FILLERS

Understanding, Avoiding, and Managing Severe

Filler Complications
Berthold Rzany, MD, ScM
Claudio DeLorenzi, MD
Berlin, Germany; and Kitchener,
Ontario, Canada
Summary: Any injectable filler may elicit moderate-to-severe adverse events,
ranging from nodules to abscesses to vascular occlusion. Fortunately, severe
adverse events are uncommon for the majority of fillers currently on the mar-
ket. Because these are rare events, it is difficult to identify the relevant risk
factors and to design the most efficacious treatment strategies. Poor aesthetic
outcomes are far more common than severe adverse events. These in contrast
should be easily avoidable by ensuring that colleagues receive proper training
and follow best practices. (Plast. Reconstr. Surg. 136: 196S, 2015.)

S
evere filler complications are fortunately
rare. However, all injectors need to be aware
of them, be able to recognize them when they
occur, and know how to manage them properly.
METHODS
The overview is based on an unsystematic
review of the literature. It benefits from the prac-
tical experience of Rzany and coworkers1–5 from
running for nearly 10 years the so far most suc-
cessful registry on adverse filler injections and the
extensive practical experience with filler compli-
cations of DeLorenzi.6,7 Furthermore, it is inspired
from the discussions during a meeting on adverse
events to fillers and botulinum toxin A, which was
held in Moscow on March 20 and 21 from Expert-
2Expert (http://www.expert2expert.co.uk/ orga-
nized by Dr. Patrick Trevidic). Common adverse
events such as hematoma and swelling (which can
be easily detected by a clinical trial) are not the
subject of this review.
EPIDEMIOLOGY OF FILLER
COMPLICATIONS
Filler complications need to be separated from
unwanted aesthetic effects due to inappropriate
use of fillers. The latter are much more common.
Adverse events to injectable fillers are rare and
often delayed events. Therefore, they will be unde-
tected in a time- and resource-constrained clinical
trial. Even hospital- or clinic-based registries will
only be able to detect not so rare events.8,9 Besides
the Germany registry data (a unique disease-based
From RZANY & HUND and the DeLorenzi Clinic.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001760
registry),1–5 most available data are based on small
case series and case reports. Case series and case
reports can point out possible products with an
increased risk; however, they are usually unable
to estimate the size of risk. In this case, a proper
epidemiological study is required, which would
then serve as a base to calculate numbers needed
to harm.10 We need to keep the lack of evidence
in mind specifically when we focus on possible
risk factors, their avoidance, and the treatment of
filler reactions.
Furthermore, outside the registries, many
physicians seem to be reluctant to report serious
adverse events, either perhaps they have the feel-
ing that they will not change anything or perhaps
fearing that others might consider that faulty
technique is at fault. Therefore, it must be clari-
fied that extremely rare events may occur to even
the most talented injectors, even when they are
practicing all known risk reduction strategies.
INAPPROPRIATE USE
Much more common than severe adverse
events after the injection of a filler is overcor-
rection and/or erroneous placement of filler.
Overcorrections are usually due to either a very
Disclosure: Dr. Rzany is a speaker and/or advisor
of the following companies: Ipsen Pharma, Galderma
Laboratorium GmbH, and Merz Pharma. Dr. De-
Lorenzi is a paid medical director for both Allergan
Canada and Merz Canada, where he is employed
to assist end-users in managing filler-related adverse
events. He is also a paid advisory board member for
several companies, including Valeant Pharmaceuti-
cals, Baxter, Johnson & Johnson, and Kythera.

