Delayed-onset Nodules (DONs) and Considering their Treatment following use of Hyaluronic Acid (HA) Fillers (original) (raw)
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Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections
Aesthetic Surgery Journal
Background The pathogenesis of delayed onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain. Objectives To formulate a rational theory for DTN development and their avoidance and treatment. Methods A multi-disciplinary and multi country DTN consensus panel was established with 20 questions posed and consensus sought. Consensus was set at 75% agreement. Results Consensus was reached in 16/20 questions regarding the pathogenesis of DTNs forming the basis of a classification and treatment guide. Conclusions The group believe that filler, pathogens and inflammation are all involved in DTNs and that DTNs most likely are infection initiated with a variable immune response. Injected filler may incorporate surface bacteria, either a commensal or a true pathogen if the skin barrier is altered. The initially High molecular weight HA (HMWHA) filler is degraded to Low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus ...
Clinical, Cosmetic and Investigational Dermatology, 2020
Background and Objectives: There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose. Materials and Methods: A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists. Results: Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3-6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement. Conclusion: A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.
Clinical, Cosmetic and Investigational Dermatology
Background and Objectives: There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose. Materials and Methods: A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists. Results: Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3-6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement. Conclusion: A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.
Plastic and Reconstructive Surgery, 2013
he aesthetic use of soft-tissue fillers has grown significantly over the past several years. Throughout this period, hyaluronic acid has remained the most popular product. The American Society for Aesthetic Plastic Surgery reported in its annual survey that the number of hyaluronic acid filler procedures was second only to the number of botulinum toxin type A injections and that over 1.4 million hyaluronic acid filler procedures were performed in 2012. 1 Calcium hydroxylapatite filler is also growing in popularity and is often combined with hyaluronic acid fillers. All hyaluronic acid and calcium hydroxylapatite fillers in current use in the United States and Europe are nonanimal derived.
Practical Approach and Safety of Hyaluronic Acid Fillers
Plastic and reconstructive surgery. Global open, 2019
Soft-tissue filler use has grown considerably related to the increasing popularity of minimally invasive cosmetic procedures. Hyaluronic acid products are currently the most utilized soft-tissue fillers. Proper working knowledge of individual products, limitations to use, and anatomic principles can improve outcomes. Prevention is key to minimize complications; however, when present, complications must be managed methodically. Complications are categorized based on the timing of presentation and include early, late, and delayed. Vascular compromise and tissue necrosis are among the most devastating complications seen with filler use. Nodules can be related to an inflammatory or infectious etiology but should be distinguished as treatment varies. Hyaluronidase is mandatory to have available as a reversal agent for hyaluronic acid products and can be used in treatment for many complications and untoward sequela.
Etiology of delayed inflammatory reaction induced by hyaluronic acid filler
Archives of Plastic Surgery
The etiology and pathophysiology of delayed inflammatory reactions caused by hyaluronic acid fillers have not yet been elucidated. Previous studies have suggested that the etiology can be attributed to the hyaluronic acid filler itself, patient immunological status, infection, and injection technique. Hyaluronic acid fillers are composed of high-molecular-weight hyaluronic acids that are chemically crosslinked using substances such as 1,4-butanediol diglycidyl ether (BDDE). The mechanism by which BDDE crosslinks the two hyaluronic acid disaccharides is still unclear and it may exist as a fully reacted crosslinker, pendant crosslinker, deactivated crosslinker, and residual crosslinker. The hyaluronic acid filler also contains impurities such as silicone oil and aluminum during the manufacturing process. Impurities can induce a foreign body reaction when the hyaluronic acid filler is injected into the body. Aseptic hyaluronic acid filler injections should be performed while considerin...
Aesthetic Surgery Journal
Background Hyaluronic acid (HA) dermal filler injection is believed to be a safe procedure. However, with the increase in the number of performed procedures and indications, the number of product-related complications, especially delayed inflammatory reactions, has also increased. Delayed-type hypersensitivity (DTH) reaction is one of these delayed inflammatory reactions, which is preventable by performing a pretreatment skin test. Objectives To find the incidence of delayed inflammatory reactions and DTH reaction after HA injection and to determine whether a pretreatment skin test is worthwhile to be performed. Methods A systematic literature review of all the relevant prospective studies, retrospective studies, and case reports on delayed inflammatory reactions and DTH reaction after HA filler injection. Results The incidence of delayed inflammatory reactions calculated from the prospective studies was 1.1% per year, and that of possible DTH reaction was 0.06% per year. Most retro...