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Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1347-1351

Complicated facial filler management by facelift

Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission02-May-2020
Date of Decision25-May-2020
Date of Acceptance05-Jun-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Mohamed A El-Nahas
MD, Shebin El Kom, Menoufia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_142_20

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The aim was to study and evaluate the role of facelift technique in the management of complications of permanent facial filler.
Facial filler complications vary from skin discoloration in the form of hyperemia, hyperpigmentation, or nodule, which may be due to accumulated filler or granulomatous reaction. Complicated patients show symptoms of abnormal skin texture and facial deformities. Treatment of these conditions in the form of drainage, excision, or intralesional laser is usually unsatisfactory.
Patients and methods
The idea of this method is to expose and radically resect all nodules with draining any fluid filler which is present in the subcutaneous layer of the face. This is achieved by facelift exposure, and after proper wash of the field, the facial skin is re-draped.
A total of seven patients with complicated filler have been treated by this technique. The operation is more difficult than ordinary facelift owing to difficult dissection in the presence of fibrosis, nodules, and scars. Moreover, the postoperative bleeding and edema are more than those seen in ordinary facelift. There were two (28%) cases of hematomas, which required evacuation in office. Paresis of the left frontal branch occurred in one (14%) patient and improved after 7 months (P = 0.013). However, there was marked improvement in the facial contour and skin quality.
The use of the facelift technique as a surgical tool to treat major complications of multiple fillers in the face has proved to be a very satisfactory method, despite being more difficult than the ordinary facelift surgery in facial rejuvenation.

Keywords: face rejuvenation, facelift, filler

How to cite this article:
El-Nahas MA, Ghareeb FM. Complicated facial filler management by facelift. Menoufia Med J 2020;33:1347-51

How to cite this URL:
El-Nahas MA, Ghareeb FM. Complicated facial filler management by facelift. Menoufia Med J [serial online] 2020 [cited 2021 Apr 19];33:1347-51. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1347/304484

  Introduction Top

The use of filler to enhance soft-tissue volumes and fill subcutaneous defects is the second most frequently performed aesthetic procedure (after botulinum toxin type A) in the United States[1]. The type of filler may be resorbable materials (e.g., hyaluronic acid), which are more common, or permanent materials[2]. There are many complications and adverse effects that occur after using filler as not all faces can accept such materials easily. Many of these complications can be self-resolved, but some of them require interference[3].

Facial filler complications manifest in different ways: they can produce skin discoloration in the form of hyperemia or hyperpigmentation or can produce nodules, which may be owing to accumulated filler or granulomatous reaction. Filler can also cause infection and abscess formation[4].

Long-standing inflammatory reaction especially after multiple filler injection represents the most common annoying complication to patients, as it rarely resolves spontaneously, with the possibility of ill-defined immune reaction to the alloplastic substances[5].

The inflammatory complications after using non-resorbable filler injections are called granulomas, which appear as lumps or nodules after injection of different materials and show (microscopically) a foreign body reaction consisting of protein absorption, macrophages, multinucleated foreign body giant cells (macrophage fusion), fibroblasts, and angiogenesis[6]. Biofilm formation is incriminated with the infection and theoretically with late immune reaction producing granulomas. All fillers (i.e., hyaluronic acid, polyacrylamide gel, and poly-l-lactic acid) supported the growth of Staphylococcus. epidermidis biofilm in vitro [7]. These lesions are challenging to be treated, as they present with symptoms of abnormal skin texture and facial deformities in the form of facial irregularities, swellings, and depressions. Among described therapeutic approaches are systemic antibiotics and anti-inflammatory drugs, intralesional corticosteroid and 5-fluorouracil injection, needle aspiration surgical drainage, and excision[8].

These methods (drainage, excision, or intralesional laser) are usually unsatisfactory in patients who have relatively big quantities and different kinds of fillers in multiple sittings in different areas of the face. The aim of this study was to provide a treatment modality that allows radical exposure and excision of all granulomas and drain all fluid fillers through facelift incision. This technique also causes marked improvement in facial contour and skin quality.