196S www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 5S • Severe Filler Complications
superficial injection of a filler that is intended for
deeper injections or the injection of too much
volume in an area with very thin skin11 (Table 1).
For poly-L-lactic acid, it could also mean skin-
colored papules after injecting too superficially,
especially if the product is insufficiently diluted,
or injecting a sufficiently diluted product with
insufficient hydration time, or poorly mixed
(which has precipitated in the syringe).2,12 The
most common indication for all kinds of over-
correction is “sunken eyes” or subocular lines
where either too much filler is injected or it is
injected in the wrong place, for example, above
the infraorbital rim (within the confines of the
orbitomalar ligament) or even too deep, that is,
retroseptal. Expert knowledge of the detailed
anatomy of the periorbital area is essential to
prevent these common errors.6 Physicians must
be aware of the surface anatomy of the regions
that they are intending to treat with fillers and
know how to judge the accurate position of the
tip of the application cannula or needle, respec-
tively, in relation to tissue planes from superficial
too deep as well as medial to lateral. Even a very
small amount of filler placed into the periorbital
space will cause severe persistent “eye bags” that
has repeatedly been observed to clinically last for
much longer than the usual duration of dermal
fillers, often extending into several years. This
may be due to the reduced breakdown or metab-
olism of hyaluronic acid (HA) filler products
within this anatomical space, where the human
vitreous lays, which is primarily HA (however,
no references have been found to support this
hypothesis).
Prevention
How can overcorrection be prevented? Basi-
cally by 2 things: (1) good initial training and
Table 1. Reasons for Overcorrection*
Product Unwanted Result
Hyaluronic acid Lumps and/or
edema
Calcium hydroxylapatite Lumps
and other non-HA fillers
Poly-L-lactic acid Small lumps
*Overcorrection can occur after injection of any kind of filler. This table gives just a brief overview on the 3 most commonly used biodegradable
products.
†Hyaluronidase does not distinguish between good or bad placed hyaluronic acid. It will dissolve all artificial hyaluronidase in the area where injected.
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
(2) continuous ongoing training. Detailed experi-
ence with the anatomy of these areas is highly rec-
ommended, and cadaver dissection courses are
now frequently available during most congresses
in that field to update knowledge for injectors.
Outlook
With the increase of filler injections and
inexperienced injectors joining the workforce,
overcorrections will continue to occur. For all
involved, it is important that through good educa-
tion and training, the incidence of overcorrection
will be curtailed. Teaching on filler and other aes-
thetic interventions should therefore start as early
as possible, for example, during medical school.14
VASCULAR OCCLUSION
Vascular occlusion is a (except for blindness)
not so rare event, with an incidence of up to 3 in
1000.9 Vascular occlusion occurs in areas, which
are supplied by only a single artery, such as the
glabellar area (the most commonly affected area
according to some reviews), the alae nasi, and the
upper lip. If the main blood vessel supplying an
area of skin is obstructed by a filler agent, the asso-
ciated vascular territory will suffer from ischemia
and necrosis. In the facial area, the arteria angu-
laris (and its branches) is one of the most com-
monly affected arteries.9
From a recent smaller retrospective study
comes some evidence that vascular occlusions
seem to be more common and more severe in
non-HA filler. Beleznay et al9 estimated the inci-
dence of vascular occlusion after filler injections
approximately 3 to 1000 for calcium hydroxyl-
apatite compared with 3–9 per 10,000 for HA
preparations (although no comparative statistics
were done). What is clear is that the reactions
Reasons Action to be Taken
Too much volume or too superficial Hyaluronidase injections, or if
11
superficial, may be simply incised
and drained with a needle stick†
Too much volume or too superficial13 “Wait and see,” injection of sterile
water into the nodules or surgical
intervention
Too superficial injection specifically of a “Wait and see” or surgical
less diluted product, or of a sufficiently intervention
diluted product with insufficient hydra-
tion time or injection of a poorly mixed
product (which has precipitated in the
syringe)2,12
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 Plastic and Reconstructive Surgery • November Supplement 2015

