Biofilm Infection After Restylane Injections to Tear Troughs

I've had great results with Restylane to the...

I've had great results with Restylane to the glabella, naso-labial folds, and around the mouth, however, I've had a disastrous result with injections to my tear troughs.

Originally I wanted a lower bleph, but my ps talked me into Restylane instead. Big mistake!

I had one set of injections that didn't seem to make much difference. 8 months later, doc suggested injecting again. At the same time he did the 2nd set of injections to the tear troughs, he also administered Botox (Dysport) to my crow's feet (which I regret because I love my laugh lines).

Two months after the 2nd set of injections, my eyes began to swell. The swelling lasts a few days, and since then, recurs about every other week. When the swelling goes down, my undereye are is left swollen, lumpy, bumpy and bruised.

Researching on Real Self, I've discovered others who've experienced the exact same thing. My doctor thinks my body is having an immune reaction to the Restylane and wants to dissolve with hyaluronidase. But there are so many horror stories here of hyaluronidase making matters worse that I haven't done it yet.

After having a neck lift last year, my lower face looks youthful and attractive, but Retsylane has now battered my eyes, making them look old, bumpy and crepe-y, and leaving me depressed and self-conscious.

Restylane has not been FDA approved for use under the eyes, and I hope it never is. Please think long and hard before using Restylane to treat bags under the eyes.

So, here's the rest of my story since I last...

So, here's the rest of my story since I last posted.

For months, my doctor seemed puzzled about what was going on with me. He thought at first that I was having an immune response to the Restylane. I kept reporting to him the repeated episodes of swelling, nodules and tenderness under my eyes.

Finally, he emailed me to tell me that he had just been to a lecture on complications with injectable fillers, and told me that he suspected I had a biofilm infection. He sent me a link to an article, and indeed the description and photos seemed to match the symptoms -- nodules, lumpiness and recurrent swelling -- that I was experiencing.

Until recently it was believed that biofilms couldn't form on temporary fillers (they're usually associated with implants such as pacemakers, and the like). Many doctors on this site have dismissed the idea of biofilms from temporary fillers.

But there have been more and more reports of biofilm infections occurring after injections of Restylane and Juvederm. Usually the first swelling episode starts several weeks to a month after injection.

The usual treatment is six weeks of two powerful antibiotics. My doc immediately put me on Zithromax and Levaquin, which I took for about eight weeks. The swelling got better within 3 days of starting the antibiotics, which made me so hopeful! For the next month I had no swelling, but I the uneven lumpiness never went away.

Unfortunately, I had some swelling again after a month on the antibiotics, even though I was still taking them. Apparently, these biofilms are extremely antibiotic-resistant which is why such a long course is needed. They hide amid the filler and it's hard for the antibiotic to reach them. I was so depressed when the swelling returned (though it never got as bad as it was pre-antibiotics).

The other treatment that's recommended to eradicate the biofilm is to dissolve the filler with hyaluronidase (Vitrase). I was extremely wary to do this after reading so many horror stories here on RealSelf about hyaluronidase making things worse. For a long time, I decided I would try to ride this thing out until the Restylane dissolved naturally, even though my eyes looked like hell and I had no choice but to hide behind eyeglasses every day.

But the more I learned about biofilm infections, I realized that it was advisable, if not necessary, to dissolve the stuff so that the biofilm no longer has a place to hang out. Further, the Restylane can last for years in the tear trough area.

So just this past weekend, I traveled back to NY to have my doctor, a board-certified plastic surgeon, attempt to dissolve the Restylane with Vitrase.

I was nervous and scared that this would only make a bad situation worse. After the injections, my left eye bruised badly and was quite swollen, though my right eye looked better (back to normal, in fact). I was, however, terribly worried about my swollen and bruised left eye, which required more injections.

Well, now it is day four after the Vitrase injections, and while I still have bruising (hidden under many layers of concealer) the swelling is disappearing and I am starting to look like my old self again for the first time in nearly six months. I am ecstatic!

My old bags are back (you really only see them when I smile), but I realize now they are not so bad, and they are FAR preferable to the awful asymmetrical lumps and bulges I have endured for the last six months as a result of the infection.

