Xanthelasma-Like Reaction to Filler Injection

Adverse effects of the aesthetic use of botulinum toxin and dermal fillers on the face: a narrative review

OBJECTIVE

To evaluate the adverse effects of facial aesthetic treatments using botulinum toxin and biomaterial implants.

METHODS

The bibliographic research for this narrative review considered articles published in journals from the Medline, Pubmed, Embase and Lilacs databases with the following terms: "dermal fillers AND complications, vascular complications AND dermal fillers, adverse reaction, AND toxin botulinum and adverse reaction AND dermal fillers". Inclusion criteria were articles available in English on adverse events with the aesthetic use of botulinum toxin and dermal fillers/biostimulators.

RESULTS

The demonstration of complications increases simultaneously with the progressive performance of facial aesthetic procedures. Quantitative statistics of the procedures and the countries that use them are skillfully classified, as well as the prosperity trends of these procedures. Complications do not receive the same relevance. There is a deficiency in dissemination of the information by the scientific community, or in other words, there is a publication bias in favor of successful results as opposed to adverse events.

CONCLUSION

The lack of knowledge about complications arising from so widely publicized and performed procedures prevents the development of evidence-based guidelines. Complications in aesthetic procedures have become a public health problem, an epidemic that occurs under the supervision of health authorities. Mandatory reporting of adverse events occurring in aesthetic procedures that require medical care aims to fill this gap. With reliable and technical data, it will be possible to identify the causes and perform interventions capable of minimizing irreversible sequelae and deaths. Complications should be promptly recognized by the dermatologist so that, when possible, they can be reversed or adequately managed.

Silicone on the Move: Migratory Siliconoma After Retinal Surgery Report of a Case and Review of the Literature

ABSTRACT

Silicone granulomas, or "siliconomas," are the common foreign-body inflammatory responses to injected silicone material. In rare cases, siliconomas develop remotely from the original site of injection, secondary to silicone migration. If a history of silicone injection is not noted, such lesions risk misdiagnosis (possibly as infection or malignancy). Intraocular silicone oil is commonly used in retinal detachment surgery, with occasional reports of granulomatous responses after its application in this context. Here, we report a 66-year-old man who developed a periocular silicone granuloma years after scleral buckle surgery for a detached retina and summarize the literature of similar reports of migratory siliconoma.

Late-onset periorbital edema in patients with a history of facial hyaluronic acid injection: A review on diagnosis and management

BACKGROUND

Hyaluronic acid (HA) injections for soft tissue augmentation, particularly in the facial area, have become increasingly popular. Nevertheless, a growing number of reports indicate complications associated with this procedure, posing challenges for practitioners. One commonly encountered complication is periorbital edema.

OBJECTIVE

To review the existing literature on late-onset periorbital edema following HA injections, focusing on clinical presentation, proposed mechanisms, risk factors, diagnostics, and management strategies.

METHODS

A literature search was conducted to find articles describing findings on malar edema and eyelid edema following HA injections. The gathered data were categorized and juxtaposed to provide a clearer understanding of this phenomenon.

RESULTS

Incidence rates of periorbital edema post-HA injection vary, with delayed onset occurring weeks to years later. The manifestation involves diffuse edema in the eyelids and malar area, sometimes worsened by trigger factors like infections. Pathophysiology discussions distinguish between inflammatory and non-inflammatory causes, highlighting lymphatic and venous flow disturbances. Risk factors include filler characteristics, injection depth, and patient predispositions. Proper patient evaluation using ultrasonography aids in treatment planning, which could involve corticosteroids, hyaluronidase for HA removal, and subsequent cosmetic procedures like radiofrequency (RF) microneedling. Surgical interventions should be considered after HA dissolution, especially in cases requiring lower blepharoplasty.

CONCLUSION

Late periorbital edema post-facial HA injections, once rare, is now frequently seen. Understanding and addressing this complication is essential for optimizing patient care and outcomes in clinical practice. Treatment typically involves adjusting hyaluronidase dosage for HA removal. Additional procedures like blepharoplasty, RF needling, or filler reinjection may enhance post-treatment appearance.