and sequelae seem to be more severe with non- Prevention

HA fillers such as calcium hydroxylapatite20–22 and
polymethylmethacrylate.23
Blindness
The most feared complication is the occlu-
sion of the ophthalmic and/or retinal artery as
blindness will invariably result.15 Blindness after
filler injections is an extremely rare event. Most
reports on blindness come from Asia,16–18 proba-
bly because of the prevalence of filler treatment
in high-risk areas, for example, areas close to
the arteria angularis and its intracerebral anas-
tomoses, due to the quest for beautification (eg,
a more convex forehead, a more European-look-
ing nose).19 The mechanism of action of embolic
blindness seems to involve the retrograde flow
of filler through the blood vessels exiting the
supraorbital area, which normally flows out-
ward from the internal carotid artery. The dense
anastomotic network between the internal and
external carotid vessels occurs in the territory
around the nose, where ascending blood from
the external carotid meets descending blood
from the internal carotid territory. Under condi-
tions of high pressure injection, filler product
may be driven upward in the ascending vessels
and forced retrograde down the vessels exit-
ing the orbit. Once the pressure is released,
the filler product is once again carried by the
normal arterial pressure gradient and is forced
outward from the intracranial regions. During
this outflow, filler product may be carried into
the central retinal artery (as well as the adjacent
arteries that exit the periorbital area), which
might result in blindness that is rarely, if ever,
reversible (Table 2).6,7,16
Good evidence confirming strategies for pre-
vention is lacking at the time of this writing. Vascu-
lar occlusions are rare events. Blindness after filler
injection is even rarer. Therefore, the present recom-
mendations are almost exclusively based on expert
opinion. Using cannulas for deep injection may
reduce the risk of vascular occlusion, but no clini-
cal or animal studies have yet been done to show a
benefit. Nevertheless, it seems reasonable to assume
that a not too small blunt cannula is less likely to pen-
etrate a small artery than a sharp fine needle, and so
it seems a priori a good practice to use it in areas of
risk. Avoiding high injection pressure and large-vol-
ume single-point injection is also advisable because
of the consequences of a large bolus within the vascu-
lar system. When a needle becomes slightly clogged,
for example, physicians should avoid increasing the
injection pressure and change the needle instead (to
avoid sudden release of the clog and an accidental
large bolus injection of filler).
The risk reduction strategies should be applied
universally because human facial vascular anatomy
is variable, and the smaller arterial vessels could
be present just about anywhere filler treatments
are done. Extra caution is warranted specifically in
the higher risk areas such as the glabella, nose, or
injection near to the probable location of named
vessels. As a concept, the areas of the face should
be considered higher or lower risk accordingly,
and it must be understood that there are no areas
that are zero risk. Even when following all known
risk reduction strategies, and being conscious of
the surface anatomy of the face and the known
pathways of the named arteries of the face, it is still
possible to accidentally inject filler material into
the arterial system. Although the authors believe

Table 2. Examples of Risk Reduction Strategies Based on Expert Opinion

Proposed Action
Cannula use
Low-pressure techniques
Small bolus (less than 0.1 ml in any
one region)
Aspiration before injection
Detailed anatomical awareness of the
likely position and depth of named
vessels in the treatment areas
Use of local anesthesia with
epinephrine before filler treatment
Assumed Result Possible Downside Risk
Less risk of accidental penetration of Small-gauge cannulas may still be sharp
arteries enough to enter arteries, especially in
scar tissues
Reduces risk of retrograde blood flow Even with low pressure, arteries will fill, but
only more slowly
If the needle tip happens to be inside Depends on the size of the artery involved.
an arterial lumen, the smaller bolus A tiny artery will fill extensively even with
will cause less vascular obstruction a small bolus
Arterial flash back is a sign of arterial Thick fillers with thin injection tubes may
penetration not reveal any flash back, even if the
lumen is inside an artery
Avoiding the main named vessels is There is quite a lot of normal variation of
good clinical practice blood vessels, even from the left to right
sides of the same individual
Epinephrine causes vascular constriction Epinephrine will cause blanching of the
and thus reduces the overall cross- skin, which may be misinterpreted as
sectional area of the arterial lumen acute vascular occlusion

