Hyaluronic acid (HA) dermal filler procedures are a mainstay of most aesthetic practices, helping to rejuvenate and contour our patients’ faces with effective and long-lasting results. As with all medical procedures, however, complications can occur. For HA dermal fillers, these can include:1
- Infection
- Lumpiness
- Migration – whereby the filler moves from the intended treatment area
- Vascular occlusion – which can lead to tissue necrosis and vision loss.
Each requires a different prevention and management strategy, which practitioners should be well-versed in before offering treatment. Within this article, I will focus on how to prevent infections associated with HA dermal filler treatment.
Types of infection
As we know, any aesthetic procedure that breaks the skin’s surfaces comes with a risk of infection. Following HA dermal filler injection, we see both early- and late-onset infections.
Typically, early-onset infections present with redness, pain and/or swelling within two weeks. They are usually due to common pathogens present on the skin such as Staphylococcus aureus or Streptococcus pyogenes.2
Late-onset infections, on the other hand, can present anywhere from two weeks to years after injection. Research suggests they’re most frequent around four months post-treatment.2 They may involve an atypical organism such as Mycobacteria or Escherichia coli.2 Often described as delayed-onset nodules (DONs), these late infections typically present as hard lumps that can come with redness or swelling, but not always. They may be solitary or multiple, and generally appear around the site of injection.3
Avoidance strategies
Patient selection
Practitioners should never rush into treatment and must always carry out a thorough consultation with the patient to ensure they are suitable. When taking a medical history, you should establish whether they have any contraindications to the HA dermal filler treatment. These can include active infections near the injection site such as acne, herpetic lesions, psoriasis or eczema, as these can carry pathogens. You should also avoid treating patients with systemic infection such as the flu, as viral infections may inhibit the immune system.
4,5 Careful assessment of immunosuppressed patients, or those with auto-immune disease, should be undertaken. While some chronic conditions may not present much risk, others could flare up and exacerbate the chances of infection.4,5 Other considerations include dental issues such as poor oral hygiene, infection or planned dental procedures, as infection of the mouth is often associated with low levels of infection in the blood.4,5 The Complications in Medical Aesthetics Collaborative (CMAC) notes that research says although the mechanism of transportation is not fully understood, it is highly likely that the rupture of blood vessels can lead to localised infection.4
Diabetes, obesity, poor nutrition status and being over the age of 65 have also been found to increase the risk of infection.4,5 While not infection related, general assessment is of course also essential.6
Product selection
It may sound obvious, but you must ensure the product you are using is in date and is licensed for treatment. You must also be confident that it has been sourced from a trusted supplier and has been appropriately stored and transported. Anything not maintained appropriately could risk contamination.6,7
Aseptic technique
Maintaining cleanliness is of course essential for every aesthetic treatment. Standard medical infection control procedures should be in place and include:8
- Bare below the elbow
- No jewellery apart from a plain metal band and/or religious bangle
- Short and clean fingernails
- Cuts and abrasions covered
- Appropriate hand hygiene followed
- PPE worn
- Clean-on uniform or scrubs worn daily
- Decontamination between patients
- Waste disposed of immediately after use in appropriate bins
Patients’ skin should be thoroughly cleansed prior to treatment. The Aesthetics Complications Expert (ACE) Group World advises disinfection with 2% chlorhexidine gluconate in 70% alcohol.6 Hair should be kept away from the treatment area with a headband for patients and practitioners, while a patient’s makeup should be completely removed before the procedure.5
A ‘no-touch’ technique is also recommended. One consensus study advises that this should consist of reducing activity in the area where procedure will be performed, checking sterile packs for evidence of damage or moisture penetration, ensuring all fluids and materials to be used are in date, ensuring contaminated equipment is not placed in a clean treatment field, not re-using single-use items, using sterile gloves and ensuring appropriate hand decontamination prior to procedure.5 If any contamination occurs during injection, it is advised that the procedure is stopped, gloves are changed and hand decontamination is undertaken. The cannula/needle should be replaced if asepsis has been breached and the contamination must be addressed.5
Aftercare guidance
Both verbal and written aftercare guidance is recommended and, to prevent the risk of infection, it is essential that patients avoid makeup and touching their face for 24 hours following treatment. High-water content cosmetics have a greater risk of microbiological contamination compared with oil-based products, while makeup brushes and sponges can present a high risk of cross contamination.5 Some people have a tendency to touch their face excessively. Anecdotally we are aware that this increases when something has changed; meaning it can be even more likely to happen after an aesthetic procedure! One study noted that 10 students touched their faces 16 times an hour on average.9 Given the amount of bacteria present on every-day objects we touch, such as our phones, kitchen service and toilet seats, it is imperative that we make patients aware that they will risk contaminating their faces through unnecessary touching.
Case study
Despite following all described preventative measures, infections can still happen; something I know from personal experience.
A few years ago, I consulted with a 38-year-old female patient who had undergone previous HA dermal filler treatment with no problems. She presented to me with concerns about her general ageing face and sagging jawline, for which I recommended HA injection in the cheeks, around the chin and along the angle of the jawline.
After a detailed consultation, the treatment went ahead with no problems. All aftercare recommendations were given – including avoiding makeup and touching the face – and the patient left the clinic happy. She called back six days later, however, highlighting that one side of her jaw felt more swollen. I advised the patient to return to clinic for an in-person review, which she declined, opting instead to send a photograph. There was no redness and she did not note any pain. I explained that swelling can happen and advised her to take an antihistamine to see if that helped.
Three days later the patient’s swelling had not improved, and she was not happy. This time, the patient agreed to come in for review and again did not report any pain or redness. I outlined that we could either dissolve the filler or watch and wait. She agreed to the latter and two days later, she started experiencing pain and tenderness. By this point, the patient was also struggling to open her mouth and chew. She was not systemically unwell.
From this, I immediately suspected infection and prescribed flucloxacillin 500mg daily for seven days. I also recommended dissolving the filler, to which the patient agreed. Upon doing so, a little puss came out of the wound, but after this there was no further sequelae. Two days later, the infection had completely resolved with no lasting impact and the patient was satisfied. The patient later admitted that she had applied makeup in the evening following treatment, which I believe may have caused the infection.
While this case had a positive outcome, it made me aware of the lack of clarity in infection management guidance. I spoke with a local maxillofacial surgeon, as well as the complications expert for the product I used and other peers. All gave conflicting advice
on what antibiotics to use and if/when to dissolve the HA. There were also recommendations to take a culture to confirm the type of infection, but at that time I did not have a culture kit or know how to process this with a lab.
Since then, I have invested in a culture kit and established a relationship with a local lab. Additionally, I have an agreed referral pathway in place if anything was to go beyond my expertise. To aid management further, I strongly believe the UK needs clearer consensus guidelines that are easily accessible for all.
Managing infection
Prevention is always better than cure, but if you do find yourself managing a patient with an infection then you must know how to do so safely and effectively. While the detail of management is outside the scope of this article, I would recommend looking into the research available, as well as joining organisations such as ACE Group World and CMAC which offer recommendations to members. As mentioned earlier, guidance does vary across the board, so I would encourage practitioners to read as much as possible to make informed decisions relevant to individual cases. In the future, I believe it would be hugely beneficial to have consensus guidelines on infection management freely available to everyone. We will then hopefully see a reduction in infection rates, an increase in safety and, ultimately, happier patients.