My doctor told me that after the Vitrase I was probably going to ask myself why I didn't do this months earlier, and he is right. I'm still on the antibiotics for another week (he switched me from Levaquin to Clindamycin when the swelling started to return). I am hoping and praying that the swelling and nodules will be gone for good.

I am uncertain as to why so many people have reported such ill effects from Vitrase, but in reading the reviews, I did notice that more than half (66%) reported positive results. I think that people who've had complications are more apt to post a negative review than someone who has had a satisfactory outcome.

I am reserving final judgment, but I am hopeful that when all is said and done, I will be able to add another positive report.

When it comes to hyaluronidase, I've learned through my experience that:

1. It is essential to go to a board certified plastic surgeon or dermatologist who's had experience dissolving fillers.

2. That they use Vitrase (no mercury preservative) rather than Wydase (which has been discontinued).

3. That the Vitrase be dated, fresh, and kept refrigerated.

4. That in the case of a biofilm infection, it is advisable to attempt to remove all the filler at once, rather than a little bit at a time in several sessions.

Hope that this information proves helpful to anyone experiencing similar symptoms after filler injections.

Four Months Since Hyaluronidase. Results Disappointing.

While I was initially hopeful after the Vitrase injections, my eyes, unfortunately, look terrible. The repeated swelling episodes have stopped since I had the Restylane dissolved (thank goodness), but my undereye area looks worse than before I had the Restylane injections. I seem to have a small permanent nodule that still becomes intermittently tender. In addition, I am left with uneven bags and asymmetrical puffiness and lumpiness.

In a month-and-a-half it will have been a year since the Restylane injections. I can't tell if there's any Restylane left, or if all the stretching and swelling from the injections and the biofilm infection are what have left my undereye area such a mess.

I have been wearing glasses for the past year to hide my eyes and have lost much confidence about my appearance. So sad after the 8 confident months I spent enjoying the results of my neck lift.

I originally wanted surgery and am so sorry that I got talked into Restylane instead. I am worried about having surgery now, in case there's any Restylane left, and worried about surgery reawakening the nasty sleeping biofilm infection.

Like so many people here who have reported bad results, I am left feeling like it was karma for my vanity.

Scheduled for Surgery in Two Weeks

Well, it's been over a year since my biofilm infection from Restylane started, and it's been over six months since I was treated with antibiotics and had the Restylane dissolved.

I am now scheduled to have eyelid surgery in two weeks. I had a consult with an top oculoplastic surgeon in LA who also happened to have published a paper on biofilms.

He recommended upper and lower eyelid surgery. He said that while he is in there, he can flush out any remaining Restylane. He also recommended fat injections in my mid-cheek area to even out the hollowness. Since it is my own fat, it cannot harbor biofilms or cause an allergic reaction), and he recommended laser resurfacing under my eyes to tighten up the lumpiness and loose skin caused by the repeated swelling episodes from the infection.

I am excited and terrified at the same time -- excited at the thought that maybe I won't have to hide my eyes behind glasses for the rest of my life, and terrified that I could have a disastrous result like I did with the Restylane. Doctors keep saying how rare biofilm infections are. (I don't believe them -- I think that there are many cases that haven't been properly diagnosed), but because I had one experience with a rare complication, it's hard for me not to fear another.

Wish me luck. I'll keep you posted!

Biofilm Infection Confirmed - Restylane still present 15 months later

On January 24, 2014 I had eyelid surgery to address not only my original eye bags, but also the lumpiness and saggy skin as a result of my biofilm infection, and subsequent dissolving with Vitrase. After surgery, my oculoplastic surgeon told me that he found remaining Restylane just under my lower lash line, which he said was a very odd place to inject filler. He said it was possible that it migrated upward. But he also said that the Restylane was "encapsulated" and that there was much inflammation, consistent with a biofilm infection. The Vitrase obviously didn't dissolve it all, and I still had Restylane present 15 months after injection. My surgeon also said that he does not recommend temporary fillers to the tear trough, and feels that the procedure is being way overdone. He prefers to use a patient's own fat, which cannot cause a biofilm since it is not a foreign body.
Dr. George Yang

What this rating system doesn't allow for is results. Dr. Yang is the most kind and caring doctor I have ever met. Very responsive to phone calls and emails, and spends an incredible amount of time with his patients. I had an extraordinary result with a necklift/lower facelift that Dr. Yang performed, and couldn't be happier. I had a less fortunate experience with Restylane injections to the tear trough area and ended up with a biofilm infection, which caused episodes of intermittent swelling, lumpiness, and nodules. The cause, at first was a mystery, even to Dr. Yang, but eventually he identified a problem that most plastic surgeons are yet unfamiliar with, and successfully treated it. I am extremely grateful to Dr. Yang for solving the mystery and his commitment to helping me find resolution. Based on my experience and research, the undereye area is a risky area to inject with fillers.