The aim of this study was to study and evaluate the role of facelift technique in management of complications of permanent facial filler.

  Patients and methods Top

First the approval of Menoufia Ethics Committee for the study proposal was taken. In the period between 2018 and May 2019, seven patients presented with complaints of generalized facial deformities in the form of swellings, depressions, and facial contour abnormalities after repeated sessions of filler injections.

All these patients were women. Patient's history was taken, documenting onset of adverse events, medications, and earlier treatment regimens and the presenting complaints. All the information about the type of filler, the amount, the injection technique, the location of the product, and the presence of an acute inflammatory reaction was documented.

The onset of the injection of the filler ranged from 2 to 3 years, and the time of granuloma appearance is after 1 year for the most rapid patient and 2 years for the delayed one; the granuloma appears in all sites that have been injected.

All patients gave informed consent for the treatment performed after explaining the procedure and possible complications. The patient was well prepared preoperatively by drainage of any infection, under the coverage of antibiotic only for the three patients who presented with the signs of infection and downsizing of granulomas by local cortisone (triamcinolone injection) and stopping of smoking, aspirin, or alcohol.

Operative procedures

Preoperative marking of the lesions and the facelift incision site was done. Overall, five cases were treated by preauricular and postauricular incisions and two patients were treated by the S-shaped facelift. The location of nodules in the face was marked before the subcutaneous injection of saline/adrenaline (1/200 000) at the incision site and in the area of facial dissection, after waiting for 10 min to allow the vasoconstrictive effect of adrenaline to occur. Meticulous subcutaneous dissection through subaponeurotic plane was done after that to the area of all nodules clinically present in the patient and also to allow good exposure. All the cysts and nodules were radically resected, and then drainage of any fluid filler that is present in the subcutaneous layer of the face was done, and every material was sent for bacteriological study. Finally, proper wash of the field was done, and the facial skin is re-draped. A suction drain is inserted, and bandages were applied.

Postoperative treatment

Patients were instructed to apply frequent lukewarm saline compresses. Frequent gentle squeezing of the treated area is recommended to ensure continuous drainage of the liquefied foreign material and necrotic inflammatory tissue. Oral second-generation cephalosporin antibiotic treatment is recommended in all patients. Patients were photographed at first consultation, early postoperatively in the third and seventh days, and after 3 and 6 months.

After healing is complete, we started facial massage and lymphatic drainage by physiotherapist to reduce edema and indurations. Cosmetic and functional results, adverse events episodes, and patient satisfaction were evaluated early postoperatively after 1 month and late postoperatively 6 months after the surgery. Results have been classified into three categories according to the patient satisfaction and surgeon judgement (marked, moderate and poor improvement).

Statistical analysis

All data were collected, tabulated and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for windows (MedCalc Software BVBA, Ostend, Belgium).

Quantitative data were expressed, for example, percentage, mean, and SD by applying descriptive statistics. P less than 0.05 is set to be significant.

  Results Top

Patient demography

The ages varied from 35 to 49 years. All the patients are females (100%). Tobacco smoking was identified in four (57%) cases, none was diabetic, three patients had hyperimmune reactions in the form of skin allergy and bronchial asthma. Patients' data are shown in [Table 1].
Table 1: Patient data

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Characteristics of the lesions

[Figure 1]a and [Figure 2]a show that all the patients were characterized by the presence of facial contour deformities especially in the cheek areas and the joules, and also there were nodules and granulomas, which were more than two in all cases. Three of our patients came with inflammatory signs (redness, hotness, tenderness, and edema) and symptoms (pain), whereas the other four patients came without any inflammatory changes. The position of the nodules was mainly in the malar and periorbital area where couscous dissection was done intraoperatively to avoid injury of facial nerve branches. Two patients had depressed scars after drainage. In five patients, the skin color is dusky, and there is skin laxity, and on palpation, there is abnormal doughy sensation.
Figure 1: (a) Preoperative photograph showing nodular lesions of malar area and upper lip; (b) facelift incision; (c) late postoperative photograph.