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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 5S • Severe Filler Complications
that we can lower the risk, we do not believe that
we can completely eliminate it. By using fillers that
have known “antidotes,” such as HA fillers and
hyaluronidase, we can decrease the risk of perma-
nent sequelae (since hyaluronidase might be used
to dissolve the occlusion if discovered in time24).
Treatment
The first clinical sign of vascular obstruction is
skin blanching that occurs simultaneously with the
injection. The duration of the blanching event is typ-
ically only on the order of minutes, and this rapidly
changes to a blotchy livedo pattern due to changes
in the skin’s venous drainage.6,7 The blotchy livedo
pattern is gradually replaced with a deep bluish dis-
coloration, and upon clinical examination, capillary
refill is found to be much slower than normal.
In the case of a vascular occlusion, a patient
may paradoxically not report any pain if the filler is
compounded with a local anesthetic or if extensive
pretreatment local anesthesia or nerve block has
been used. The onset of pain may thus be delayed
in presentation by a few hours. Vascular occlusion
occurs contemporaneously with the filler injection,
but of course the patients’ symptoms will depend
on the size and location of the vascular obstruc-
tion, and the nature of the filler material. If the
filler material sticks to itself, it may cause complete
obstruction of a larger vessel, possibly allowing for
some collateral blood flow, whereas if the mate-
rial disperses into, say, 40- or 50-μm particles that
separate, they are carried by the blood flow down
the various sized vessels to eventually reach the size
that they can no longer pass through (the capillary
bed). It may take some time to see the extent of
obstruction because of the different pathophysiol-
ogy of different filler materials.
The first action must be to cease all injections
immediately. If an HA filler was used, hyaluroni-
dase should be injected into the area where the
filler was injected and in any areas where the signs
of ischemia are evident. Remember that blood ves-
sels may transport filler materials distally or even
proximally (depending on injection pressure),
anatomically away from the original injection site,
and sometimes even to the contralateral side of the
face. Hyaluronidase injections need to be repeated
hourly until blood circulation has been again
established (DeLorenzi C, personal communica-
tion, 2015). In case of visual loss, the injection of
hyaluronidase has to be done immediately16 in case
of other areas as fast as possible. From animal stud-
ies,24 it is known that occlusion after HA injection
and its effects can be reversed when the hyaluroni-
dase is injected within 4 hours after the occlusion.
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Later injection might, however, be beneficial to
as the affected area might be decompressed and
probably healing accelerated in case the vessel can
be made penetrable again. In contrast to human
skin, the retina, the brain, and muscle tissues are
highly sensitive to hypoxia and begin to show seri-
ous degradation within moments after the onset
of ischemia. Therefore, as mentioned before, in
case of acute blindness, hyaluronidase needs to be
injected immediately intraorbicular.
In case of occlusion by a non-HA filler, the ther-
apeutic situation is much more difficult. Several
interventions as topical nitroglycerin ointment
have been proposed, however, with little evidence.
A recent study25 was not able to show a significant
benefit of topical nitroglycerin ointment in an
animal model. For the use of hyperbaric oxygen,
we just have a single case report where the postint-
ervention photographs still depict scaring.20
Outlook
Will there be an increase of vascular occlu-
sions with an increase of filler use? Probably yes.
However, the increased awareness of the risk of
vascular occlusion and potential risk factors hope-
fully will not mirror the increase of filler use. Fur-
thermore, with the increased awareness of the
benefits of hyaluronidase, the sequelae after an
HA-filler embolus should decrease, too. To have
this risk further reduced, in our opinion, any new
filler entering the market targeted for high-risk
areas should be accompanied by an antidote.
IMMUNOLOGICAL REACTIONS
All injected fillers have the potential to elicit
an adverse event. These reactions can be grouped
depending on the time from injection to onset as
acute, subacute, and delayed. “Subacute” is some-
what vaguely defined; it generally encompasses
reactions that occur weeks following injection.
Reactions can also be grouped according to the
clinical diagnosis ranging from abscesses to nod-
ule formation.26
Abscesses usually are acute or subacute
although cases occurring after several months
or years have been reported. Usually, these late
abscesses are not a sign of bacterial infection. If the
abscess is fluctuant, it must be drained and its con-
tent (even when a noninfectious origin is likely)
