Treating Permanent Dermal Filler Complications

Treating Permanent Dermal Filler Complications

Injectable cosmetic fillers have quickly become a cornerstone treatment in the field of aesthetics in the last few decades. Soft tissue augmentation has existed since the early 20th century, when industrial-grade silicone was used. Injectable cosmetic fillers started with bovine collagen in the 1980s. It developed in the 1990s to become the second-most popular minimally invasive aesthetic procedure in North America that mainly focused on volumizing and recontouring the facial region. In 2013, more than 2.2 million soft tissue dermal filler procedures were done.

Many practitioners and patients alike attribute the rising popularity of this treatment to its capabilities to provide solutions to the axiom of an aging face, where dermal, subcutaneous, and even osseous atrophic changes can be seen. It replaces the lost volume seen from these changes and attempts to restore some presence of youthfulness back into the patient; overall, it is part of a foundation that supports facial rejuvenation. In 2010, over 200 fillers from 60 different manufacturers were available worldwide. Although many seem to be similar to one another, there are crucial distinctions between the products that medical professionals must know for optimal use. Inexperienced practitioners that inappropriately substitute one product for the other only invite complications that ultimately lead to reduced patient satisfaction and patient safety. The ideal dermal filler is effective, easy to inject, nonreactive, has a low incidence of side effects, and is, most importantly, long-lasting. The need to fulfil the last criterion has propelled the advancement of cosmetic fillers into categories based on longevity; these categories include temporary, semi-permanent, and permanent. Permanent fillers provide excellent long-term results but carry more potential for adverse events and generally require a higher level of expertise for their administration. Furthermore, its complications, if they do occur, tend to be less forgiving than temporary or semi-permanent fillers because of the lack of degradation of these fillers, meaning they tend to remain intact inside the skin for a significantly longer time than other, less permanent fillers. As such, it is therefore vital that every aesthetic practitioner know the potential complications that can occur with treatment from permanent fillers and how to deal with them. This article will focus on these issues so that you may know how to advise your patient regarding this type of treatment.

Issues with permanent fillers

To help increase aspects of patient safety, rigorous clinical trials are required, as per the standards set by the FDA, to scrutinize all potential complications of a drug/treatment prior to its release to the general public. Due to the stringent requirements for approval by the FDA, permanent fillers are less likely to be found in North America. Bellafill is only one such permanent filler that has undergone this process to gain acceptance in the United States. In Europe on the other hand, the standards for the European Union differ insomuch that they require a CE certificate. This certificate concerns only the technical aspects of the manufacturing process, which means that the biological safety of the permanent filler is not taken into consideration. As you can imagine, the identification of the dermal filler complications can then only be done in a retrospective manner and only through anecdotal evidence. This difference explains why most reported permanent dermal filler complications come from Europe.

The increase in demand for long-lasting cosmetic fillers has made patient education an essential part of the treatment plan. Temporary cosmetic fillers are capable of being broken down and resorbed into the surrounding tissues in a relatively short amount of time, while permanent cosmetic fillers tend to resist being broken down. Due to this, permanent fillers are characterized by their irreversibility, even as the facial shape changes with age. They are able to achieve full and long-lasting correction but carry the risk of more severe and even permanent adverse effects. In addition, infection rates have been reported to be up to 19% for one particular permanent filler.

Complications of cosmetic fillers

However, all cosmetic fillers have adverse effects regardless of their duration of action. Generally, complications can be divided into early (immediate post-treatment to 14 days), late (14 days to one year), and delayed (more than one year) reactions. Early reactions common to injections are erythema, pain, edema, bruising, and bleeding. They are transient in nature, usually mild to moderate in severity, and lasts less than 14 days as mentioned above. They can be avoided with good injection technique and skilled maneuvering. More serious early complications are under- or over-correction, implant visibility, wrong tissue plane filler placement, infection, intravascular injection, and embolism resulting in blindness. While most of these can be mitigated with the administration of hyaluronidase if hyaluronic acid cosmetic fillers are used, permanent cosmetic fillers can result in permanence with any of these complications. The examples below are a list of complications that have been further elucidated so as to further expand this article’s discussion of the technicalities of permanent cosmetic fillers.


This is an iatrogenic complication that arises when too much permanent dermal filler has been placed in a particular area and when the degree of fibroplasia that will occur over time has been underestimated. These are common mistakes most inexperienced practitioners will make, as they may not know that permanent fillers depend mainly on volume replacement by fibroplasia over time. The soft tissue will be augmented beyond what is appropriate if permanent fillers are not placed in small amounts over multiple sessions whose intervals allowed adequate time for tissue augmentation to occur.

Direct arterial embolization:

This is a deadly consequence and occurs particularly in areas such as the glabellar supratrochlear arterial branches, labial artery, nasal dorsal artery, and the angular vessels along the nasolabial folds. Early manifestations are blanching and excessive pain. This complication is typically treated aggressively with vasodilating agents, such as nitroglycerin paste, for topical application.

Compromise of the venous circulation:

If large quantities of filler are deposited, it may displace and compromise blood vessels, such as the angular vessels. Symptoms such as dull aching pain, swelling, and a patchy violaceous discoloration of the skin can occur.


It should go without saying that care should be taken to ensure that both sides are augmented equally. However, in the case of permanent cosmetic fillers, this may be exceptionally challenging because they do not show an immediate volume correction. As such, awareness during product placement is essential. Allow adequate time to pass between injection sessions to help you avoid placing too much in one area.


