A 45-year-old female patient sought help after suffering a negative reaction from dermal filler injection to her upper and lower lips for aesthetic purposes from an overseas clinic. During the initial consultation we discussed the background to her lip filler procedure. This had been the patient’s first cosmetic dermal filler injection. Wary of overly inflated lips, the patient researched clinics and chose an established company in California with certified dermatologists. She paid at the higher end of the procedure scale of prices in the belief she would receive the best product administered by a skilled practitioner.
The patient’s consultation provided neither a detailed explanation as to the type of filler used nor adequate post-treatment care and advice. The patient contacted the clinic one hour post procedure to ask why she had uneven and painful lips and was advised it was because she had not massaged her lips.
Three months’ post treatment, back in the UK, the patient was experiencing difficulty with her speech, and had painful lumps and swelling at night time. The patient went to visit a local beautician who attempted to squeeze the lumps out through incisions to the upper and lower lips. The only result was increased swelling, pain and infection.
The patient presented to Harley Street Injectables a month following her visit to the beautician (four months post treatment) with painful, swollen lips which affected her day-to-day activities, including work and socialising.
She was staying at home with increasing anxiety and felt she could not leave the house due to embarrassment (Figure 1).
Time and adverse reactions
The patient provided a timeline during the consultation, which guided the diagnosis as some adverse events occur immediately after filler injections, while others do not. The types of complications that could occur following filler treatment, according to time of onset, are illustrated in Figure 2.1
Initial observations showed the patient had a severe lip infection. After careful manipulation of the upper and lower lips it was possible to palpate and view uneven surfaces through the swelling, which were painful to the touch. The pain and swelling had come weeks later than the injection, so I then needed to assess whether the lumps were filler nodules, granuloma or delayed hypersensitivity. Descriptions of how they present are detailed in Figure 3.2
Step one: control the infection
As with any procedure that penetrates the skin, soft-tissue filler injections can be associated with infection.3 Because chronic inflammation or infection leading to the formation of a granuloma can interfere with the wound healing process, infection control is essential.4
Moreover, wound infections are often associated with aesthetically and functionally unfavourable scarring.5 Erythematous nodules, multiple red and tender lumps that persist beyond the first few days of treatment, may be signs of inflammation.6-8 Additionally, there is a risk for infection with swelling following filler injection and resultant abscess, however this is beyond the scope of this article as it did not occur with this patient.
As a first-line treatment, a course of amoxicillin/clavulanic acid wasprescribed for 14 days. Whether the infection was secondary to the filler nodules or the primary cause of possible granulomas, it was necessary to reduce the pain and swelling before an informed decision on how to treat the lumps could be made.
A secondary reasoning behind prescribing antibiotics ahead of treatment of the lumps was due to the likelihood of the lumps being filler nodules. Confirmation from the original clinic that a hyaluronic acid (HA) based filler has been used allowed for treatment by hyaluronidase. Hyaluronidase should be used with caution if infection is also suspected since this may lead to the infection spreading further along the tissue plane.9 It was for this reason,and the health of the patient, that resolving the infection before treatment was pursued. When the patient presented for her second appointment two weeks later, the infection had been treated, the patient’s lips had reduced to a normal size and the suspected filler nodules were much more evident (Figure 4).
Step two: identify the lumps
During the two-week follow up, it was evident the swelling and some of the tenderness had resolved but the lumps remained. I therefore needed to identify the cause of the lumps before proceeding to treatment. The potential causes reviewed were granuloma, delayed sensitivity and filler nodules.
Granuloma
Granulomas are relatively rare complications with a frequency of occurrence reported as 0.02-0.4% after HA use for dermal filler in the dermis.10 Granuloma, which is a chronic inflammatory reaction with various aetiologies, can be defined as a tumour composed of a collection of immune cells, mainly macrophages.11
In the case of foreign body granulomas, macrophages are activated and fused into multinucleated giant cells12,13 via non-allergic reactions that occur six to 24 months after filler injections.14-16 Given the lumps were early complications for this patient, coupled with the relative rarity of occurrence, the diagnosis of cystic granuloma was excluded.