Rare and novel complications of botulinum neurotoxin type A and dermal filler injections

Botulinum neurotoxin type A (BoNTA) and filler injection procedures usually provide predicted outcomes with a low incidence of complications. Most of the complications after these procedures have been extensively discussed. In this study, we report on these injectables' less well-known, recently reported, and novel complications and attempt to clarify the underlying mechanisms. Counterfeit or mishandled BoNTA has been associated with botulism. BoNTA has been linked to uncommon complications, including morphea-like lesions, nontuberculous mycobacterial infections, vascular occlusion, and pseudoaneurysm of the superficial temporal artery. Unusual complications from filler injection include nonscarring alopecia, intraoral necrosis, nontuberculous mycobacterial infections, xanthelasma-like reactions, intracranial perforation, and pneumosinus dilatans. Post-BoNTA injection nodules and filler infection from bone destruction due to cocaine use are new complications. These complications pose a challenge for diagnosis and treatment. This publication aims to assist in promptly identifying and managing these rare and novel complications when necessary.

A Scoping Review of Hyaluronidase Use in Managing the Complications of Aesthetic Interventions

BACKGROUND

Hyaluronidase is used as an adjunct or main treatment to manage complications associated with cosmetic hyaluronic acid (HA) filler injections such as necrosis, blindness, hypersensitivity, delayed nodules, and poor aesthetic outcomes.

OBJECTIVE

To systematically map the available evidence and identify the gaps in knowledge on the effectiveness of hyaluronidase use in managing the aesthetic complications associated with HA injections (vascular occlusion, blindness, nodules, delayed hypersensivity, granuloma, poor aesthetic outcome).

METHODS

PubMed, Medline, Embase and Cochrane databases were used up to May 2022, to look for randomized clinical trials (RCTs), clinical trials, and retrospective case-control studies reporting on the use of hyaluronidase for managing the HA filler injection complications.

RESULTS

The database search yielded 395 studies; of those 5 RCTs (all carried out in the USA) were selected (53 subjects), indicating the effectiveness of hyaluronidase for removal of un-complicated injected HA nodules (forearm, upper arm, or back skin). The follow-ups ranged from 14 days to 4 years. The amount of HA filler injected into each site varied from 0.2 to 0.4 mL. A dose dependent response was observed for most HA fillers. No major adverse reactions were reported. Overall, for removal of every 0.1 mL of HA filler they injected 1.25-37.5 units of hyaluronidase (single injections). When 3 consecutive weekly hyaluronidase injection was used much lower doses of 0.375-2.25 unit was utilised. There was no evidence in a form of RCTs, clinical trials, and retrospective case-control studies on the removal/reversal of HA injections in the facial skin, or management of over-corrections, inflammatory nodules, or tissue ischemia/necrosis associated with HA filler injection.

CONCLUSION

Based on studies on the forearm, upper arm and back skin, hyaluronidase can be used for the reversal of uncomplicated HA filler injection nodule. However, further adequately powered studies are warranted to establish the ideal treatment protocol/dose of hyaluronidase for reversal of HA filler injections in the facial region or management of complications associated with aesthetic HA injection.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Multiple Cases of Facial Disfigurement From Filler Use and One Injector

PURPOSE

To present a case of facial disfigurement from an injectable permanent filler and describe the consequences to patients exposed to the same injector (common source outbreak).

METHODS

Case report and discussion of a common source outbreak after a group of persons developed complications years after permanent filler given by one injector.

RESULTS

A 39-year-old transgender model underwent polymethylmethacrylate (Artefill) facial filler injections to the lips, cheeks, and chin in 2018. A year later, the patient presented to the emergency room with severe facial swelling and difficulty breathing. Treatments have included 4 surgeries to remove filler and scar tissue and chronic low-dose oral steroid therapy. Upon questioning the patient, 6 additional people suffered from similar facial swelling years after injection by the same injector. The injector cannot be located.

