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Aesthetics Journal
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Case Report: Managing a Mid-face Filler Complication
the manufacturers of the filler used were immediately contacted for further advice, as were members of the committee of the Aesthetics Complication Expert group to seek additional guidance on managing this case. The group comprises experienced aesthetic practitioners who have created complication management guidelines focussed on evidence-based medicine.
Dr Yusra Al-Mukhtar shares her experience of treating a mid-face infection caused by filler injection
Within two days of the patient seeing me, she started to develop a mild swelling on her left cheek, but this disappeared soon after, as did her swelling on the right side. I discussed with the patient the option of injecting the area with hyaluronidase, an enzyme known to break down hyaluronic acid, which would help to break down the product placed to allow full penetration of the antibiotics. The patient declined to do this for fear of losing the bulk of the treatment, and wanted to continue on her antibiotics to see if this would settle without dissolving the product. Indeed, the infection seemed to get better for the coming days, before suddenly returning. On October 18, two weeks after treatment, she developed a diffuse swelling around her right eye and zygoma, which would get better throughout the day and evening only to return by morning. She also started to develop symptoms of extreme pain on the right cheek and itchy skin. Unfortunately Patient A could not come to see me in clinic as she was away on a trip,
On October 3 2015 a 46-year-old female (Patient A) attended an advanced dermal filler course to have a treatment whereby a hyaluronic acid filler suitable for volume replacement was placed in the midface to create a lifting effect. Patient A was medically fit and well, not taking any medication at the time, was not immune compromised in any way and was a nonsmoker. She had a known allergy to penicillin. Patient A had received treatment using a number of different fillers to her nasolabial folds over the preceding eight years. Treatment During the treatment session, it was noted that Patient A’s face was mildly asymmetric and so her left and right mid-face were treated using different volumes of product to correct the pre-existing asymmetry. The non-surgical prep included cleaning the face using 20% chlorhexidine as a surface disinfectant of the skin. An aseptic technique was used, and product was injected using sterile 27-gauge needles. There were three injectors, each qualified doctors, who attended the training course, which I led. The filler of choice was hyaluronic acid, designed to restore
Figure 1: 10 days after treatment
volume and create a lift in areas where marked flattening and volume loss had been noted. The hyaluronic acid filler of choice was deposited supraperiosteally, after aspirating, and a total volume of 0.1ml placed at the zygomaticotemporal suture site on the left and right cheek and 0.3ml on the left at the most anterior projection in the ogee curve of the face to accentuate the anterior projection of the zygoma, whilst 0.2ml was deposited on the right side of the cheek. A further 0.2ml was placed in the base of the nasojugal groove to lift the malar depression and support the tear trough, to improve continuity of the lidcheek junction. Patient A also had 0.1ml of product injected in the prejowl sulcus and 0.1ml to the angle of the mandible on both the left and right side. In addition, she had a total of 1ml of another hyaluronic acid, designed to be injected into the dermis, to her nasolabial folds and marionette lines using a retrograde linear technique in a maximum of 0.05ml per aliquat. Complication Six days post treatment Patient A contacted the team via our emergency email to let us know she had developed a swelling, which had appeared soon after her treatment as a bruise under her right eye, but had started to throb and the pain seemed to be getting worse. She had seen her GP who started her on 500mg of erythromycin four times a day, as she had a penicillin allergy.2 She attended my clinic on October 13, 10 days after her aesthetic procedure. On examination, she had mild swelling over her right zygoma below the infraorbital rim, 1cm in length and 2cm across, a localised swelling that was tender on deep palpation with mild erythema of the overlying skin. The swelling was not fluctuant and there was no pointing (Figure 1). Patient A was prescribed metronidazole and
Figure 2: Two weeks after treatment
Figures 2: Two weeks after treatment
Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016