5 out of 5 stars Overall rating
5 out of 5 stars Doctor's bedside manner
5 out of 5 stars Answered my questions
5 out of 5 stars After care follow-up
5 out of 5 stars Time spent with me
5 out of 5 stars Phone or email responsiveness
5 out of 5 stars Staff professionalism & courtesy
5 out of 5 stars Payment process
5 out of 5 stars Wait times
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I wrote an honest review of my original doctor on yelp and a day later his wife went on Facebook by 9am and said how I'm trying to ruin her husband and extort money by asking for a refund. My mouth literally hung open reading post after post about how horrible I am. I can't imagine a doctor allowing his wife to cross such a boundary. I've read so many posts here saying how their doctors help even if they don't know about these infections but they don't leave them to deal with it alone. I met them through a friend of mine and the wife wanted me to work her out and do a swap of services. I haven't seen her for probably close to 10 years and she is saying things that I don't know how she would know. What happened to patient confidentiality? It is so hurtful and to kick someone when they are down is cruel. I am in antibiotics and have had several injections to dissolve this. I am so worried and having this woman berate me over a minimal amount of money is despicable. I don't understand how a doctor says to find someone else and then ex
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This posted before I was done. I was saying how it is hard to understand how a doctor says to find someone that deals with these infections and then throw up their hands, not follow up on a patient's progress and expect them to bear the cost and on top of it have their wife start ranting on Facebook. I had to block her and she evidentially took her page down. This is the last thing I need. Caring costs nothing but is the most valuable.
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4halex that's awful! How did you find out about the facebook posts? How many units of hyaluronidase has everyone had? Has it helped at all?
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I've had 4. 2 with the juve injector and 2 with my PS (who's now treating me). I had juve put in my lips 3 monts after the juve in my nose and left cheek hollow (before the reaction on the cheek hollow started). So I'm trying to get rid of all juve in my face only because if concern it does/may migrate to areas of the face with more fluid. I may get more...I write my wonderful PS this morning. He's been great about responding to this issue, although he's never encountered it before .
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There was an email that said I had a comment on facebook. She wouldn't stop so I had to block her. The fact that her husband who practices in Beverly Hills would condone such behavior speaks volumes about him. What happened to patient confidentiality? It's so unethical and am going to report him to the medical board. My Yelp review was 100% truthful and have the emails to prove it. Caring about your patient doesn't cost anything but it is invaluable if you do. No patient wants to be left on their own when there is a complication. if a doctor doesn't know what to do, then they should bring in as many others to ensure their patient receives the best possible treatment. You don't just throw up your hands and say I haven't dealt with anything like this so you should find someone who has. They both are very showy, the Porshe, and gold rolex type which is fine but to tell me I'm extorting money and want something for free is slander. All I asked for was reimbursement so I could pay to get this fixed. He didn't want to bother so why should I have to bear the cost while he dumps me and keeps my money? I can't imagine ever doing something like that and probably would get reimbursed by the company. His actual cost is nowhere near the amount I paid. I am going tomorrow for the fourth shot to dissolve this, I am not sure how many units I have had but will ask tomorrow. I also want to know why It changes throughout the day. There is a big bag under my left eye and a couple of lumps on my right but the redness and discoloration have not gone away which scares me. Everything I have read doesn't sound to encouraging. They should not inject this in the tear trough area without disclosing that there is a higher risk factor involved. I would have never done it had I known and certainly would have never used Voluma knowing that it is harder to dissolve!
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Hi SadieBee - Biggyc here again! I wanted to ask you more about the biofilm experience. I'm on my 3rd week of a strong antibiotic Bactrim and have had 3 treatments of hyaluronidase. And really, the improvement is slight to me. I know you said you were on antibiotics for 8 weeks - did you find it took several weeks before you saw your swelling reduce? It just seems like that by now, if the antibiotics are going to clear up any infection, it would have by now. Yet, I still have this "pillow" on top of my cheek (where the juvederm was put in) and under my eye. Sometimes they look separate, other times they look joined. So confusing. I'm just at the point where I'd rather get on with this and have my PS look at the site and my implant underneath and see what's going on. Otherwise, it's all guess work with the current treatment path - one of the more frustrating elements of this issue. But if you experienced reduced swelling or relief later in the treatment, that gives me some hope to continue on the current path. Did you find that to be the case...like maybe the 6th, 7th or 8th week saw major improvement? THANK YOU! BiggyC