CONCLUSIONS

Care must be taken in giving all facial fillers, particularly permanent ones. When one source patient is identified, questioning the patient's knowledge of others affected is critical to help manage an epidemic problem and to report a rogue injector. Physicians have a duty to investigate and report such cases.

A Case of Orbital Granuloma Secondary to Dermal Filler Injection

A foreign body granulomatous reaction is a rare complication of the subcutaneous injection of fillers. We describe a 57-year-old female that presented with a six-month history of a non-painful, right lower eyelid mass. She had a dermal filler in the zygomatic region several months before the onset of her symptoms. Anterior orbitotomy and pathology revealed multinuclear giant cells consistent with a hyaluronic acid-based filler. This case describes the clinical presentation, histopathologic features, and treatment of an orbital granuloma secondary to dermal filler injection. Our case was uncommon because the zygomatic filler migrated across the orbital septum. Additionally, transconjunctival orbitotomy was used instead of a hyaluronidase injection due to the inferior location of the granuloma.

Complications of Nonpermanent Facial Fillers: A Systematic Review

Background:

A variety of complications after injection of nonpermanent fillers for facial rejuvenation have been reported so far. However, to date, the overall complication rate is still a matter of debate. The aim of this study was to perform a systematic review of literature to assess the type and severity of associated complications following injections in different anatomical regions of the face.

Methods:

The entire PubMed/Medline database was screened to identify case reports and clinical studies describing complications that have occurred after injection of nonpermanent fillers in the face. These complications have been reviewed and analyzed according to their occurrence in different anatomical regions of the face.

Results:

Forty-six articles including a total of 164 patients reported on a total of 436 complications during the time period between January 2003 and February 2020. The majority of the complications were reported after injections to the nose and the nasolabial fold (n = 230), the forehead and the eyebrows (n = 53), and the glabellar region (n = 36). Out of 436 complications, 163 have been classified as severe or permanent including skin necrosis (n = 46), loss of vision (n = 35), or encephalitis (n = 1), whereas 273 complications were classified as mild or transient, such as local edema (n = 74), skin erythema (n = 69), and filler migration (n = 2). The most severe complications were observed in treatments of nose, glabella, and forehead.

Conclusions:

Nonpermanent facial fillers are associated with rare but potentially severe complications. Severity and impact of complications depend on the anatomical region of the face and eventually require profound knowledge of facial anatomy.

Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review

Tear trough deformity is a popular target for the treatment with filler injections. The side effects are generally mild and transient. However, delayed complications may occur. We aim to perform a thorough systematic review of the published literature related to delayed complications after tear trough filler injections. A search of published literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in June 2021 and included PubMed, ScienceDirect, and Embase databases. The Medical Subject Headings (MeSH) terms used included the following terms: delayed complications, nodules, granulomas, swelling, discoloration, dermal filler, hyaluronic acid (HA), polyacrylamide, calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), eyelid, periorbital, periocular, and tear trough. Twenty-eight articles consisting of 52 individual cases were included in the final analysis. 98% (51/52) of patients were female and had an average age of 48.3 years. HA was the most reported product (71.2%, 37/52), followed by PLLA (4/52, 7.7%), and CaHA (4/52, 7.7%). The most common delayed complication with any dermal filler was swelling (42.3%, 22/52) followed by lumps or nodules (25.0%, 13/52). Xanthelasma-like reaction (17.3%, 9/52), migration (7.7%, 4/52), discoloration (3%, 3/52) also occurred. The average time of onset of any complication was 16.8 months with xanthelasma-like reaction appearing soonest (mean: 10 months) and discoloration appearing latest (mean: 52 months). Most swelling cases were caused by HA. Semi-permanent fillers such as PMMA and synthetic fillers such as PLLA were more likely to be associated with lumps and nodules than other complications. It is important that clinicians who perform tear trough augmentation with dermal fillers have a thorough understanding of the risks of the procedure to diagnose and manage them promptly as well as provide patients with accurate information regarding the potential adverse effects.

Filler Migration to the Orbit

BACKGROUND

Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications.