This is a concern for all permanent cosmetic fillers where large injected volumes are concerned. The large volume increases the risk of the product tracking along the tissue planes, and the product can end up into distant body sites.

Contour and textural irregularities:

Permanent fillers best function when they are placed deeply into the deep reticular dermis, subcutaneous tissue, or deeper. In addition, the particulate component of a few permanent cosmetic fillers, such as polymethylmethacrylate (PMMA), and the acrylic hydrogels are not suitable for the smooth, soft, and pliable nature of superficial placements.

Foreign body granulomas and late-onset granulomas:

These are the most challenging complications to treat, and they are more prone with permanent cosmetic fillers. They are manifestations of the host’s natural immunologic response to a foreign body. It is characterized by macrophages and the formation of foreign body giant cells that arrive to both phagocytose the foreign material and deposit fibroblastic collagenous materials. In normal circumstances, it creates a controlled fibrous area around the filler material, and augmentation occurs in a controlled manner. If the fibroblastic response does not stop, however, it will manifest as a foreign body granulomatous complication.

Bacterial biofilms:

These are persistent subclinical infections of the surface of the permanent filler material. They are living colonies of bacteria that adhere to the foreign body surface (i.e. bolus of permanent filler) and are encapsulated by a protective matrix that avoids host immune response and antibiotics. These have also been involved in granuloma formation. They remain quiescent for months or years and can produce inflammatory and infectious processes.

Removing permanent fillers

In the case of removal of permanent fillers, consider minimally invasive techniques, such as needle aspiration, extrusion after incision, and liposuction, first. Surgical removal and laser destruction will be necessary if these prior modalities have been exhausted and the problematic area is still persistent. Keep in mind that complete removal of all filler particles may not be possible and that the best option is to reduce the incidence of recurrent biofilm infection. Permanent fillers are produced in discrete collections with capsule formation; hence, removal is easier in this regard, but there have been cases where removal can cause permanent damage to nearby structures. Also, introduction of infection during the removal process can lead to permanent scarring.

Depending on the area injected, removing through the complex anatomical regions of the face can be a daunting challenge for many practitioners. Extensive knowledge of the craniofacial region is essential in this process. Preoperative MRI with contrast can help determine the exact site to be removed and the method of removal (e.g. open or surgical needle, stab incision expression). An experienced radiologist can help guide approaches of incisions into the filler targets and can demonstrate that a complete-as-possible filler removal was performed.


You must grasp that all cosmetic fillers are not created equal and that treating the aging face requires tactful management so that you deliver desired outcomes to your patients Any cosmetic may cause the filler complications as mentioned above. The increasing use of these fillers and its expansion into the cosmetic industry has demanded that practitioners be versatile and knowledgeable. Indeed, the modern aesthetic practitioner must be aware of these possibilities and recognize the products, complications, and treatment strategies. Surgical costs of removing the fillers are also higher than the initial injection procedure. Most patients are not aware of these implications; therefore, it falls onto the duties of the medical professional to inform patients and bring their expectations in line.


  • Lim LM, Dang JM, et al. ‘Dermal Filler Devices Executive Summary,’ FDA, (2018) ac/08/briefing/2008-4391b1-01%20-%20fda%20executive%20 summary%20dermal%20fillers.pdf
  • Nadarajah JT, Collins M, Raboud J, Su D, et al., ‘Infectious Complications of Bio-Alcamid Filler Used for HIV-related Facial Lipoatrophy’, Clin Infect Dis (2012); 55(11): pp.1568-74.
  • Salati SA & Al Aithan B, ‘Complications of Cosmetic fillers – An Experience from Middle East’, Journal of Pakistan Association of Dermatologists, (2012); pp.22:12-18
  • Sclafani AP & Fagien S, ‘Treatment of Injectable Soft Tissue Filler Complications’, Dermatol Surg (2009); 35: pp.1672-1680.
  • Lloyd’s Register Quality Assurance, (2016), medical-devices/regulation
  • Medicines and Healthcare products Regulatory Agency and Department of Health, ‘Medical devices regulation and safety’, 2015, medical-devices-regulation-safety
  • Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg 2010;26:289e91.
  • Kim YJ, Choi KS, ‘Bilateral blindness after filler injection’, Plast Reconstr Surg, 131(2013).
  • Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S, ‘Blindness following cosmetic injections of the face’, Plast Reconstr Surg, 129(2012).
  • Bray D, Hopkins C, & Roberts DN, ‘A review of cosmetic fillers in facial plastic surgery Current Opinion in Otolaryngology & Head and Neck Surgery’, 18(2010),pp.295–302.
  • Wu H, Moser C, Wang H, Høiby N & Song Z, ‘Strategies for combating bacterial biofilm infections International Journal of Oral Science’, 7(2014) pp.1–7.
  • Medicines & Healthcare products Regulatory Agency (2016),
  • FDA, ‘Soft Tissue Fillers Approved by the Center for Devices and Radiological Health,’ FDA, 2015, http://www. CosmeticDevices/WrinkleFillers/ucm227749.htm
  • GMC, ‘Guidance for all doctors who offer cosmetic interventions’, General Medical Council, (2016), http://www.
  • RCS, ‘Professional Standards for Cosmetic Practice’, Royal College of Surgeons, docs/professional-standards-for-cosmetic-surgery 
  • Khetarpal S, Dover JS. Complications of permanent fillers. (ed). Soft Tissue Augmentation: Procedures in Cosmetic Dermatology Series, 4th ed. Elsevier; 2018. pp. 203-214.

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