What is the treatment protocol for late-onset inflammatory response to Hyaluronic Acid Dermal fillers?

Question

I'm having a delayed reaction of non-painful nodules, redness & bumps @ injection sites, & swelling in all places I had HA fillers (Vo) injected and some places I had Botox injected. Vollure and Botox: 6/29/18 (but had prev injections back to 7/2017) 1st nodule: 9/10/18 but escalated fast to nodules all over my face. 2 rounds of Pred. 100mg Minocycline injection of Hylenex Is there anyone in the NYC area that is experienced/has treated this type of delayed reaction with success? Thank you!

Kenneth D. Steinsapir, MD · Answer

What is critical is having sufficient hyaluronidase enzyme to remove as fully as possible all of the filler.  Although Allergan implies in their marketing that Vollure is a high G prime filler, it is not.  It is still a so-called smooth filler that spreads out once injected.  For that reason, injectors often underestimate the amount of enzyme needed. For a routine removal of product under the eyes, I will often use 150 units of enzyme in each under eye area. For individuals in your situation, I will often double that amount. Most injectors are afraid to inject the volume of enzyme that is needed.  They simply lack the experience in working with the product.  There is a lot of nonsense over the enzyme. Ill informed individuals stirring fear by posting on the internet that the enzyme wrecked their face.  There is no truth to these concerns.  You need sufficient enzyme or risk leaving residual product that can cause more inflammation.

Brian Maloney, MD, FACS · Answer

Our bodies are loaded with hyaluronic acid, however the fillers have two components that are different from ours. They are made by small bacteria. Fragments of these are in the fillers(the same bacteria make our antibiotics and contain the same fragments). The cross linking is another part of the filler that may stimulate a response. Sometimes a cold or underlying medical condition may stimulate the response.The treatment that I have had success with is injecting the hyaluronidase mixed with a low dose steroid. The enzyme dissolves the filler and the steroid helps to decrease your bodies immune response. Most cases will respond quickly, however I have seen a few cases that required multiple rounds of injections . The good news is that they all eventually resolved.

Jason Emer, MD · Answer

I recommend following up with a cosmetic dermatologist. It can take a series of treatments with hyaluronidase to dissolve filler. Best, Dr. Emer

Monika Soni, MD · Answer

Thank you for your question! I am so sorry this happened to you.  I agree with the other doctors that you need to dissolve every bit of filler, which can be a little tricky because even the "highly cross-linked"  like vollure and volbella  fillers do spread a little after injected.  When this type of late inflammation occurs,  it can be frustrating to treat.  All of the filler must be dissolved and it is common to take antibiotics for a while, 2-4 weeks is not unheard of. Best of luck!

Emil A. Tanghetti, MD · Answer

Nodules after Voluma, Volbella and Vollure have been reported. These reactions have been reported months after injection and sometimes have been associated with recent dental work. Some people have felt that they are related to the development of a biofilm in the area of injection. They generally are best treated with a course of antibiotics such as doxycycline or minocycline. They generally take 6-8 weeks to resolve. Dissolving this type of hyaluronic acid can be challenging. I would suggest following up with a trusted provider and continuing your course of antibiotics for 6-8 weeks.

Carmen A. Traywick, MD, FAAD · Answer

It would be best to continue following up with your injector or see a board certified dermatologist or plastic surgeon. Protocol is unique to the injector. Hope this helps.

Deborah Kessler Hudak, MD, MHA · Answer

The fact that you got redness, bumps and nodules at sites of needle punctures...and not just where the Vollure was injected, I believe it is possible you have  a hypersensitivity reaction to the needle punctures, and not the injected material.  I have a patient that a Dermatology friend of mine helped me with who had this unusual disorder.  We treated her with steroid pills. The fact you do not mention itch, also makes it more likely this is a hypersensitivity reaction and not an allergy reaction...although the Prednisone you were prescribed would douse any itching! 
If the reaction was solely due to the hyaluronic acid filler, Hylenex (hyaluronidase, an enzyme that breaks down hyaluronic acids) would treat it well.
Perhaps you should get the input of a dermatologist.  You are a good historian, so with all the data, hopefully someone can make the correct diagnosis for you...which is key in recommending the best treatment.

Susan Longar, MD · Answer

I am so sorry this happened to you.  I agree with the other doctors that you need to dissolve every bit of filler, which can be a little tricky because even the "highly cross-linked"  like vollure and volbella  fillers do spread a little after injected.  When this type of late inflammation occurs,  it can be frustrating to treat.  All of the filler must be dissolved and it is common to take antibiotics for a while, 2-4 weeks is not unheard of.  I hope this helps!
Although these complications are rare, it is devastating when it happens because we are, after all, talking about your face.
Best Wishes

What is the treatment protocol for late-onset inflammatory response to Hyaluronic Acid Dermal fillers?

Answers (8)

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