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Hi Biggyc. Funny timing. (Well, not really funny at all.) At four months post-surgery, after we felt confident that my surgeon had removed any remaining Restylane, I woke up this morning with a recurrence of the swollen nodule and tenderness that I experienced for so many months while the infection was active. My surgeon is putting me back on Clindamycin for 12 days. Of course, I am not a doctor, but based on my exhaustive research on biofilm infections, I do not think that Bactrim is a drug of choice for a biofilm. Because biofilms create encapsulations around their colonies (think of a walled fortress), it is very hard for the antibiotic to penetrate and reach the bacteria. This is a very drug-resistant infection, which is why it usually requires long-term treatment (six weeks MINIMUM) of usually a combination of two powerful antibiotics. Usually Cephalexin 500 mg + Clindamycin 150 mg. See more on recommended treatment here: http://drnaomi.com.au/dermal-filler-infections-restylane-subq-infections-2/ Even months after I finished the antibiotics, and had the Restylane dissolved, I still experienced recurrences. And here now, four months after surgery, I am experiencing the same symptoms again. I hate to tell you this, but if you do indeed have a biofilm infection, it is very hard to get rid of. Bactrim is a pretty common all-purpose antibiotic, and I am guessing you need something stronger. I have just been researching dermatologists closer to home who are familiar with treating biofilm infections, since my surgeon who is 3,000 miles away. There are very few of them. I will probably have to travel to Boston, which is four hours away. I don't know where you are, but there is a dermatologist in NY, Rhoda Narins, who has written on how to treat biofilm infections from fillers: http://dermatologytimes.modernmedicine.com/dermatology-times/news/modernmedicine/modern-medicine-feature-articles/biofilms-dermal-fillers-manag It may require travel to get the proper treatment. All that said, when my infection was first suspected, and I started on the two antibiotics, my symptoms improved in three days. But they only *improved.* I continued to have recurrences (though milder) months later, and now again a year after I had the stuff dissolved. I just read that biofilms are thought to occur in one out of 1,000 cases of filler injections. I'm guessing that statistic is higher than previous thought, based on the increasing number of reports on RealSelf. But keep researching yourself, educating your doctor, and be persistent in seeking the proper care.
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Hi SadieBee - thank you so much for responding to my post. I am so sorry to hear you have a reoccurrence. This is just such an incredibly horrific issue! Aren't we the lucky 1 of a 1000?! I cannot believe how easy it is to get and difficult to treat. My PS in Augusta, GA (I live in Atlanta, GA) has been great, but him having not experienced treating this before, he's aiming in the dark as I am. I've forwarded him your story and links, but I wonder if he's just in a place where he's doing what he can, but it's not his specialty. So far, he hasn't charged me for treatment - even though I told him he should (I've had 2 vitrase treatments and about 4 total visits). He's extremely kind and did a perfect job with my mid face implants in 2012. I'm going to send him an email again tomorrow and mentioned the two antibiotics you were on and see if he might consult with Dr. Narins in NYC. If he doesn't want to, which is understandable, I mean everyone has their specialty or focus, I will have to find someone who is more suitable. I think he's got it in the back of his mind that it could have infected my implant (which is usually what biofilms are found on - artificial objects in our body) and therefore, I think since he put them in, he'd like to be in charge of removing it. However, I'm going to clarify with him because I need someone to take me by the hand with an aggressive treatment that will rectify this. I've reached the place in this experimentation where I feel like it's almost on the right track, but not all the way. I know you have to be dismayed that it has come back again. I hope your round of antibiotics kick it. I'm wondering if this stuff is recurring for life? Am also wondering if I get the implant out, would I at least be able to smile? I just cannot believe I am having to deal with all of this without having any local doctor know what the hell is going on? It's like being in the Twilight Zone. And, honestly, I may drive up to Franklin, NC and see a spiritual healer who works with glyphs. I kid you not! A friend of mine in Oregon suggested it. At this point, I'm ready for anything. Tonight I'm just so frustrated and it bums me out that you have it again, too. FOOEY. I'll keep you posted on what is going on. THe funny thing is, if I don't smile, this doesn't look that bad. But when I do (or try) the left side cannot move because of swelling. And both nurses at my PS's office and the doctor who injected it initially said (before we knew what was going on) "wow, the volume looks great!" Yeah, if only it didn't hurt, I could smile and not look freakish and there wasn't an infection going on, this would be fabulous! (I think I'm starting a one woman routine out of this ordeal...it's ironic humor, I guess.) Thank you again! Kick that nasty stuff! xo Biggyc