OBJECTIVES

We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed.

METHODS

A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections.

RESULTS

Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively.

CONCLUSIONS

Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

LEVEL OF EVIDENCE: 4

Lower eyelid xanthelasma following hyaluronic acid filler injections to the tear troughs

INTRODUCTION

Adverse effects from dermal fillers are uncommon. We report a case of filler-induced xanthelasma at the bilateral infraorbital region in a 43-year-old woman after multiple injections of hyaluronic acid to correct tear trough depression.

MATERIAL AND METHODS

We report a case of a 43-year-old woman with a chief complaint of skin discoloration of the bilateral lower eyelids. Her history was significant for ten sessions of hyaluronic acid filler for tear trough deformity between December 2008 and May 2016. On clinical examination, she exhibited thin, soft, and yellow papules to her lower medial infraorbital hollows. A punch biopsy showed foamy histiocytes with a background of hypervascularization and focal extracellular lipid in the superficial dermis, consistent with xanthelasma.

RESULTS

Xanthelasma was treated with multiple passes of Er:YAG laser (Sciton Contour TRL) with a 4 mm spot size, fluence 7.5 J/cm2, and ablate/coagulate 50/50 at 6 Hz until clearance occurred. The perilesional skin was treated with 1-2 passes, fluence 7.5 J/cm2, ablate/coagulate 50/0 to blend in the cosmetic unit. Six-month follow-up showed notable improvement of all lesions.

DISCUSSION

There is a paucity of treatments described for filler-induced xanthelasma reaction. While broad conclusions cannot be drawn from one case, our experience indicates that complete resolution can be achieved with Er:YAG ablation. We hypothesize that this laser is an optimal treatment, as it can vaporize the lipid contents while minimizing adverse effects, such as scars and hyperpigmentation.

Granulomas in Dermatopathology: Principal Diagnoses - Part 1

This series of 2 articles on dermatopathologic diagnoses reviews conditions in which granulomas form. Part 1 clarifies concepts, discusses the presentation of different types of granulomas and giant cells, and considers a large variety of noninfectious diseases. Some granulomatous diseases have a metabolic origin, as in necrobiosis lipoidica. Others, such as granulomatous mycosis fungoides, are related to lymphomas. Still others, such as rosacea, are so common that dermatologists see them nearly daily in clinical practice.

The use of periocular fillers in aesthetic medicine

The periocular area is the first to display signs of ageing. Dermal fillers are an increasingly popular, minimally invasive method for facial rejuvenation. The eye is anatomically delicate and complex. Therefore, special consideration must be taken if dermal fillers are employed. This article examines the literature to assess the efficacy and safety of dermal fillers around the eye as well as the management of complications secondary to dermal filler use, such as oedema, granuloma formation, filler migration, xanthelasma, skin necrosis and visual loss. Hyaluronic acid (HA) is the most popular and commonly employed dermal filler for periocular use. It is effective, with good observer improvement and patient satisfaction (p<0.0001). Ninety percent of adverse events are mild in nature and self-resolve within 1 month. Malar oedema is a delayed complication unique to the periocular area, occurring in 11% of patients. This can be managed with use of hyaluronidase if a HA filler has been employed. Other complications, such as granuloma formation, filler migration and xanthelasma, have also been reported with variable management outcomes. Vascular adverse events include skin necrosis and visual loss. No Level 1 evidence exists for the management of visual loss. Two cases of visual restoration have been identified in the literature; however, this is rare.

Xanthelasma palpebrarum after hyaluronic acid injection in the lower eyelid: A case report and review of the literature

BACKGROUND

Hyaluronic acid filler treatments are a very popular nonsurgical procedure worldwide, most wanted to create a more attractive profile and correct facial aging. Since its usage has expanded, more complications have been seen.

AIMS

To report a probably new adverse effect related to injectable fillers.

PATIENT

A 38-year-old white woman who underwent hyaluronic acid filling in the periorbital area and presented twelve months after with two symmetrically yellowish plaque lesions on the lower eyelids, with no edema or nodules.