sent for bacterial microscopy and culture. In case
of accompanying cellulitis, an appropriate antibi-
otic should be added immediately. Hyaluronidase
according to the labeling should not be used in the
presence of active infection (cellulitis) because it
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 Plastic and Reconstructive Surgery • November Supplement 2015
may facilitate the spread of infection into adjacent
tissues (n.b. hyaluronidase has been used in abscess
reactions after HA-fillers without signs of worsen-
ing the accompanying inflammation).
Nodule formation, not as depot of the prod-
uct but as a sign of an exaggerated immune
response, is the most common adverse event to
all fillers. Some colleagues advocate that biofilm,
a low-grade bacterial colonization, may play a
significant role in nodule formation27,28 by trig-
gering an immunological reaction. When antibi-
otics or 5-fluorouracil seems to be beneficial, it is
uncertain if this is due to bactericidal, anti-inflam-
matory, or immunomodulatory effects or a combi-
nation of these26,28 (Table 3).
However, before any intervention is consid-
ered, it is important to identify the relevant filler.
Dadzie et al29 showed that injected filler families
can be distinguished by histopathology, that is,
a HA filler can be distinguished from a methyl-
methacrylate filler.
Risk Factors/Prevention
If we knew the exact constellations trigger-
ing an immunological adverse event, it would be
much easier to avoid such reactions. However,
because of the limited available evidence on the
pathophysiology, the potential risk factors, and
the benefit of avoidance, we do not know much.
Products
HA filler products dominate the filler mar-
ket, with estimates of 85–95% of the entire filler
market over the entire world.33 However, not all
HA products are similar. Some products seem to
have a higher risk of an adverse event. This has
even happened with well-known products. At the
Table 3. Treatment Approach in Case of Filler-Induced Nodular Immunological Reactions
Step 1 In case of an HA filler Inject hyaluronidase around
the nodule (in the nodule
if possible)30
Step 2 Start an immunomod- Inject steroids* and/or
ulatory treatment 5-fluorouracil†31
Or start an oral steroid
treatment as pulse (eg,
methylprednisolone)
And/or doxycycline
And/or fumaric acid tablets Is a drug used in psoriasis and has shown some effect in
Step 3 Surgical treatment Excision
Laser
*Usually 10 mg triamcinolonacetonide diluted with, for example, lidocaine [either 1:4 or 1:5 (DeLorenzi C, personal communication; see
Moscow meeting in Methods section]).
†5-Fluorouracil diluted 1:1 with lidocaine.
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
end of the last century, it became apparent that
Restylane in the original form elicited inflamma-
tory reactions and led to changes in the manufac-
turing process. Friedman et al34 reviewed the data
of all unwanted effects of the Restylane range of
products (HA) reported globally (Europe, Aus-
tralia, South America, Asia) to the manufacturer
(Q-Med now a Galderma company, Uppsala,
Sweden) between 1999 and 2000. In 1999, based
on 144,000 treatments, the incidence was calcu-
lated as 0.15%; in 2000, based on approximately
262,000 treatments, the incidence was calculated
as 0.06%. The differences between these inci-
dences were explained through changes made
in the manufacturing process (which involved
sourcing a better quality raw HA product with
a much lower protein content).35,36 More recent
examples are HyaCorp HS and H1000, products
from a smaller manufacturer (Bioscience, now
Dümmer, Germany). When it became apparent
that there were several cases of adverse events
with these 2 products, with an estimated risk
of adverse event of 1.4% [Skipr. Tot nu toe 25
klachten over rimpelfiller. Online in the internet:
http://www.skipr.nl/actueel/id12523-tot-nu-toe-
25-klachten-over-rimpelfiller.html (2012-10-25)],
the product in 2012 underwent investigation by
the Dutch authorities. (Please note that here a
risk of less than 2:100 was thought to warrant fur-
ther investigation.) Finally, the company opted to
withdraw HyaCorp H-S 500, H1000, and HyaCorp
L from the European market in August 2013.
Permanent products pose several challenges
when it comes to nodule formation. As they remain
in the body, the lifetime risk increases specifi-
cally, especially in products with an increased risk.
Here is an example: hydroxyethylmethacrylate
and ethylmethacrylate microspheres suspended
Do not forget that bovine hyaluronidase might rarely elicit
allergic reactions. Please note that hyaluronidase will not
affect the body’s own hyaluronic acid
Be careful of steroid atrophy
For example, methyprednisolone 60 mg × 2 days; 40 mg
× 2 days; 20 mg × 2 days then off for 1 week. Extend
dosing if required
For example, 40 mg 1 × 1 or in more inflammation up to
100 mg 2 × 1 over 3–6 weeks
sarcoidal granulomas
Be aware of scar formation
Diode and CO2 lasers are used to drill openings in the
granulomas and then the filler is extruded32
 Volume 136, Number 5S • Severe Filler Complications

