5. Avoid
1.Exposure to extreme heat
2.Massaging treated areas for 6hs
3.Strenuous physical activity
for6hs
• Sleep with the head elevated over
night
• Chemical peels, laser should be
spaced out at least 2 Wks
Ayman Elwan, MD
6. COMPLICATIONS: Early
• pain
• edema
• Bruising
• Erythema
• lumps, asymmetry, contour
irregularity
• hypersensitivity
• local tissue necrosis due to
vascular occlusion
Ayman Elwan, MD
7. COMPLICATIONS: Early
• Infections
• Tyndall effect
• Retinal artery occlusion
Immediate blurring or loss of
vision during injection
Ayman Elwan, MD
8. Pain
• Why? When to stop?
• More with PLLA & CaHA
• Emla?
• Cryo?
• Infiltration?
• Mixed lidocain with filler?
Ayman Elwan, MD
9. Erythema
• Normal
• Persistent: what to do?
Bruising
• When?
– Stop anticoagulants
– avoid vigorous exercise for the first 24
– Elevate head during procedure
– Small G needles or blunt cannula
– Limit the numbers of puncture site
• Persistent: what to do?
Ayman Elwan, MD
10. Oedema
1. Short term post traumatic
2. Antibody mediated (angioedema)
3. Non antibody mediated (delayed)
4. Malar oedema (inferaorbital hallow inj. &
malar septum)
Measures
– Avoidance ……
– Allergen should be removed
– HA: hyaluronidase
– Non-HA: extrusion, dispersion or laser breakdown
– Lowest dose of systemic steroids
Ayman Elwan, MD
12. Infection
• Rare
• Staph – Strept ………Atypical
• If abscess: Regular management
• Mid facial & periorbital: ? Intracerebral complications
• Antibiotics used…………??
• Herpetic outbreaks: ttt &/or prophylaxis
• Tyndal Effect
– Why?
– With what filler?
– How long does it stay?
– Management: hyalurindase Vs Mechanical extrusion
Ayman Elwan, MD
13. Vascular Compromise
• Most serious.
• Incidence rate 0.001%
– Intravascular injection into an artery: embolism
– Partial or complete interruption of vascular supply
by extravascular compression:
• by the filler
• secondary edema & inflammation
– Cause: irreversible tissue necrosis in both antegrade
and retrograde fashion
– Areas vulnerable: single blood supply
• NLF Glabella
• Alar base Nose Lip
Ayman Elwan, MD
16. A 25-yr old woman who had a filler (Artecoll; Artes Medical, San Diego,
California) injected into her forehead and nose.
She suffered pain that was accompanied by pus discharge and skin necrosis
after 5 days.
The adipose-derived stem cells were abstracted and injected into the
damaged area on the nose tip.
(A) The patient came to the clinic with a pustule and necrosis after filler
injection.
(B) Two days after adipose-cell derived stem cell injection.
(C) Ten days after adipose-derived stem cell injection.
The necrotic area shows nearly complete re-epithelization. (D) Six months
after adipose-derived stem cell injection. The necrotic lesion was healed without
scarring or pigmentation.
(E) One year after stem cell injection.
There were no demonstrable findings other than a small linear scar.
17.
18.
19.
20.
21. Risk factors for vascular compromise
• Large volume bolus injections
• Small sharp needles
• High pressure injections
• Deep plane of injection: larger vessels
• Common with:
– autologous fat injection
–Particulate filler and CaHA
Ayman Elwan, MD
22. How to diagnose Vascular Compromise?
• Immediate or delayed up to 6 hours
• Pain inconsistent with that of injection
• Area of blanching
• Two days:
–Painful Violaceous reticulated patch
–Necrotic eschar on top of an ulcer with
scar formation
Ayman Elwan, MD
23. How to manage?
Emergency
• Stop injection immediately
• Inject hyaluronidase into the injection site
REGARDLESS OF THE FILLER FOR:
– edema reducing benefits
– Reduce occluded vessel pressure
• Prednisone 20-40 mg daily for 3-5 days
• 2% nitroglycerine paste massaged every 1-2 hours and 3 times a
day at home
• Warm compresses,10 minutes every 1 hour
• Aspirin 325 mg under the tongue
• Alprostadil (PGE1) 60 microgram IV daily for 6 days
Ayman Elwan, MD
24. In a case study of 12 cases of
vascular compromise in 10
years from 2003 to 2013 out of
a total 14,355 filler injections
(0.05%) all cases of vascular
compromise resolved fully
Ayman Elwan, MD
25. How to avoid vascular compromise?
• Know the anatomy
• Aspirate
• Use a reversible filler
• Take good history including previous surgeries
• Use a wide bore cannula
• Inject slowly
• Stop injection when resistance is increased
• Inject across lines rather than along lines
• Extensive gentle pretunneling
• Better low volume….on multiple sessions…sp risk areas
• Fractionated incremental injections avoiding bolus
injections
Ayman Elwan, MD
26. Retinal Artery Occlusion
A rare event occur when the filler
enters the ocular circulation
through retrograde arterial flow
after injection into one of the
distal branches of the ophthalmic
artery
Ayman Elwan, MD
29. Pathophysiology
Intravascular injection one branch
Intra-arterial pressure
Filler
proximal to origin of CRA
Pressure released
Filler
distally into CRA
visual impairment or blindness
Ayman Elwan, MD
30. Iatrogenic Retinal Emboilism TTT
• No treatment exists
• Therapy should be directed to:
lowering intraocular pressure
dislodge the embolus
more peripheral vessels
retinal perfusion
Ayman Elwan, MD
31. What to do ??
• Anterior chamber decompression with a needle or
sharp cutting blade paracentesis
• Ocular massage to lower intraocular pressure
• IV diuretics:
– Acetazolamide(500 mg)
• Carbon dioxide rebreathing and hyperbaric oxygen
therapy
• Systemic and topical corticosteroids were successfully
administered in one case with full recovery of sight
• Systemic fibrinolytic agents and antiplatelet drugs
Ayman Elwan, MD
32. A case study of 32 cases of blindness
after:
Fat transfer: 15
Injection of other materials: 17
None of six cases from fat injection
group who receive therapy had any
return of vision
Other materials group only 3 patients
recovered their sight
Ayman Elwan, MD
36. Non inflammatory nodule
•2-4 weeks after injection
•Results from:
–Poor technique
•Overcorrection
•too superficial placement
• intramuscular placement
•Particular fillers such as PMMA,CaHA in
highly mobile areas as lips
Ayman Elwan, MD
37. HOW TO MANAGE?
•HA filler: hyaluronidase
•Non-HA filler:
–vigorous massage
–be disrupted with lidocaine or saline
–intralesional corticosteroids alone or
with 5-Fluorouracil 50mg per ml
–Excision
–Aspiration?
Ayman Elwan, MD
38. Inflammatory nodules (Biofilm)
• Densely packed communities of
microorganisms
• Survive within a self-developed
polysaccharides matrix of fibrinogen and
fibronectin:
– prevents antibiotics from destroying all the
microorganism
– releases free-swimming bacteria in the tissues & can
cause local infection
– systemic infection or granulomatous inflammatory
response
– culture resistant and antibiotic resistant
Ayman Elwan, MD
39. Diagnosis of biofilm
• histoy of filler injection: PAAG
–ideal medium for flourishing of low
virulence bacteria found in normal skin
flora
• pain, swelling, erythema
• Induration
• fluorescence in situ hybridization
technique
• scintigraphy with radiolabeled
autologous white blood cells
Ayman Elwan, MD
40. Treatment of biofilm
•Antibiotic treatment for 4-6 weeks
–Quinolones
–Macrolides
–Rifampicin?
•Removal of the filler:
–hyaluronidase with HA fillers
–nonbiodegradable filler removal technique:
•direct excision
•large needle drainage
•incision & drainage via manual expression
• copious saline irrigation
Ayman Elwan, MD
41. Large needle suction aspiration
of nonbiodegradable fillers
an in-office technique that
facilitates safe and accurate
removal of fillers with
minimal risk of permanent
scarring
Ayman Elwan, MD
42. Surgical technique of aspiration
• pretreatment with oral antibiotics (clindamycin300
t.d.s for 1 day)
• local antiseptic cleansing
• local anesthesia in the area of needle entry (5-7 mm
inferior to the collection)
• A 14 g, 1.5-inch needle on a 10-ml syringe is used to
enter the skin and puncture the collagen capsule
• needle can be angled to remove products in
multiple passes
• needle can be removed and bimanual massage is
used to work the filler out
Ayman Elwan, MD
43. • beneficial to have two clinicians working on one
area of the face so that steady pressure can be
uniformly applied
• you will not remove all the filler in one session:
– because there are multiple tracts under the skin
connecting pockets
– we commonly see one previously drained area
reaccumulate with product from another tract
• we have to wait 45 days between treatments
• oral antibiotics for 5 days after the procedure
• one week for follow up
Good results with high patient satisfaction
Ayman Elwan, MD
52. Inflammatory foreign body granuloma
• with all injectable dermal fillers
• several months to years after
injection
• due to granulomatous reaction
• hypersensitivity reaction?
Ayman Elwan, MD
53. Risk factors for development of
foreign body granuloma
• properties of the filler
• injection of large volume
• intramuscular injection
• previous infection
• Trauma …………
• interferon therapy
Ayman Elwan, MD
54. Diagnosis of foreign body granuloma
• red papule, nodules or plaques
• with or without ulceration
• lesions become firmer over time due to
fibrosis
• ULTRASOUND
• C.T scan
• Histopathology (multi-nucleated giant
cells with few epithelioid histiocytes)
Ayman Elwan, MD
56. Conclusion
• Complications of facial filler injections
have recently heightened awareness of the
possibility of iatrogenic blindness
• Early recognition and treatment are
essential for treating ocular circulation
emboli
• Shortening of the ischemic period increase
the probability of residual visual function
Ayman Elwan, MD
57. In a short span of time fillers have
come to play an important role in
the non surgical management of
ageing skin
Technique is a safe simple and
effective modality when used by:
a properly trained
physician ………..??
Ayman Elwan, MD