RESULTS

The lesion appeared to be xanthelasma, in a patient with no history of hyperlipidemia. Histological analysis showed unspecific findings with rare histiocytes present in the papillary dermis. The patient was treated with hyaluronidase infiltration in both lower eyelid areas as an attempt to minimize the appearance of the lesions, with a satisfactory response.

CONCLUSIONS

As hyaluronic acid fillings are becoming more popular, all physicians have to be aware of its complications. The xanthelasma-like reaction is probably a new adverse effect related to injectable fillers and it is important to be alert to this possibility.

Polycaprolactone-based dermal filler complications: A retrospective study of 1111 treatments

Background

Aging signs can be corrected through volume restoration in multiple soft tissue layers and in the supraperiosteal plane using hyaluronic acid (HA) or nonhyaluronic acid (non‐HA) fillers. The non‐HA bioresorbable polycaprolactone (PCL)‐based filler with collagen‐stimulating properties has a proven safety profile, but rare potential complications such as nodules and granuloma can occur. Furthermore, PCL‐based fillers cannot be immediately removed by injection of an enzyme. These potential drawbacks have yet to be described in the literature.

Aims

The author performed 1111 treatments between 2015 and 2018. This study aims to review and analyze these treatments to ascertain the complication rates of the PCL‐based filler. Suggestions for complication prevention and management are also discussed.

Methods

780 patients treated with the PCL‐based filler were reviewed by the physician between April 2015 and May 2018. During this period, 5595 syringes were used in 1111 treatments. All complication data were acquired by phone interviews, reports by patients, or observation at follow‐up visits. Complications were subdivided into early‐onset (occurring up to 2 weeks after treatment) and late‐onset events (occurring more than 2 weeks to years after treatment).

Results

Among the 1111 treatments, there were 50 cases (4.5%) of edema that lasted longer than 2 weeks, 30 cases (2.7%) of bruising, 8 cases (0.72%) of malar edema, 5 cases (0.45%) of temporarily palpable lumps and 2 cases (0.18%) of discoloration. There were no cases of intravascular injection, nodules/granulomas, or infection.

Conclusion

The complication rate of the PCL‐based filler was found to be low, and there were no cases of intravascular injection, nodules, and/or granulomas during the 3‐year observation. Longer‐lasting edema was associated with a higher injection volume and malar edema was related to lymphatic compression.

Polycaprolactone: How a Well-Known and Futuristic Polymer Has Become an Innovative Collagen-Stimulator in Esthetics

Compared to other domains, tissue engineering and esthetics have dramatically expanded in recent years, leading to both major biomedical advances and futuristic perspectives. The two share a common approach based on biomaterials, especially polymers. This paper illustrates this with the example of polycaprolactone (PCL), a polymer synthesized in the early 1930s, and one of its most recent applications, a PCL-based collagen stimulator, a filler used in esthetics. PCL is biocompatible and biodegradable. Its specific physicochemical and mechanical properties, viscoelasticity and ease of shaping led to the production of PCL-based products with various shapes and durations dependent on its biodegradation kinetics. PCL has been safely used in the biomedical field for more than 70 years, from sutures to tissue and organ replacement by 3D printing. The PCL-based collagen stimulator is composed of PCL microspheres suspended in a carboxymethyl-cellulose gel carrier providing immediate and sustained volumizing effects when injected; the morphology, the biocompatibility of the PCL microspheres embedded with the collagen fibers produced all contribute to the creation of a unique 3D scaffold for a sustained effect. Its safety has been investigated in clinical studies and vigilance surveys. Recently published experts' recommendations on injection modalities and techniques should help further optimize treatment outcome and safety. This paper also integrates reviews and recommendations on the prevention and management of adverse events related to dermal and subdermal fillers including the PCL-based collagen stimulator. In addition, in terms of efficacy and safety, this product benefits from its daily clinical use in esthetics worldwide and continuous extensive fundamental and clinical research, both on it and the PCL polymer. Forthcoming data from further investigations will reinforce knowledge of the product and procedures in the field.