MIAMI BEACH Inappropriate placement and potential sensitivity reactions are possible complications of fillers, and asymmetry, swelling, and bruising can occur after injections with botulinum toxin, Dr. Joel L. Cohen said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.
"Most people have moved away from injecting Radiesse in lipsit can migrate superficially and give a 'popcorn' appearance," he said. "Most of our patients are of the age that they think back to Goldie Hawn in the 'The First Wives Club.'"
Permanent fillers can be less forgiving and require more expertise to inject. ArteFill became the first nonresorbable, injectable filler implant approved for aesthetic use in the United States in October 2006. Complications reported with an earlier formulation approved outside the United States, ArteColl, might apply to ArteFill as well. "If placed too superficially, like any filler, it can cause nodules, but these are long-term nodules," said Dr. Cohen, a dermatologist in Englewood, Colo.
Adverse events associated with poly-L-lactic acid (Sculptra) include granulomas reported in several studies, especially from the European experience (Dermatol. Surg. 2005;31:7726), and infections. "Infraorbital skin can be thinner, so infraorbital area injections with Sculptra can be problematic," Dr. Cohen said. To avoid pitfalls, "inject deeper and use higher volume reconstitutions."
When hyaluronic acid fillers are not injected deeply enough, especially in the tear-trough area, there can be a Tyndall effect, he said. Treatment of this adverse event is to nick the skin and try to express the product, or treat with a laser, or try to dissolve the product with hyaluronidase.
Dr. Cohen treated a woman who had previously been injected with a hyaluronic acid product and then developed delayed erythematous nodules (Dermatol. Surg. 2006;32:42634). It is hard to know if this was an infection or a type of sensitivity. Three negative cultures were performed, and her indurated nodules finally cleared after a few courses of antibiotics over several months, he added.
Other adverse scenarios with fillers include the potential of inducing a herpes simplex virus (HSV) sore. "Think about prophylaxis [for HSV] when doing lip augmentation or injecting etched-in lip lines, especially in patients with a significant history of cold sores. Though, fortunately, I have not yet seen a postprocedure HSV flare with an aesthetic patient, I did see this in one of my Mohs surgery patients a few days after a lip repair," he said.
Necrosis is really the complication of most concern. This process can occur from excessive product placement compressing arterioles or from frank intravascular placement of product, Dr. Cohen said.
To avoid this complication, know the facial vasculature of the areas being injected, he advised. "I have participated in treatment of three patients that received hyaluronic acid fillers who were diagnosed by their injecting physicians with 'impending necrosis' a few hours later. The skin was developing localized areas of patchy, purple reticulated discoloration [visible] on photos sent to me. I recommended hyaluronidase injections in and around the area to try to decompress the vessels and to facilitate flow, and fortunately this was successful." (Case report in press.)
There are fewer adverse events reported with use of botulinum toxin, compared with fillers, but asymmetry, unwanted migration, swelling, and bruising have all been seen and have been reported to the FDA after botulinum toxin injections (J. Am. Acad. Dermatol. 2005;53:40715).
"Complications from fillers, botulinum toxins, and lasers are very often related to inexperienced injectors/providers or … unsupervised and inadequately trained nonphysician providers," he said.
The physicians who are supposed to be supervising these procedures are rarely present and "have no training or experience themselves in the procedures in which they are supervising and just want to make a buck," said Dr. Cohen, chair of the American Society for Dermatologic Surgery's patient education committee.
He applauded the Florida legislature for passing "very appropriate" supervision guidelines in 2006 and said that these kinds of guidelines are needed on a national basis.
For any procedure, appropriate patient selection is important to minimize complications. For example, "some patients with a significant redundancy in their brow and lid skin should not be treated with botulinum toxin in their lower forehead, as this will only accentuate the problem and exacerbate the brow ptosis and redundant eyelid skin," Dr. Cohen said.
Dr. Cohen evaluates patients while they are animated to help determine botulinum toxin dosing and placement, but he recommends injecting while the patient's face is relaxed. A zygomaticus muscle pulled up at the cheekbone when the lower crow's-feet are being injected, for example, might have a higher risk of inadvertent spread to the muscle that would cause an asymmetric smile for 34 months, he said.