in HA were available in Europe as DermaLive
(Dermatech, Paris, France) from the end of the
1990s until 2007. This product consisted of 40%
bacterial HA and 60% acrylic hydrogel particles
(diameter of 45–65 µm). A similar formulation
with larger-sized particles (about 85–110 µm) and
a somewhat higher HA content was marketed as
DermaDeep (Dermatech) and was intended to
be injected deeper.37 Early after the introduction
to the market, there were case reports of nodule
formation due to hydroxyethylmethacrylate.38,39
Other adverse events included abscesses and ulcer-
ation, which occurred sometimes years and even
decades after the initial injection.3,5 In 2001, the
overall incidence of late side effects and complica-
tions (nodules, swelling, and erythema, on average
6 months after injection) based on data from the
manufacturer was given as <1.2 per 1000 patients.37
As the observation period was limited in this early
article, the real risk might even have been higher.
Although this product is no longer manufactured,
however, as it is a permanent product, it is highly
likely that adverse events to this permanent prod-
uct will continue to present years after its use. With
a permanent product, the second challenge is the
treatment in case of nodule formation. Here, the
treatment is much more challenging when com-
pared with biodegradable products.3
These examples show that some products
might have higher risks, which might lead to modi-
fications in the production process or a withdrawal
of the filler from the market. These products were
put on the market without preceding good clini-
cal trials. With this in mind, some advice would be
to avoid fillers that enter the market without good
clinical trials. In our opinion, permanent products
should be avoided because of the increased life-
time risk of adverse events unless very compelling
evidence of safety and efficacy is provided.
nothing like “THE” risk factor. Based on single cases
and case reports in the literature, it seems likely that
acute autoimmune diseases and interferon therapy
might be risk factors for foreign body or sarcoid-like
reactions after filler injections.40 In a patient with
previous permanent filler injections in the same
area that is to be treated anew, this constellation
might be considered a risk factor for an adverse
event (eg, might introduce contamination into a
permanent implant). It should be remembered that
the number of organisms required to cause clini-
cal infection is drastically reduced from 100,000 to
100 per gram of tissue in the presence of a foreign
body,41 such as permanent filler. Dermal fillers are
approved by the Food and Drug Administration as
implants (even though they are injected as medica-
tions). When an implant is contaminated with bac-
teria, it is impossible to sterilize it or to “uninfect”
it in any way. Hence, any treatment given over top
of a permanent implant risks contamination of the
existing implant and might lead to pronounced
inflammation or even abscesses. Therefore, even
without good evidence of an increased risk,1 it is
not recommended to routinely treat over the top
of permanent fillers. In certain circumstances, it
might, however, be necessary to improve the overall
aesthetic appearance of the patient by adding small
superficial amounts of an HA filler over a perma-
nent filler to decrease the signs of aging or com-
plications. This need to be done with caution and
only after extensive education of the patient (Rzany
B, personal communication, 2015) and using con-
siderable care in the use of appropriate skin prep
and drape of the treatment site. In other words, the
injector should use the same precautions as might
be expected when dealing with other permanent
implants (ie, consider using Centers for Disease
Control and Prevention–recommended chlorhexi-
dine skin prep and sterile technique).

