Dermal Filler
Complications:
The Essential Guide for 2023
CONTENTS
HERE ARE THE COMPLICATIONS WE’RE GOING TO BE
COVERING IN THIS GUIDE:
NON INFLAMMATORY LESIONS 01
LUMPS IN LIPS 02
INFLAMMATORY LESIONS 03
HAEMATOMA 04
BACTERIAL INFECTION 05
NERVE INJURY 06
SALIVARY GLAND INJURY 07
BLINDNESS 08
IMPENDING NECROSIS 09
PRESSURE NECROSIS 10
Necrotic Injury presenting with normal
CASE STUDY: CRT. 5 things you need to know 11
STROKE 12
INTRODUCTION
DERMAL FILLER
COMPLICATIONS
In this guide, Dr. Tim covers a range of complications that can arise from medical
aesthetic treatments. He discusses both serious complications such as vascular
occlusion and blindness, as well as more common ones such as lesions and bruising.
With his extensive knowledge, he shares how to recognize and effectively manage these
complications.
As a healthcare practitioner delivering medical aesthetic treatments, such as lip fillers,
jawline contouring, non-surgical rhinoplasty, or cheek volumizing injectable treatments, it
is important to be familiar with the different types of dermal filler complications and how
to prevent, diagnose, and treat them. Complications, regardless of their severity, can be
uncomfortable and traumatic for the patient and stressful for the clinician. It is crucial to
remain calm, utilise your training, and find the best approach for recognizing and treating
the complication.
01 NON INFLAMMATORY LESIONS
Non-inflammatory lesions are bumps or lumps under the skin that are not painful and do
not involve inflammation. They can be caused by injectable fillers and are most common in
the lips. Non-inflammatory lesions are generally considered to be the most common adverse
effect of dermal fillers, aside from bruising. They are relatively easy to manage because there
is no biochemical reaction between the filler product and the body. Often, simple massage
techniques can help to resolve non-inflammatory lesions.
However, it is important to consider the psychological and psychosocial impact on the patient
when dealing with non-inflammatory lesions. Small, less visible lumps may not require treatment
and can resolve on their own. However, larger, more visible lumps may cause significant distress
to the patient, in which case a more aggressive approach to resolution may be necessary.
MASSAGING THE LIPS HELPS REDUCE LUMPS
It is important to properly investigate and diagnose lumps caused by dermal fillers
in order to distinguish between non-inflammatory and inflammatory lesions.
Inflammatory lesions are caused by a foreign body or allergic reaction and are
characterized by redness or tenderness. They require a different approach to treatment.
02 LUMPS IN LIPS
As non-inflammatory lesions are often seen in the lips after filler, let’s dive into how
you can diagnose and recognise the different types of lesions in the lips specifically.
When diagnosing lumps in the lips following a lip filler procedure, it is important to
consider the patient’s background, including their age, sex, medical status (including
known medical conditions, medication, and allergies), and their mental health and
psychological status. This information can help to correctly interpret the patient’s
symptoms and physical examination findings. It is also important to gather information
about the specifics of the procedure, including the product used, the amount injected,
the injection location, and the method of injection.
There are three broad categories of lumps in the lips following a dermal filler treatment:
those related to the procedure, those related to the product or substance used, and
those related to underlying medical conditions. Here, we will focus on those caused by
the dermal filler product or other substances and foreign bodies. Substance-related
lumps can be divided into two types: acute reactions, which occur soon after the
procedure, and chronic reactions, which may take months to develop.
An acute reaction may be indicated by a
history of inflammation or previous procedures
that caused excessive swelling, or by the
presence of bruising after the procedure.
The most extreme swelling following lip filler
treatment usually occurs around 6 hours
after the procedure, but if the patient is
experiencing a reaction, the inflammation may
persist for longer and worsen the following
morning. If the expected swelling gets worse
rather than resolving, it may indicate an
allergic reaction to the product or substance,
which requires treatment.
