Large Swelling Immediately After Dermal Filler Treatment

Imagine that you have just injected a patient’s lips or cheek. Suddenly, the area swells up like nothing you have ever seen before. It’s an unfamiliar sight… you panic… you vaguely remember about some of the rare but catastrophic complications of dermal filler. You reach for your emergency filler pack. Should you do that? Are you sure?

This person does not have skin ischaemia or a haematoma. That’s probably why she looks so smug

Skin ischaemia is now a complication of dermal filler treatment that most practitioners are aware of but thankfully, few have experienced it first hand. With an estimated incidence of 1 in 1 million, in an industry still experiencing record growth rates, the occurrence of dermal filler related skin ischaemia and many other complications are bound to increase. Haematoma formation (a large, swollen bruise) is another, more common and less severe complication of dermal filler; one that differs from skin ischaemia is almost every possible way, is frequently being misidentified as skin ischaemia by aesthetic practitioners from various medical and non-medical disciplines. Whilst it is vitally important that aesthetic practitioners identify skin ischaemia and take action if they suspect this, it is also important that misdiagnosis is avoided so that perceived rates of skin ischaemia are not inflated and that unnecessary stress is not brought upon these practitioners and their patients. So, what’s the difference?   Ischaemia would be white and painful and not associated with swelling. If you see swelling develop before your eyes, you may have hit a blood vessel, causing a haematoma/large bruise. It may not look discoloured like a bruise yet, but this may just be because the bruising is so deep that you can’t see it through the skin. No treatment is needed other than applying pressure for 4-5 minutes.    

Haematoma (definition): An accumulation of free blood anywhere in the body, that has partially clotted to form a semi-solid mass. Haematomas may be caused by injury or may occur spontaneously as a result of a bleeding or clotting disorder. In some sites, as within the skull, enlarging haematomas may be very dangerous. Infected haematomas may form abscesses.
This is a classic haematoma. Think “learning to snowboard”.

What if I treat it as Skin Ischaemia just ‘to be sure’? 

Well, you may scare your patient (if they understand what you’re doing). While you’re off unnecessarily looking for your emergency skin ischaemia pack, a haematoma could be growing inside your patient and you aren’t stopping it. GTN patches and paste will almost definitely give the patient a headache if they don’t already have one. Hyalase itself will likely cause a temporary loss of soft tissue volume in the area treated, but this should resolve within two weeks. If you were to go ahead and give aspirin (indicated in ischaemia where there has been a fully resolution after steps 1-3, but it turned out to be a haematoma, you may make the haematoma larger, but probably not. Miscellaneous – Both haematomas and skin ischaemia are covered in the Flourish consent form for dermal filler. – It doesn’t matter what party season your patient is about to enter (even if it’s her wedding) – there is little that you can do to reduce the duration of resolution for their haematoma, other than making a quick diagnosis and applying pressure immediately to limit the volume of blood that escapes beneath the skin – Does arnica cream help reduce bruising? My answer will be the most controversial part of this article – NO, it’s homeopathy and there is no evidence that it works (1, 2).   Like this article? Why not take a look at the syllabus for our online Advanced or Foundation courses? Maybe there’s something in there that could boost your clinic’s potential for 2018!  

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References (Arnica)

1) C. Stevinson et al. Homeopathic Arnica for Prevention of Pain and Bruising: Randomised Placebo-Controlled Trial in Hand Surgery. Journal of the Royal Society of Medicine (2003)

2) N.Brito. Systematic Review on the Efficacy of Topical Arnica montana for the Treatment of Pain, Swelling and Bruises. Journal of Musculoskeletal Pain (2014)