Delayed sensitivity
When hyaluronic acid replaced bovine collagen in dermal filler treatments, very few adverse reactions secondary to injections remain.17 However, nonallergic local side effects at the sites of injections are frequent, including pain, bruising, and transient oedema. These tend to disappear in a few days and usually require no treatment.18 It has been suggested that the reason HA fillers cause more swelling and bruising than collagen fillers is the anticoagulant effect of HA, which has a structural similarity to heparin.19,20
Immediately after injection, skin erythema is usually transient and normal. If erythema lasts for more than several days, it is likely to be a hypersensitivity reaction.21 However, erythema should be differentiated from infection. Delayed hypersensitivity was considered as the patient did not have a dermal filler history; however, as the nodules were even in size and white in colour, it was more likely they were filler nodules.
Filler nodules
Lumps or nodules usually appear as cystic, oedematous or sclerosing types shortly after treatment in the form of well-confined palpable lesions, which can result from injection in areas of thin soft-tissue coverage (e.g. eyelids, nasojugal region, and lip), injection of too much material, clumping of the filler, or dislocation by movement of the muscles.21-24
The lips are an area of high mobility with thin mucosa. Measures to avoid visibility of the implanted material include firm massage and meticulous placement of filler in the deep supraperiosteal plane.25,26
If HA filler is injected too superficially, or if there is an uneven distribution of the injected product, visible, pale nodules in the skin may result.27 This was observed in the patient. The original clinic had told the patient to massage the lumps in her lips post treatment, providing a strong indication that the lumps were a result of an incorrect dermal filler injection technique. In my practice, I advise patients not to touch the area injected with filler because of risk of infection so therefore do not advise them to massage. I personally massage the area after injecting the filler as I know the right pressure and technique. The uneven lumps had occurred immediately after treatment, their visual appearance and the probability of an HA-related granuloma being so low, it was reasonable to explore treatment as HA-based filler nodules.
Step three: action taken
1500 units of hyaluronidase was reconstituted with 10ml of bacteriostatic saline. A patch test was administered to the patient’s arm using 10 units of solution with no adverse reaction. Then, 2ml of the dilution was injected into the nodules via 10 unit bolus injections using a 25 gauge insulin syringe into the upper and lower lip, massaging at the same time. After one hour the patient felt more movement in her lips and the nodules had decreased in size. She was advised to return in two weeks’ time for a follow up.
The two-week follow-up consultation concluded the successful treatment of the incorrect filler procedure and associated infection. The patient did not present inflammation or pain to her lips. Her lips were even and soft to touch. The patient’s desired result of undoing the filler revision was fulfilled and as a result she felt healthy and confident in herself (Figure 5).
Summary
This paper has concentrated on the differential diagnosis of nodules consequent from dermal filler injection. Although neither dermal filler granulomas nor delayed hypersensitivity were present with this patient, it is important that the aesthetic injector is fastidious in minimising the conditions that predispose their formation.
Dermal filler-related granulomas may be prevented by meticulous cleansing and disinfecting of the skin, sterile injection technique (avoiding injection through any nasal or oral mucosa), prophylactic antibiotics, as well as using smaller gauge needles to minimise trauma and access for bacteria.28 Patients should be advised to avoid makeup immediately before and after injection. For more information on the risk of infection from makeup, you can read ‘Special Feature: Make-up Post Procedure’ on the Aesthetics website.29
Overcorrection with dermal filler, injecting too large a volume of the wrong type of filler for the tissue type, and lack of even redistribution of the filler due to lack of massage, should be avoided. Correct injection technique with placement of needle at the appropriate depth before injecting and discontinuing injecting before retraction of the needle is recommended.28
Counselling the patient and adopting preventative measures such as appropriate filler choice and prevention of infection should be an integral part of any treatment using dermal filler injections. Patient consent, education and adequate follow-up support should be fundamental throughout the entire consultation process.