02 LUMPS IN LIPS
12 MONTHS + The patient may have a laid-back personality
and not seek treatment for the reaction due
A chronic reaction to a dermal to a desire to not cause a fuss or be a burden.
filler treatment may take a In some cases, the reaction may be related to
long period of time to develop, the introduction of other substances or foreign
potentially up to 12 months or bodies, such as makeup, if the patient does not
more after the procedure. follow aftercare instructions.
Symptoms of a chronic reaction may include initial swelling and tenderness around the area of
the lump, which may be accompanied by mild redness. These symptoms may resolve and then
recur as the lump becomes harder and more difficult to treat. On palpation, the lump may feel
firm and discreet, with a solid or rubbery texture, and may be surrounded by collagen deposition.
It is important to closely monitor the patient for any changes in their symptoms and to consider
the possibility of a substance-related reaction if the lumps do not resolve on their own or with
treatment. If you’d like even more learning on how to diagnose and treat lumps in lips go here.
03 INFLAMMATORY LESIONS
By their nature, inflammatory lesions or nodules are a more serious prospect when it comes
to dermal filler complications than non-inflammatory lesions. They can be caused by many
different mechanisms, manifesting in slightly different ways, and thus needing managing in
distinct ways, all of which must be investigated.
Depending on the cause, which may be post-procedural inflammation, infection, a viral reaction
or a hypersensitivity reaction, the physical attributes will vary, so it’s important to learn how to
diagnose inflammatory lesions or better still, prevent them from occurring through improved
product selection, aftercare advice for patients and aseptic techniques. As they can have
multiple causes, a complete diagnosis of the cause of an inflammatory nodule is seldom possible
in clinical practice, but routes to resolution mean that management techniques are often
successful.
EXAMPLE OF INFLAMMATION
Serious and rapid onset of inflammation due to hypersensitivity is thankfully
considered to be quite rare but can occur in immunosuppressed patients or those with
systemic illness, so proper patient selection and consultation is also paramount.
04 HAEMATOMA
Haematoma, alongside ecchymosis, petechiae and purpura are medical terms used to describe
what we usually all refer to as bruising. Bruising is the number one side effect, some argue,
complication, from dermal filler treatment. It is, however, 100% a significant issue for patients
and is something all healthcare practitioners should try to avoid causing as much as possible.
Bruising affects a patient’s appearance, quite dramatically, and tells the world around them what
they have been up to due to its visibility. Bruising, particularly around the eye area can have a
negative psychological effect on an individual as they explain to worried friends, family or work
colleagues that they haven’t been in a fight.
EXAMPLE OF HAEMATOMA
Despite its apparent insignificance as a complication, it should not be a side effect ignored by
clinicians as it can negatively impact on your practice. Patients will not thank you for it and may
lose trust in your skills and abilities. If they are really unhappy then you may risk retaining them
as a patient as they seek out another clinician for their next treatment, plus they could help to
damage your reputation if they tell their friends and family about their experiences. Similarly, any
such side effects add to your aftercare workload as a patient with a bruise still needs managing,
providing emotional support and aftercare guidance, and you still need to write up the notes
and do the paperwork. Avoiding giving patients bruises is therefore something we should all be
doing and there are many best practical ways to help you to reduce bruising. Dr Tim is proud
that after many years’ experience in aesthetic practice, he has substantially reduced the rate at
which he causes bruising in his patients. You can learn these skills too.
05 BACTERIAL INFECTION
Bacterial infections following dermal filler procedures are generally rare, but can occur if proper
preventive measures are not taken. These infections can range in severity, from transient
inflammation to biofilm or abscess formation, and in rare cases, septicaemia which can be life-
threatening. The most common cause of skin infections is staphylococcus aureus, and most
reported cases of bacterial infections related to dermal fillers are caused by external bacteria
entering the skin. To prevent these infections, it is essential for practitioners to use aseptic
techniques, clean the skin before injecting, and use sterile equipment in a properly disinfected
clinical setting.
