Preventing the Complications Associated with the Use of Dermal Fillers in Facial Aesthetic Procedures: An Expert Group Consensus Report

Abstract

Background: The use of dermal fillers in minimally invasive facial aesthetic procedures has become increasingly popular of late, yet as the indications and the number of procedures performed increase, the number of complications is also likely to increase. Paying special attention to specific patient characteristics and to the technique used can do much to avoid these complications. Indeed, a well-trained physician can also minimize the impact of such problems when they do occur.

Methods: A multidisciplinary group of experts in aesthetic treatments reviewed the main factors associated with the complications that arise when using dermal fillers. A search of English, French and Spanish language articles in PubMed was performed using the terms "complications" OR "soft filler complications" OR "injectable complications" AND "dermal fillers". An initial document was drafted that reflected the complications identified and recommendations as to how they should be handled. This document was then reviewed and modified by the expert panel, until a final text was agreed upon and validated.

Results: The panel addressed consensus recommendations about the preparation, the procedure and the post-procedural care. The panel considered it crucial to obtain an accurate medical history to prevent potential complications. An additional clinical assessment, including standardized photography, is also crucial to evaluate the outcomes and prevent potential complications. Furthermore, the state of the operating theatre, the patient's health status and the preparation of the skin are critical to prevent superficial soft tissue infections. Finally, selecting the appropriate technique, based on the physician's experience, as well as the characteristics of the patient and filler, helps to ensure successful outcomes and limits the complications.

Conclusions: This consensus document provides key elements to help clinicians who are starting to use dermal fillers to employ standard procedures and to understand how best to prevent potential complications of the treatment.

Level of evidence v: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Keywords: Aesthetic procedures; Complications; Dermal fillers; Prevention.

Fig. 1

Flow diagram of the consensus process

Fig. 2

Different divisions of the face. a Division of the face into vertical fifths. 1: Pa right–Ex right, 2: Ex right–En right, 3: En right–En left, 4: En left–Ex left, 5: Ex left–Pa left. b Division of the face into horizontal thirds. 1 upper third: Tr–Gl, 2 middle third: Gl–subN, 3 lower third: subN–Me. Pa postaurale, Ex exocanthion, En endocanthion, Tr trichion, Gl glabella, Me menton, SubN subnasale

Fig. 3

Soft tissue points that can be used to obtain face measurements (adapted from Milutinovic et al. [20]). Soft tissue points from top to bottom: trichion (Tr): the beginning of the forehead when one lifts the eyebrow, glabella (Gl): the most prominent point of the forehead at the superior aspect of the eyebrows, postaurale (Pa): the most posterior point on the helix (outer rim of the ear), lateral canthus (LC): lateral canthus of the eye, exocanthion (Ex): the most lateral point of the palpebral fissure at the outer canthus of the eye, endocanthion (En): the most medial point of the palpebral fissure at the inner canthus of the eye, lateral cheek (Lchk): lateral border of the cheeks, lateral nose (Ln): lateral side of the nose, subnasale (SubN): the point in the midsagittal plane where the nasal septum merges into the upper lip, stomion (Sto): the midpoint of the intralabial fissure, cheilion (Ch): the corner of the mouth, menton (Me): the most inferior point on the soft tissue chin

Fig. 4

Different parameters to calculate the length of the face (adapted from Milutinovic et al. [20]). Facial measures (Fig. 1a, b): (Tr–Me): height of the face. (Lchk right–Lchk left): width of the face. (Me–Sto): the lowest point on the chin, and the point where the upper and lower lip merge. (Sto–LC): the point where the upper and lower lip merge, and corner of the eye. (Me–Ln): the lowest point on the chin and the outer edge of the nostril. (Ln–Tr): the outer edge of the nostril and highest point of the forehead

Fig. 5

The Mid-Face Volume Deficit Scale was designed to evaluate the overall volume deficit of the mid-face, from 0 [none] to 6 or severe