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Oh no!! I can't believe it's back. What a nightmare. Is your nodule the same size as it was before surgery? I'm traveling to see an expert on biofilms next week. It took a long time to get an appointment.
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I would be concerned, too, about the biofilm spreading to your implants. Until recently, doctors thought that biofilms could only form on solid implants. Since there has been awareness of that for some time, there must be doctors familiar with treating that. Probably infectious disease specialists. Your doctor should treat you for this at no charge. I believe that is standard practice. The doctor who injected my Restylane didn't charge me for the Vitrase injections or subsequent office visits. Glad you can keep a sense of humor about it. It's hard!
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Hi depressedgirl - let us know how it goes. Do you mind sharing with us who the doctor is... Just in case. :) Best of luck to you!
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After the Vitrase injections, I had one remaining and persistent small nodule under my right eye. When I had my eyelid surgery, my surgeon found some remaining filler under my right eye and removed it. Immediately after the surgery, the nodule was small, but palpable. Not tender. Then it got so small I could barely feel it, and I hadn't had any swelling or tenderness for these past four months since surgery. Today the nodule is back to the size it was pre-surgery, and somewhat tender, but not excessively so. It's not visible, thank goodness, but I do have a couple of small bumps (pimple-like, but not red) underneath. I hate to go back on the antibiotics, but fear I have no choice. Ugh. Will keep you posted.
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depressedgirl, I would also like to know who you are seeing. Please feel free to PM me if you don't feel like posting publicly. Wishing you lots of luck, too!
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Hi SadieBee - how have you been? I just remembered that you mentioned this nodule coming back...has it been resolved? Hope you're doing well!
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Hi biggyc. My doc had me take 300 mg of Clindamycin for 12 days after the nodule reappeared a few weeks ago. Seems to have cleared it up, but I am left wondering is there are still minute amounts of the Restylane still left which might have contributed to this flare-up.
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Glad it's improved for you! Yes, I wonder about all of this now. So many common experiences in our small percentile of bad reactions to fillers. Based on your experience and yet another person in England, I'm beginning to see surgery in my future. Really unbelievable...but I don't want this to let this drag out for much longer. Her's was for 3 years. Understandably, since no one really knows much about this except for those of us going through it. So after 6 plus hyaluronidase treatments, and some improvement, there is still a lingering lump or mass that is not budging. So, I'm ready to just get on with it. Sucks not to be able to smile without looking like the joker on one side of my face.
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I am experiencing the same thing. The initial reaction was bad but subsided until a couple of months later. I went to my doctor who saw the lump but sent me home even asking him about the possibility of a biofilm infection and dissolving it. He brushed my concerns off and had to send him additional photos which changed his mind. He didn't know what to do but conferred with a dermatologist who advised putting me on antibiotics. I finally had to go to another doctor who said it should be dissolved and just had my second injection. It is very red and am furious at my doctor who should of dissolved it in the beginning and is more concerned about being sued then his patient.
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Hi 4halex - almost identical to my issue with biofilm. Between antibiotics and 3 hyaluronidase injections I'm finally seeing improvement. I will still need more dissolving. But I had to do all the research and mention the prescribed treatment! Not the doctor who did it nor his useless nurse! It's infuriating how ignorant they are of their own field. They were clueless of biofilm infection due to improper prep for fillers. I should be their paid consultant now. Thanks to so many on realself documenting their stories I'm finally getting some improvement. Grateful!