EXAMPLE OF IMPETIGO
The greatest risk of bacterial infection is in injections around the lips, especially at the oral
commissures where the entry point is closest to the wet-dry border. It is also important to note
that even with proper preventive measures, patients may inadvertently introduce bacteria to the
injection sites through their own actions. Therefore, it is important to educate patients on proper
aftercare to reduce the risk of bacterial contamination. Aesthetic clinicians should be familiar
with the signs and management of skin infections, such as impetigo, erysipelas, and cellulitis,
in order to properly treat any infections that may occur.
06 NERVE INJURY
Nerve injuries are rare complications that can be caused by mechanical actions during dermal
filler treatments, such as piercing, compressing, tearing, or injecting a nerve. These injuries
can also be caused by the filler product itself if it has a high viscosity. In addition, it has been
hypothesized that needle trauma may trigger a varicella-zoster outbreak, which is the virus that
causes chickenpox and shingles. If a patient develops shingles, it can disrupt the proper function
of the nerves and require its own diagnosis and management.
There are three types of nerve injuries that can occur:
NEUROPRAXIA
1 Neuropraxia is the least severe and involves
dysfunction of the myelin layer of the nerve.
AXONOTMESIS
2 Axonotmesis also involves damage to the
myelin layer, but also includes damage to the
axon of the nerve. However, the endoneurium
is preserved, so the nerve will recover.
NEUROTMESIS
3 Neurotmesis is the most significant damage
to the nerve fibers and can result in slow or
poor regrowth, permanent damage, or loss of
nerve function.
To prevent nerve injuries, it is important for
clinicians to educate themselves and undergo
training in facial anatomy so they understand the
location of the nerves in the face.
EXAMPLE OF HERPES SIMPLEX
PRESENTING AFTER LIP FILLER
07 SALIVARY GLAND INJURY
A recent trend for chin and jawline contouring dermal filler treatments has led to an increase in
salivary gland injuries, particularly as these are usually performed with a cannula.
Understanding the anatomy of this area is paramount when performing such treatments as you
risk tearing or penetrating the parotid and submandibular glands.
TO AVOID SALIVARY GLAND INJURY THE PASSAGE OF YOUR INSTRUMENT
SHOULD BE IN THE HYPODERMIC FAT
Salivary gland injuries can be difficult to spot so it’s important to understand the ways that you
can diagnose a salivary gland injury as they have similar symptoms and manifestations as
inflammatory lesions, which can catch out even the most experienced aesthetic clinician.
08 BLINDNESS
Blindness, both temporary and permanent,
caused by dermal filler injection to the face is
often regarded as the most serious and terrifying
complication documented in relation to this
treatment. The earliest paper on this came
from Lazzeri et al in 2012 who published a study
which discussed blindness following cosmetic
injections of the face. Since then, many more
studies of published cases have been undertaken
and peer-reviewed, including a review of the world
literature on avoiding and treating blindness
from fillers which analysed 98 reported cases.
The conclusion of this review by eminent doctors
stated:
Although the risk
of blindness from
fillers is rare, it is
critical for injecting
physicians to have
a firm knowledge of
the vascular anatomy
and to understand
key prevention
and management
strategies
FILLER INJECTED INTO THE ARTERIES
OF THE EYE CAN CAUSE BLINDNESS
Thankfully, causing vision loss with dermal
filler treatment is rare, but with the increasing
popularity of filler procedures in the mid and While it is not possible to guarantee 100%
upper face, particularly non-surgical rhinoplasty, prevention, a thorough understanding of facial
the number of reported cases has also increased. anatomy and proper injection techniques can
Blindness from dermal filler injections is caused greatly reduce the risk of this serious complication.
when the filler is injected into a facial artery In the event that a vascular occlusion does occur, it
or vein, causing a vascular occlusion that cuts is important for practitioners to be able to quickly
off the blood supply to the eye(s). It is essential diagnose and effectively manage the situation in
for healthcare practitioners to have a good order to restore blood flow and avoid permanent
understanding of key anatomical features and damage to the retina. Click here to learn more
danger zones in order to prevent this complication about what to do if this unfortunate event ever
from occurring. occurs.