Patients Outlook
When it comes to patients, risk factors become The treatment of these reactions still presents
less clear. Even when analyzing the cases of the a lot of questions. Ideally, we would have liked clin-
Berlin Registry, it became apparent that there is ical trials comparing immunomodulatory versus

Table 4. Safety Kit

Drug Others
In case of overcorrection Hyaluronidase*,†
In case of a vascular occlusion Hyaluronidase*,‡ Ophthalmologist and/or eye clinic in case of
Drugs or interventions that increase the acute blindness after filler injection§
blood flow
*Several vials should be available (in case of large affected areas or the need of repeated injections).
†Usually 1 ml of hyaluronidase should dilute 1 ml of misplaced hyaluronic acid.
‡In case of vascular occlusion, the hyaluronidase should be injected not only in the treated areas but also in the area where the emboli most
likely went.
§In case of acute blindness, the injections need to be done immediately intraorbicular.16

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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • November Supplement 2015
antibiotic treatment (for those advocating the bio-
film theory) in immunologically mediated nodule
formation. But these trials do not exist and would
be very difficult to do so. Therefore, we need to
collect and analyze data from cases and case series
and draw the best possible evidence out of these.
SAFETY KIT
Every physician who works with injectable fill-
ers needs to have a safety kit. The safety kit should
contain numbers of specialists as well as drugs as
antidotes. So far hyaluronidase is the only avail-
able antidote for HA injections. In case of vascular
occlusion after a non-HA filler, hyaluronidase may
be beneficial by increasing the local perfusion pres-
sure of collateral vessels that may reduce the zone
of necrosis. As said before, this recommendation is
based on expert opinion. However, it is an interven-
tion that will not cause significant harm (Table 4).
SUMMARY
Adverse events, both vascular and nonvascular,
after filler injections do occur and will continue
to occur, and this may increase as the number of
filler injections continues to climb. True adverse
events need to be separated from unwanted aes-
thetic effects due to the inappropriate use of fill-
ers. In both cases, prevention is the best medicine
and experience and education are our best tools.
Predictable results are obtained by using predict-
able products, with a predictable methodology, in
a predictable patient. Outside the United States
make sure any new product you consider using is
backed by good controlled clinical trials.
Berthold Rzany, MD, ScM
RZANY & HUND
Privatpraxis für Dermatologie und Ästhetische Medizin
Kurfürstendamm No. 183
Berlin D-10707, Germany
rzany@kudamm183.de
ACKNOWLEDGMENTS
The authors thank Patrick Trevidic for providing
a 2-day forum solely to discuss on adverse reactions to
injectables with Expert2Expert. Some parts of this article
were modified from the following book: Injectable
Fillers in Aesthetic Medicine.42
REFERENCES
1. Bachmann F, Erdmann R, Hartmann V, et al. Consecutively
injected fillers in the same region do not pose an increased
risk for adverse reactions. J Eur Acad Dermatol Venereol.
2011;25:737–738.
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
2. Robner F, Robner M, Hartmann V, et al. Decrease of reported
adverse events to injectable polylactic acid after recom-
mending an increased dilution: eight year results from the
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