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Figure 2: a) Preoperative photograph showing nodular swelling periocular and in malar area; (b) late postoperative edema; (c) preoperative and postoperative photographs of a patient.

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Surgical details

The operation is more difficult than ordinary facelift owing to difficult dissection in the presence of fibrosis, cysts and nodules, and skin scars. We have chosen the usual preauricular and postauricular facelift incision in five cases when preoperatively the facial figure has improved by posterior and upward finger traction of facial skin and there was more neck laxity. However, the inverted S-shaped incision was used in two cases where the neck was not very lax, and by preoperative examination, the facial figure improved better by vertical upward finger traction.

Postoperative details

Regarding postoperative complications, there were hematomas in two (28%) cases managed by evacuation in office. Paresis of the left frontal branch occurred in one (14%) patient, which improved after 7 months.

The striking feature in the postoperative period was the massive edema in more than three patients which resolved completely afterward. We think that this is owing to lymphatic obstruction by the filler migration and chronic inflammatory reaction [Figure 2]b. There were no infections, widened or hypertrophic scars, loss of hair, and skin necrosis recorded in any patient. Postoperative complications data are shown in [Table 2]. All patients were followed up postoperatively for a period of up to 6 months and were evaluated according to the final result from the functional and aesthetic point of view. Also, patient satisfaction after the operation has been evaluated by examination of the facial contour, presence of nodules, and facial skin asymmetry. A total of six (86%) patients had shown marked improvement, one (14%) patient had shown moderate improvement, and one patient needed facial fat graft to correct mild facial asymmetry 1 year after surgery.
Table 2: Postoperative complication data

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Case demonstration

Case demonstration incudes two patients: the first patient is a 39-year-old woman who presented with nodular lesions of malar area and upper lip [Figure 2]a, [Figure 2]b, [Figure 2]c, and the second patient is a 45 year-old woman who presented with nodular swelling periocular and in malar area [Figure 2]a,[Figure 2]b,[Figure 2]c.

  Discussion Top

Injection of the dermal fillers has become one of the most popular procedures in cosmetic surgery, which in its ideal form should be associated with few adverse effects that decrease and get better with time[9]. Multiple injections of filler may be complicate by facial deformities and abnormal skin texture. Treatment of these complicated cases requires a radical procedure that allows resection of the nodules and that what our technique provides. Treatment of these conditions in the form of drainage, excision, or intralesional laser is usually unsatisfactory. In 2009, a small number of patients (n = 20) complaining of inflammatory reactions, visible lumps and nodules, dislocation, and accumulation of the product, treated with intralesional laser treatment, were described by Cassuto et al.[10]. In 2016, the same authors published an article regarding a large number of treated patients (n = 219) who experienced an improvement of their complaints[3]. Almost all patients noted an improvement after intralesional laser treatment, although not always as much as they hoped for[11]. Moreover, fillers injected in the orbital region are more difficult to remove, leading to less satisfactory results[11]. Our technique of using facelift incision after good preparation of the patient in the form of stop smoking, alcohol, and intralesion injection of cortisone (triamcinolone injection) for three times between 2 weeks apart and at least 1 month before the surgery downsizes the granulomatous lesions, leaving only the filler increments, and decreases the chances of excision of normal tissues. Moreover, it leads to good visualization of all nodules and cysts, facilitating radical resection and proper wash of the field. Preoperative antibiotics are mandatory in our protocol, as we agree with other authors who documented the role of bacterial biofilms in adverse nodular reactions following treatment with filler injections, which leads to facial deformities[12],[13]. Moreover, experimental studies have shown that filler (i.e., hyaluronic acid, polyacrylamide gel, and poly-l-lactic acid) can support the growth of bacteria (S. epidermidis biofilm) in vitro. We make sure that it was inflammatory granuloma by histopathological examination of all nodules after we excised them as a biopsy in all of our cases. We are now more convinced that hyperimmune reaction mechanisms can cause granuloma formation after filler injection, as three of our patients (43%) had hyperimmune systems manifested by allergic skin conditions and bronchial asthma. The time of granuloma appearance, which was at least 1 year after filler injection, makes us sure that it is not a delayed-type hypersensitivity reaction, which was also confirmed by histopathological examination. Our study also has shown a striking feature in the postoperative period which is the massive edema in more than three patients which resolved completely afterward. We think that this is owing to lymphatic obstruction by the filler migration and chronic inflammatory reaction. We also think that facial massage and lymphatic drainage by physiotherapist is very helpful to reduce edema and indurations after these surgery, especially after having patients with massive postoperative facial edema. The skin quality improved very much in our patient regarding the color and texture, which was a bonus for the good results of these procedure.