09 IMPENDING NECROSIS
Vascular occlusion, or VO, is a hot topic amongst medical aesthetic practitioners and is one of
the most common complications possible when delivering dermal filler treatments. If an artery
is blocked or occluded by product during a dermal filler procedure, it means that oxygenated
blood cannot reach an area of tissue. With a lack of oxygen, cell function will become impaired,
eventually leading to cell destruction which is referred to as impending necrosis – skin necrosis
caused by a vascular occlusion.
One method for preventing vascular occlusion is by aspirating to ensure that you are not in an
artery. This is performed by pulling back on the syringe plunger once the needle placement
is where you want it, holding the plunger for several seconds and checking for flashbacks of
blood which would indicate a positive aspiration and a sign that you have placed your needle
within an artery. This allows you to retract your needle and choose an alternative entry point or
angle for injection which is away from the artery. Learning how to aspirate and how long to wait
when performing a dermal filler injection can help you to prevent both vascular occlusion and
impending necrosis.
STAGES OF NECROSIS
Dr Tim explores his own case study and experience
in dealing with a vascular occlusion during a
lip filler treatment in a recent podcast: A true
story: emergency reversal of filler. You can
also download a free step-by-step guide to the
emergency reversal protocol.
VASCULAR OCCLUSION AFTER LIP FILLER
10 PRESSURE NECROSIS
This type of complication can occur when injecting the nasal tip and is characterized by redness
and pain. However, a capillary refill test (CRT) may not show any obvious concern, leading to a
false sense of security. It is important to recognize that this could also be a pressure injury, which
is equally concerning. The minimal vasculature and reduced blood pressure in the nasal tip make
it more susceptible to pressure injuries, and the confined space in the nose can also contribute
to pressure differences when injecting. If not treated early, this can result in the formation of a
pressure sore and potentially lead to superficial or more complex necrosis.
If you notice persistent redness in the lower third of the nose following a non-surgical rhinoplasty
procedure, especially if injections were made into the nasal tip, it is likely a sign of this type of
pressure injury. The injury presentation may have a more diffuse boundary, with significant
redness around the area of product placement fading laterally. It is important to note that this
type of pressure injury is specific to the nasal tip and does not follow the path of major vessels, as
is typically seen with intravascular occlusion.
PRESSURE NECROSIS CAN BE CAUSED BY INJECTING THE TIP OF THE NOSE
The confined space in the nose, particularly in the lower third where the skin is tight and there is
limited room for product placement, means that injecting high volumes of dermal filler products
in this area to achieve an aesthetic result can increase the risk of nasal complications such as
pressure injuries. Any quantity over 0.5ml may increase the risk of causing a complication. It is
important to consider the mobility of the individual nose you are injecting, as this can affect
whether increased product placement only increases pressure rather than achieving the desired
lift or enhancement. Learn more about how to identify pressure necrosis here.
11 CASE STUDYNECROTIC INJURY PRESENTING WITH NORMAL CRT. 5 THINGS YOU NEED TO KNOW
A recent case seen in a clinic involving a patient who experienced severe pain following a non-
surgical rhinoplasty procedure has shed light on a rare and serious type of injury that can occur
to the nose. The patient’s presenting symptom was pain, but interestingly, the capillary refill,
which is a measure of blood flow through the small blood vessels in the skin, was normal. This
has led clinicians to consider the potential causes and risk factors for this type of injury, which is
known as a necrotic injury, or tissue death.
The clinicians initially thought that the patient’s normal capillary refill in the skin was reassuring
and indicated that there was no necrosis, or tissue death. However, as they examined the patient
further, they realised that the injury was deeper in the septum of the nose, possibly caused by
injury to the mucoperichondrium, a membrane covering the cartilage. The clinicians determined
that the injury was a necrotic injury and it was likely caused by a disruption of the blood supply
to the septum. This realisation led the clinicians to understand that the normal capillary refill in
the skin did not necessarily mean that there was no necrosis deeper in the nose.
