Soft tissue augmentation is a common procedure performed by dermatologists to address many patient concerns such as aging, loss of volume, scarring, tear trough hollowing, lip thinning, asymmetry, and hand rejuvenation.
Compared with cosmetic surgery, soft tissue augmentation is an affordable minimally-invasive procedure with little to no downtime. In the 2016 report log by the American Society of Plastic Surgery, soft tissue augmentation with fillers ranked second in number of cosmetic procedures after botulinum toxin type A injection with more than 2.6 million treatments performed.1 Even though soft tissue augmentation is a safe procedure, it can still present complications. In this article, we present a case of a patient with a nodule on the nasolabial fold after injection of a hyaluronic acid (HA) filler.
Case
A 46-year-old woman presented to our practice with an erythematous nodule on the left nasolabial fold after receiving an HA (Restylane) injection 2 months prior by an injector at another practice. The patient stated that 2 weeks after the procedure, she noticed the area became progressively swollen and painful and drained a yellowish discharge. She went to an urgent care center and was given a 2-week course of clindamycin and amoxicillin clavulanic that decreased the size of the nodule and improved the pain. However, 2 days after finishing the antibiotics, the area became swollen, painful, and started to drain again. She then consulted another practitioner who prescribed oral ciprofloxacin for 10 days followed by intramuscular ceftriaxone (Rocephin) and vancomycin with the same response.
Figures 1. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules.
The patient had onabotulinumtoxin A (Botox) in the past but denied the use of previous fillers. She denied any medical problems or allergies. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules (Figure 1). No discharge was present but the area was very tender to palpation. Incision and drainage was attempted and was unsuccessful. A bacterial culture was taken from the area which was negative for growth. An injection of 0.1 cc of 10 mg/cc intralesional triamcinolone was administered followed by 0.1 cc of hyaluronidase. The patient was also given cephalexin, 500 mg twice daily for 2 weeks. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted. This will be addressed in her next appointment in 1 month (Figure 2).
Figures 2. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted which will be addressed in her next appointment in 1 month.
Discussion
Soft tissue augmentation is a very desirable cosmetic procedure because it is fast, effective, and has relatively few complications. Because these procedures are increasing in numbers, the dermatologist should be familiar with the potential side effects and how to prevent and to treat them to improve patient safety and satisfaction. Early complications include edema, injection associated discomfort, bruising, and erythema, and they are usually self-limited, resolving within 1 week.2
Among the most serious acute complications are the ones related to vascular occlusion and nerve damage. They can be avoided with skillful technique and knowledge of the anatomic area where the procedure is performed.3
Another complication that can be seen after soft tissue augmentation is nodule formation. The etiology of nodules can can be divided into 2 categories: inflammatory and noninflammatory. Inflammatory nodules are either a result of an infection (biofilms) or foreign body granulomas. Noninflammatory nodules are secondary to the material injected too superficially and are evident shortly after the procedure. Hyaluronidase is the treatment of choice if the filler is HA. If other material is used, they can respond to vigorous massage or potentially extrusion of the material.4 Even though inflammatory nodules have 2 different etiologies, it can be difficult to elucidate its real cause. Foreign body granulomas are an uncommon complication of this procedure, with a rate of approximately 0.4% for HAs and 0.001% for calcium hydroxyapatite.5
Typically, they are treated with intralesional steroids and hyaluronidase with good resolution. If no clinical response is seen, a biofilm should be suspected and the patient should be placed on broad-spectrum antibiotics for a minimum of 4 weeks that include quinolones and macrolides.4 Biofilms are microenvironments that are formed around the filler by the adjacent bacteria, they elaborate extracellular matrix of exopolysaccharides that also include HA. The bacteria adhere to this matrix protecting it from antibiotics.6,7 When a biofilm is present, it usually will not render any result on the bacterial culture making the diagnosis difficult. Besides antibiotics, hyaluronidase should be used in these cases along with antibiotics to disrupt the protective microenvironment.7
Our Patient
In our patient, even though the nodules had been there for 2 months, they resolved with intralesional triamcinolone and hyaluronidase, making the diagnosis of noninflammatory nodules more plausible. To prevent biofilms, it is critical to undergo thorough cleaning of the patient’s face before the procedure, avoid injection in areas that may be swollen or infected, reduce the amount of needle sticks, and use the smallest sized needle.3
Soft tissue augmentation is a common procedure for dermatologists. Serious complications are very uncommon, however, knowledge of how to prevent and to treat them is paramount.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Micrographic Surgery and Procedural Dermatology Fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and a practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Plastic surgery statistics. American Society of Plastic Surgeons website. https://www.plasticsurgery.org/news/plastic-surgery-statistics. Accessed June 22, 2017.
2. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications of dermal fillers. Semin Plast Surg. 2016;30(2):83-86.
3. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-1121.
4. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;12(6):295-316.
5. Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures. J Am Acad Dermatol. 2015;73(1):15-24.
6. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J. 2013;33(4):561-575.
7. Beer K, Avelar R. Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations. Dermatol Surg. 2014;40(11):1175-1179.
Soft tissue augmentation is a common procedure performed by dermatologists to address many patient concerns such as aging, loss of volume, scarring, tear trough hollowing, lip thinning, asymmetry, and hand rejuvenation.
Compared with cosmetic surgery, soft tissue augmentation is an affordable minimally-invasive procedure with little to no downtime. In the 2016 report log by the American Society of Plastic Surgery, soft tissue augmentation with fillers ranked second in number of cosmetic procedures after botulinum toxin type A injection with more than 2.6 million treatments performed.1 Even though soft tissue augmentation is a safe procedure, it can still present complications. In this article, we present a case of a patient with a nodule on the nasolabial fold after injection of a hyaluronic acid (HA) filler.
Case
A 46-year-old woman presented to our practice with an erythematous nodule on the left nasolabial fold after receiving an HA (Restylane) injection 2 months prior by an injector at another practice. The patient stated that 2 weeks after the procedure, she noticed the area became progressively swollen and painful and drained a yellowish discharge. She went to an urgent care center and was given a 2-week course of clindamycin and amoxicillin clavulanic that decreased the size of the nodule and improved the pain. However, 2 days after finishing the antibiotics, the area became swollen, painful, and started to drain again. She then consulted another practitioner who prescribed oral ciprofloxacin for 10 days followed by intramuscular ceftriaxone (Rocephin) and vancomycin with the same response.
Figures 1. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules.
The patient had onabotulinumtoxin A (Botox) in the past but denied the use of previous fillers. She denied any medical problems or allergies. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules (Figure 1). No discharge was present but the area was very tender to palpation. Incision and drainage was attempted and was unsuccessful. A bacterial culture was taken from the area which was negative for growth. An injection of 0.1 cc of 10 mg/cc intralesional triamcinolone was administered followed by 0.1 cc of hyaluronidase. The patient was also given cephalexin, 500 mg twice daily for 2 weeks. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted. This will be addressed in her next appointment in 1 month (Figure 2).
Figures 2. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted which will be addressed in her next appointment in 1 month.
Discussion
Soft tissue augmentation is a very desirable cosmetic procedure because it is fast, effective, and has relatively few complications. Because these procedures are increasing in numbers, the dermatologist should be familiar with the potential side effects and how to prevent and to treat them to improve patient safety and satisfaction. Early complications include edema, injection associated discomfort, bruising, and erythema, and they are usually self-limited, resolving within 1 week.2
Among the most serious acute complications are the ones related to vascular occlusion and nerve damage. They can be avoided with skillful technique and knowledge of the anatomic area where the procedure is performed.3
Another complication that can be seen after soft tissue augmentation is nodule formation. The etiology of nodules can can be divided into 2 categories: inflammatory and noninflammatory. Inflammatory nodules are either a result of an infection (biofilms) or foreign body granulomas. Noninflammatory nodules are secondary to the material injected too superficially and are evident shortly after the procedure. Hyaluronidase is the treatment of choice if the filler is HA. If other material is used, they can respond to vigorous massage or potentially extrusion of the material.4 Even though inflammatory nodules have 2 different etiologies, it can be difficult to elucidate its real cause. Foreign body granulomas are an uncommon complication of this procedure, with a rate of approximately 0.4% for HAs and 0.001% for calcium hydroxyapatite.5
Typically, they are treated with intralesional steroids and hyaluronidase with good resolution. If no clinical response is seen, a biofilm should be suspected and the patient should be placed on broad-spectrum antibiotics for a minimum of 4 weeks that include quinolones and macrolides.4 Biofilms are microenvironments that are formed around the filler by the adjacent bacteria, they elaborate extracellular matrix of exopolysaccharides that also include HA. The bacteria adhere to this matrix protecting it from antibiotics.6,7 When a biofilm is present, it usually will not render any result on the bacterial culture making the diagnosis difficult. Besides antibiotics, hyaluronidase should be used in these cases along with antibiotics to disrupt the protective microenvironment.7
Our Patient
In our patient, even though the nodules had been there for 2 months, they resolved with intralesional triamcinolone and hyaluronidase, making the diagnosis of noninflammatory nodules more plausible. To prevent biofilms, it is critical to undergo thorough cleaning of the patient’s face before the procedure, avoid injection in areas that may be swollen or infected, reduce the amount of needle sticks, and use the smallest sized needle.3
Soft tissue augmentation is a common procedure for dermatologists. Serious complications are very uncommon, however, knowledge of how to prevent and to treat them is paramount.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Micrographic Surgery and Procedural Dermatology Fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and a practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Plastic surgery statistics. American Society of Plastic Surgeons website. https://www.plasticsurgery.org/news/plastic-surgery-statistics. Accessed June 22, 2017.
2. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications of dermal fillers. Semin Plast Surg. 2016;30(2):83-86.
3. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-1121.
4. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;12(6):295-316.
5. Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures. J Am Acad Dermatol. 2015;73(1):15-24.
6. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J. 2013;33(4):561-575.
7. Beer K, Avelar R. Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations. Dermatol Surg. 2014;40(11):1175-1179.
Soft tissue augmentation is a common procedure performed by dermatologists to address many patient concerns such as aging, loss of volume, scarring, tear trough hollowing, lip thinning, asymmetry, and hand rejuvenation.
Compared with cosmetic surgery, soft tissue augmentation is an affordable minimally-invasive procedure with little to no downtime. In the 2016 report log by the American Society of Plastic Surgery, soft tissue augmentation with fillers ranked second in number of cosmetic procedures after botulinum toxin type A injection with more than 2.6 million treatments performed.1 Even though soft tissue augmentation is a safe procedure, it can still present complications. In this article, we present a case of a patient with a nodule on the nasolabial fold after injection of a hyaluronic acid (HA) filler.
Case
A 46-year-old woman presented to our practice with an erythematous nodule on the left nasolabial fold after receiving an HA (Restylane) injection 2 months prior by an injector at another practice. The patient stated that 2 weeks after the procedure, she noticed the area became progressively swollen and painful and drained a yellowish discharge. She went to an urgent care center and was given a 2-week course of clindamycin and amoxicillin clavulanic that decreased the size of the nodule and improved the pain. However, 2 days after finishing the antibiotics, the area became swollen, painful, and started to drain again. She then consulted another practitioner who prescribed oral ciprofloxacin for 10 days followed by intramuscular ceftriaxone (Rocephin) and vancomycin with the same response.
Figures 1. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules.
The patient had onabotulinumtoxin A (Botox) in the past but denied the use of previous fillers. She denied any medical problems or allergies. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules (Figure 1). No discharge was present but the area was very tender to palpation. Incision and drainage was attempted and was unsuccessful. A bacterial culture was taken from the area which was negative for growth. An injection of 0.1 cc of 10 mg/cc intralesional triamcinolone was administered followed by 0.1 cc of hyaluronidase. The patient was also given cephalexin, 500 mg twice daily for 2 weeks. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted. This will be addressed in her next appointment in 1 month (Figure 2).
Figures 2. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted which will be addressed in her next appointment in 1 month.
Discussion
Soft tissue augmentation is a very desirable cosmetic procedure because it is fast, effective, and has relatively few complications. Because these procedures are increasing in numbers, the dermatologist should be familiar with the potential side effects and how to prevent and to treat them to improve patient safety and satisfaction. Early complications include edema, injection associated discomfort, bruising, and erythema, and they are usually self-limited, resolving within 1 week.2
Among the most serious acute complications are the ones related to vascular occlusion and nerve damage. They can be avoided with skillful technique and knowledge of the anatomic area where the procedure is performed.3
Another complication that can be seen after soft tissue augmentation is nodule formation. The etiology of nodules can can be divided into 2 categories: inflammatory and noninflammatory. Inflammatory nodules are either a result of an infection (biofilms) or foreign body granulomas. Noninflammatory nodules are secondary to the material injected too superficially and are evident shortly after the procedure. Hyaluronidase is the treatment of choice if the filler is HA. If other material is used, they can respond to vigorous massage or potentially extrusion of the material.4 Even though inflammatory nodules have 2 different etiologies, it can be difficult to elucidate its real cause. Foreign body granulomas are an uncommon complication of this procedure, with a rate of approximately 0.4% for HAs and 0.001% for calcium hydroxyapatite.5
Typically, they are treated with intralesional steroids and hyaluronidase with good resolution. If no clinical response is seen, a biofilm should be suspected and the patient should be placed on broad-spectrum antibiotics for a minimum of 4 weeks that include quinolones and macrolides.4 Biofilms are microenvironments that are formed around the filler by the adjacent bacteria, they elaborate extracellular matrix of exopolysaccharides that also include HA. The bacteria adhere to this matrix protecting it from antibiotics.6,7 When a biofilm is present, it usually will not render any result on the bacterial culture making the diagnosis difficult. Besides antibiotics, hyaluronidase should be used in these cases along with antibiotics to disrupt the protective microenvironment.7
Our Patient
In our patient, even though the nodules had been there for 2 months, they resolved with intralesional triamcinolone and hyaluronidase, making the diagnosis of noninflammatory nodules more plausible. To prevent biofilms, it is critical to undergo thorough cleaning of the patient’s face before the procedure, avoid injection in areas that may be swollen or infected, reduce the amount of needle sticks, and use the smallest sized needle.3
Soft tissue augmentation is a common procedure for dermatologists. Serious complications are very uncommon, however, knowledge of how to prevent and to treat them is paramount.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Micrographic Surgery and Procedural Dermatology Fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and a practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Plastic surgery statistics. American Society of Plastic Surgeons website. https://www.plasticsurgery.org/news/plastic-surgery-statistics. Accessed June 22, 2017.
2. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications of dermal fillers. Semin Plast Surg. 2016;30(2):83-86.
3. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-1121.
4. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;12(6):295-316.
5. Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures. J Am Acad Dermatol. 2015;73(1):15-24.
6. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J. 2013;33(4):561-575.
7. Beer K, Avelar R. Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations. Dermatol Surg. 2014;40(11):1175-1179.
Climbing the mountain to get to dermatology residency is bone breaking enough, but what about the next apex, even more specialized training such as a Dermatopathology Fellowship?
Climbing the mountain to get to dermatology residency is bone breaking enough, but what about the next apex, even more specialized training such as a Dermatopathology Fellowship?
The implementation of a dedicated shelf exam for dermatology can help standardize fourth-year rotations, leveling the playing field for students from less-prestigious medical schools and helping them demonstrate their enthusiasm for our...
The implementation of a dedicated shelf exam for dermatology can help standardize fourth-year rotations, leveling the playing field for students from less-prestigious medical schools and helping them demonstrate their enthusiasm for our...
A healthy 42-year-old woman with fair skin (Fitzpatrick type 2) and no significant past medical history presented to the clinic with concerns about a dry, rough lesion on her left ear.
A healthy 42-year-old woman with fair skin (Fitzpatrick type 2) and no significant past medical history presented to the clinic with concerns about a dry, rough lesion on her left ear.
A literature review was conducted to explore recent studies focusing on diagnostic approaches and treatment options for nail psoriasis and nail lichen planus.
A literature review was conducted to explore recent studies focusing on diagnostic approaches and treatment options for nail psoriasis and nail lichen planus.
1. According to Dr Linda Stein Gold, how do nonsteroidal topical therapies compare to traditional steroid-based treatments for managing psoriasis and AD?a) They are less effective but safer.b) They are as effective as mid-potency steroids and...
1. According to Dr Linda Stein Gold, how do nonsteroidal topical therapies compare to traditional steroid-based treatments for managing psoriasis and AD?a) They are less effective but safer.b) They are as effective as mid-potency steroids and...
Assess your understanding of biologic therapy in pediatric atopic dermatitis with this expert quiz. Explore practical barriers to treatment, considerations for young children and caregivers, and real-world factors that influence successful...
Assess your understanding of biologic therapy in pediatric atopic dermatitis with this expert quiz. Explore practical barriers to treatment, considerations for young children and caregivers, and real-world factors that influence successful...
Test your knowledge of treatment escalation in pediatric atopic dermatitis. This clinical quiz explores when topical therapy is no longer sufficient and when to initiate systemic treatment in children.
Test your knowledge of treatment escalation in pediatric atopic dermatitis. This clinical quiz explores when topical therapy is no longer sufficient and when to initiate systemic treatment in children.
Test your clinical understanding of fibrotic remodeling and the mechanisms underlying persistent itch and chronic disease activity in prurigo nodularis.
Test your clinical understanding of fibrotic remodeling and the mechanisms underlying persistent itch and chronic disease activity in prurigo nodularis.
Test your expertise in identifying risk factors for persistent pediatric atopic dermatitis and understanding the interplay between barrier dysfunction and immune dysregulation.
Test your expertise in identifying risk factors for persistent pediatric atopic dermatitis and understanding the interplay between barrier dysfunction and immune dysregulation.
Assess advanced clinical reasoning in pediatric atopic dermatitis, including implications of type 2 inflammation for diagnosis, treatment timing, and systemic therapy decisions.
Assess advanced clinical reasoning in pediatric atopic dermatitis, including implications of type 2 inflammation for diagnosis, treatment timing, and systemic therapy decisions.
Challenge your understanding of direct and indirect cytokine–nerve interactions and mechanical hypersensitivity of type 2 signaling in prurigo nodularis.
Challenge your understanding of direct and indirect cytokine–nerve interactions and mechanical hypersensitivity of type 2 signaling in prurigo nodularis.
How should clinicians redefine severe alopecia areata? When is it appropriate to treat ≤20% scalp involvement with oral JAK inhibitors? This expert-level quiz explores remission durability, treatment withdrawal, and practical strategies for...
How should clinicians redefine severe alopecia areata? When is it appropriate to treat ≤20% scalp involvement with oral JAK inhibitors? This expert-level quiz explores remission durability, treatment withdrawal, and practical strategies for...