  Conclusion Top

The use of the facelift technique as a surgical treatment provides a very useful and satisfactory method for patients complaining of facial deformities after repeated filler injection. Although the operation is difficulty than the ordinary facelift surgery and takes longer postoperative recovery time, if the patients are selected well with good preoperative preparation of the patients and efficient postoperative care, the patients show marked improvement in shape facial contour and skin quality.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rohrich RJ. Advances in facial rejuvenation: botulinum toxin A. Hyaluronic acid dermal fillers, and combination therapies – consensus recommendations. Editor's Foreword. Plast Reconstr Surg 2008; 121:1–2.  Back to cited text no. 1
Bergeret-Galley C, Latouche X, Illouz YG. The value of a new filler material in corrective and cosmetic surgery: DermaLive and DermaDeep. Aesthetic Plast Surg 2001; 25:249–255.  Back to cited text no. 2
Cassuto D, Pignatti M, Pacchioni L, Boscaini G, Spaggiari A, De Santis G. Management of complications caused by permanent fillers in the face: a treatment algorithm. Plast Reconstr Surg 2016; 138:215–227.  Back to cited text no. 3
Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol 2013; 6:295–316.  Back to cited text no. 4
Nicolau PJ. Long-lasting and permanent fillers: biomaterial influence over host tissue response. Plast Reconstr Surg 2007; 119:2271–2286.  Back to cited text no. 5
Christensen L, Breiting V, Janssen M, Vuust J, Hogdall E. Adverse reactions to injectable soft tissue permanent fillers. Aesthetic Plast Surg 2005; 29:34–48.  Back to cited text no. 6
Saththianathan M, Johani K, Taylor A, Hu H, Vickery K, Callan P, et al. The role of bacterial biofilm in adverse soft-tissue filler reactions: a combined laboratory and clinical study. Plast Reconstr Surg 2017; 139:613–621.  Back to cited text no. 7
Conejo-Mir JS, Guirado SS, Munoz MA. Adverse granulomatous reaction to Artecoll treated by intralesional 5-fluorouracil and triamcinolone injections. Dermatol Surg 2006; 32:1079–1081.  Back to cited text no. 8
Broder KW, Cohen SR. An overview of permanent and semipermanent fillers. Plast Reconstr Surg 2006; 118:7–14.  Back to cited text no. 9
Cassuto D, Marangoni O, De Santis G, Christensen L. Advanced laser techniques for filler-induced complications. Dermatol Surg 2009; 35:1689–1695.  Back to cited text no. 10
Schelke LW, Decates TS, van der Lugt CI, Pelzer L, de Mey G, Velthuis PJ. Intralesional laser treatment for dermal filler complications. Plast Reconstr Surg 2018; 141:1361–1369.  Back to cited text no. 11
Marusza W, Mlynarczyk G, Olszanski R, Netsvyetayeva I, Obrowski M, Iannitti T, et al. Probable biofilm formation in the cheek as a complication of soft tissue filler resulting from improper endodontic treatment of tooth 16. Int J Nanomed 2012; 7:1441–1447.  Back to cited text no. 12
Rohrich RJ, Monheit G, Nguyen AT, Brown SA, Fagien S. Soft-tissue filler complications: the important role of biofilms. Plast Reconstr Surg 2010; 125:1250–1256.  Back to cited text no. 13


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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