ARTERIES AND BLOOD SUPPLY IN THE NOSE
11 CASE STUDY
NECROTIC INJURY PRESENTING WITH NORMAL CRT. 5 THINGS YOU NEED TO KNOW
Here are 5 points that all clinicians who inject noses
should be aware of when it comes to this rare but
serious complication:
Details of the procedure matter. In order to determine
1 the potential risks and causes of a necrotic injury, it is
important to have as much information as possible about
the details of the procedure. This includes where and when
the patient was injected, what product was used, the
depth of injection, and the instruments used. Without this
information, it can be more difficult to pinpoint the cause
of the injury.
Haematomas can cause necrosis in the septum. If a
2 clinician injects a dermal filler in a way that causes trauma
to a blood vessel in the septum, it is possible to form a
haematoma, or a localized collection of blood outside of a
blood vessel. If this haematoma occurs over the septum, it
can lead to necrosis, or tissue death.
Injecting filler in the wrong area can cause necrosis. If a
3 clinician injects filler into the middle of the cartilage in the
inferior aspect of the nose, it is possible to separate the
mucoperichondrium (a membrane covering the cartilage)
from the cartilage, leading to necrosis.
Vascular occlusions can cause necrosis. If a clinician injects
4 a large amount of filler into the superior labial artery, which
supplies blood to Little’s area in the nose, it is possible to
block off the capillaries and cause necrosis.
Injecting off the bone in the inferior third of the nose can
5 cause septal necrosis. If a clinician injects too deeply in the
inferior third of the nose, off the bone, it is possible to cause
an injury to the septum, the midline partition separating
the nostrils.
11 CASE STUDY NECROTIC INJURY PRESENTING WITH NORMAL CRT. 5 THINGS YOU NEED TO KNOW
While necrotic injuries to the nose are rare, it
is important for clinicians who inject noses to
be aware of the potential risks and causes. By
understanding these points, clinicians can take
precautions and be better prepared to manage
any complications that may arise.
It’s important to note the
following:
Necrosis can be caused by vessel occlusion,
1. compression, and in the case of the nose,
separation of the vascular tissue from
avascular tissue - the septum.
Assessments should consider the full
2. anatomy of the nose, not just the skin on the
surface. NECROSED SEPTUM
Injection techniques should reflect the
3. additional risk in this area, and deep injections
through the midline may be the highest risk.
If you want to find out more about this case, watch a full 15 minute
analysis of the case study here.
12 STROKE
The likelihood of causing a stroke from a dermal filler treatment is very slim as the product
must enter the intracranial circulation and come to rest in an artery supplying part of the brain.
Blockage of a vessel in this region will cause hypoxic damage to the brain in a matter of three
minutes.
There are two main routes by which filler can enter the cerebral circulation. The first is by
retrograde flow of filler product from the facial artery into the common carotid artery and then
into the internal carotid. The second is by filler product entering through the ophthalmic artery
via one of the three vessels in the orbit, the supratrochlear, supraorbital or lacrimal arteries.
Understanding the FAST acronym for rapid assessment of stroke should be within every
clinician’s armament.
Dermal filler complications can be a daunting prospect, but understanding, preventing,
diagnosing, and managing them is essential for safe and successful treatments. This ultimate
guide covers the unique symptoms and signs of various complications that can occur across the
face, including the lips, cheeks, nose, and tear troughs. By learning all the relevant knowledge, you
can implement preventative measures and confidently design treatment plans for your patients
without fear. However, this guide should only serve as a starting point as you continue to master the
management of dermal filler complications.
To fully master aesthetic complications, check DR TIM’S YOUTUBE
out Dr. Tim’s Dermal Filler Complications To expand your knowledge
Course. This comprehensive program offers on facial anatomy, injection
instant access to learning materials and technique, and more, visit Dr.
resources to help you become an expert in the Tim’s YouTube channel for
management of aesthetic complications. helpful tutorials and advice.
Text copyright ©️ Dr Tim Pearce 2022.
Dr Tim Pearce has asserted his right to be identified as the
author of this work in accordance with the Copyright, Designs and
Patents Act 1988. All rights reserved. No part of this publication
may be reproduced or transmitted in any forms or by any means,
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storage without prior permission.
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