Filler safety: complications and how good practice prevents them

Key takeaways

• Over 90% of adverse events from hyaluronic acid fillers are mild and temporary, according to an ophthalmology review.
• The serious risk is a blocked blood vessel. Sudden severe pain, pale or dusky skin and any vision change need immediate action.
• Hyaluronidase, an enzyme that dissolves hyaluronic acid, should be available wherever fillers are done.
• Some problems, such as nodules or swelling under the eyes, can appear weeks or even years later.
• A trained doctor, a licensed product and a plan with small amounts matter more than price.

What is normal after filler?

Normally, you can expect some of these for a few days:

• Swelling, which can be more noticeable on the second day and around the lips and eyes
• Bruising, more likely if you take aspirin or other blood thinners
• Tenderness and a slightly firm feeling
• Redness at injection points

The FDA lists these as the common risks. They settle on their own.

What are the less common complications?

An important point from the same ophthalmology review: some of these, such as swelling under the eyes and migration, can show up months or years after treatment. So you should tell any doctor treating you that you have had filler, even if it was long ago.

What is a vascular occlusion, and why does it matter?

See, what happens is, the face is full of small blood vessels, some of which connect with the vessels supplying the eye. If filler enters a vessel, or presses on one from outside, blood flow to that patch of skin can be blocked. That is called a vascular occlusion.

The FDA lists this as the most serious risk of fillers. It can cause skin damage and, rarely, vision loss or stroke. The ophthalmology review lists the area between the eyebrows, the nose, the folds beside the nose and the forehead among the highest-risk sites for eye complications.

Warning signs, usually immediately or within hours (from a 2021 management guideline): - Pain that is sudden, increasing or much worse than expected, near or away from the injection site - Skin that turns pale, then dusky, or develops a purple, net-like pattern - Skin colour that does not quickly return when pressed

Any change in vision, eye pain or stroke symptoms during or after filler is an emergency. The guideline notes that damage to the retina may happen within about 12 to 15 minutes.

How is a blocked vessel treated?

The 2021 guideline describes the core steps: stop injecting immediately, assess the area, and give hyaluronidase promptly, in high doses, repeated if needed. It describes hyaluronidase as highly effective in preventing tissue damage. Warmth and massage are also used. The patient should be kept informed throughout.

That is very important to understand. These steps only work if the doctor recognises the signs at once and has the enzyme in the room. That is why the fillers on our menu are hyaluronic acid fillers, and why you should always ask whether hyaluronidase is in the room before any filler, wherever you have it.

How does good practice prevent complications?

Basically, prevention is about many small habits rather than one trick.

• Anatomy knowledge. The guideline advises grading areas by risk rather than calling any area "safe", and understanding vessels in three dimensions.
• Small amounts, slowly. Small deposits, placed in the right layer, with time between sessions to see how the tissue settles.
• Not relying on one test. The guideline notes that pulling back on the syringe to check for blood is unreliable, with reported reliability of only 33 to 63%. It is not a substitute for anatomy and technique.
• Needle or cannula chosen for the area. Both can cause occlusion; the guideline is clear neither removes the risk.
• Hyaluronidase on hand, and a plan for emergencies.
• Observation after higher-risk areas. The guideline suggests 30 to 45 minutes of observation after treating areas such as the nose, between the eyebrows or the forehead.
• Licensed products only. The FDA advises never buying filler online, and states that needle-free "pens" are not approved for filler injection.
• Clean technique, and waiting if there is active acne, infection or a cold sore near the area.

Questions to ask before any filler

• Which product is this, and is it hyaluronic acid?
• How much will you use, and can I have that in writing?
• Do you have hyaluronidase here today?
• What would you do if a blood vessel were affected?
• Who do I call tonight if something feels wrong?

A careful doctor will be comfortable answering all of these. My article on why some faces look overdone covers the other kind of complication: too much filler over time.

How we approach this at Dr Tvacha

At our centres in Thane, Andheri, Bandra and Dahisar, fillers follow a Rs 499 face assessment and a medical history, with the product, amount and price written down before treatment. The fillers we use are hyaluronic acid fillers, and I prefer small amounts with a review before adding more. If you have had filler elsewhere and something feels wrong, you are welcome to come and be assessed. Read about the Long Game Anti-ageing Plan or how fillers work.

Written by

Dr Amit KarkhanisAesthetic Physician · MBBS, Dip. Dermatology (UK) · Reg. No. 2001/02/1124

Founder of Dr Tvacha, practising in Thane since 2005. Leads the weight loss and hair programmes.