Safety of Hyaluronic Acid as a Soft Tissue Filler in Facial Cosmetic Surgery

As minimally invasive cosmetic facial surgery has grown in popularity, such procedures have been incorporated into those offered by oral and maxillofacial surgeons.  Dermal fillers provide an effective and immediate minimally invasive solution to the lack of soft tissue volume in several areas of the face. A wide range of complications have been reported in association with dermal fillers including bruising, edema (i.e. trauma induced, angioedema), skin discoloration (i.e. Tyndall effect), infection, inflammatory and non-inflammatory nodules (i.e. foreign body granulomas), neuropraxia, tissue necrosis, and in rare cases blindness due to vascular retrograde injection and small vessel occlusion. Of the variety of dermal fillers, hyaluronic acid (HA) fillers have emerged as the most commonly used (1). In 2011, there were 1,206,186 soft tissue augmentations performed with HA fillers, comprising 84% of all fillers used that year in the United States. The purpose of this study was to assess the safety and predictability of HAs as soft tissue fillers used by oral and maxillofacial surgeons in an outpatient setting. A retrospective assessment of the adverse outcomes of the administration of HA in 90 patients between the ages of 29 and 88 with ASA classifications I and II in an office based oral and maxillofacial surgery practice was performed.  Of these 90 patients, 52 received multiple injections and/or returned for future soft tissue augmentation with an HA.  To be considered an adverse outcome, reports of at least one of the following inclusion criteria must have been made: embolization, arteriole occlusion, injectable-related vascular compromise and local skin necrosis, cellulitis, hypersensitivity reaction, nodules and/or granulomas, overcorrection and/or implant visibility or patient unhappy with outcome (2). Out of all of the procedures, only one adverse outcome was reported. This complication was a hypersensitivity reaction to a nasolabial fold augmentation. Symptoms presented as early as 4 days after HA administration.  These included bilateral swelling with periorbital edema. No symptoms of fever, chills, malaise or weakness were reported. The reaction was treated by reversal of the HA filler with a hyaluronidase injection which was able to dissolve the filler.  Considerable improvements were seen at post operative visits 2 and 4 weeks after reversal. Ultimately, our study shows that HA fillers have proven to be successful, safe, and predictable.  The ability of HA to be reversed contributes to its safety as it provides an immediate and effective treatment for any potential adverse reactions associated with the filler.

References:

1. Ferneini EM, Jackson T, Ferneini CM, Banki M. A Review of New Facial Filler Techniques for Facial Rejuvenation.  Am J Cosmet Surg, 31(3): 166-173, 2014.
2. Ferneini EM, Gady J, Nuveen E.  Complications associated with Facial Soft Tissue Fillers.  Am J Cosmet Surg, 31(4):238-242, 2014.