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I sure hope I can say the same! It is a disgrace for a doctor to worry more about himself than his patient and most of all not listen. It was only when he called the dermatologist that he became worried, not when I kept telling him something is wrong. I asked for a reimbursement since he said he didn't know what to do and I had to go to another doctor who has done clinical trials of these cosmetic products. A caring doctor would want whats best for his patient and to make sure he finds an expert that has dealt with adverse reactions, not leave it to the patient to find. He should of volunteered to reimburse me since I will have to pay to fix it. Thank you for sharing your story, it is so helpful!!
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I swear it sounds like our doctors are the same guy! He did actually give me hyaluronidase 2x but he was still ignorant about biofilm snd offered no proactive treatment plan. And you're right, it's just wrong. He's not the doctor who's treating me know. I have also asked for a refund - so far his nurse is giving me the runaround. But if I don't get any satisfaction I will give them several bad/truthful reviews. But I'm being patient for now...bringing them kicking and screaming into acknowledging what happened. Best if luck to you! Keep us posted. Btw I'm reading a great book for self healing called "You Are The Placebo". Really awesome!
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Thanks again for all your helpful information.:))
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Jumping in on the conversation here. Just had lots of bad tissue removed from my submental region where a previous p.s. put in Alloderm then two others continued to fill the sunken area under my chin (from bad lipo 13 years ago) with repeated Juvederm injections over a course of 4 years. My new and improved ENT facial p.s. never heard of injecting Juvederm in that part of the body and recommended removing Alloderm and anything that looked bad, then doing a lower facelift/necklift to tighten. I had showed him 2 path lab reports from previous nodule removals from my chin scarline that indicated inflammation granulomas" and that's why he thought all the filler remnants needed to go. He said during surgery there was so much that looked bad someone asked if I had insurance on file. All the bad stuff went to a path lab and I'm awaiting the report. Did any of you have granulomatous tissue removed and sent to a path lab from your "biofilm infections"? I'm wondering if a path lab can confirm the source is "biofilm." On the other hand, there were so many possible sources of infection under my chin since 2 prior surgeons did scar revisions there and didn't wear masks, use betaidine or prescribe post-surgery antiobiotics; not only that, didn't give me anything resembling a satisfactory cosmetic result. I found out it is impossible to get money back. Your only recourse is telling your story on RealSelf to save others from going through a similar bad journey with the same P.S. I felt kind of bad later on for calling them out for their self-centered careless behavior but how else are they going to learn? You'd think it would make them want to make amends with you but mine never did. Then, a satisfied patients of one theirs commented I was wrong for "bashing" her surgeon because he gave her great service...pfffft, whatever. Obviously RealSelf didn't find anything wrong with my posts otherwise they would have taken them down but when I asked to have my posts reduced they said they had to leave the whole story as is for others to understand my journey. Just letting you know for future reference if you give your p.s. a bad review it can't be undone.
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cbaker, I hope that you will finally have resolution to your problems, and that you will soon be free of symptoms. I am not sure if my ps sent the encapsulated pockets of remaining Restylane that he removed from under my right eye, but the fact that it was encapsulated and the area was inflamed was consistent with biofilm infection. The nature of a biofilm is that the bacteria forms a protective barrier (the encapsulation) around the foreign body/substance to hide out in and protect itself from antibiotics and the body's own defense mechanisms. The growing number of RealSelf reports of biofilm infections after fillers makes me think that there really needs to be a class action lawsuit against the manufacturers of these fillers. Neither doctors nor patients are being informed about these risks, and patients who develop such an infection aren't getting proper treatment.
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Wow Cbaker...that's quite a journey. I haven't had my situation confirmed as biofilm yet. But I believe the initiator of this post (SadieBee) did have hers confirmed. This post has been a god send. Even if I don't get a refund, that I'm getting help and recovering is certainly the best thing that happens overall. That, and making sure I review the doctor (and his staff) fairly (which means honestly what happened) on realself, yelp and others will be at least helping others be aware, as well as, a form of gratification is okay. I am just happy that I am on my way to being well again. And I will never get fillers again. This is just not worth it. Best to you all!
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Here here, SadieBee!
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