptoms days after a dermal filler treatment.1 They likely did not have enough knowledge and experience in regards to identifying and managing dermal filler complications.
This case did have an unusual presentation, so it is unfair to think that the original practitioner did not know it was a compression at an early stage. However, they should have known that something was not right. The original practitioner most certainly should have asked a colleague for their advice at this stage, rather than the patient feeling that nothing has been done and for her to seek further advice on her own. I believe it’s important that patients stick to their original practitioner, and they need to feel as though their concerns are taken seriously.
There was no evidence of infection, so the patient should not have been on prednisolone for so long. As far as I am aware, there was no reason for the surgeon to believe this was herpes and the symptoms did not seem consistent of herpes infection. If I was treating this patient, I would have started her on prednisolone 30mg for one week and seen her after three days just to be sure there was no infection. At that point, I would have seen it was a reaction to the filler and I would have injected hyaluronidase.
Instead of treating her myself, I referred her back to her original practitioner for treatment. This is because I do not believe in making a practitioner look negligent in the eyes of the patient. Everyone can make a mistake and the practitioner was really concerned about the patient’s wellbeing, which is why she finally referred her to me for an opinion. The practitioner was also fully capable of performing the hyaluronidase treatment as per my advice; however, if they were not, I would have quite happily step in to help.
All practitioners must keep good patient records, including before and after photos to manage a patient’s treatment journey. In this case, the symptoms should have been recognised and the filler should absolutely have been dissolved earlier. Practitioners need to take patient concerns seriously and see patients as often as required. They should also establish a good network of colleagues that they can trust for advice when needed. Finally, I recommend that all practitioners complete thorough training in anatomy and complication prevention, diagnosis and management skills.
Dr Beatriz Molina will be speaking at the Aesthetics Conference & Exhibition on Friday April 27 at 10:30am on unique delivery methods with plasma.