Dermatologists map complications in facial fillers in Brazil

A Brazilian survey of 160 dermatologists published this year mapped the incidence and causes of complications in facial fillers in Brazil. The perception of a growing demand in offices for correction of problems, ranging from asymmetry to blindness, motivated the study.

The survey, carried out in 2021, took into account the medical records submitted by participants from 19 states. The number of procedures performed, the types of products and details of the complications treated in the previous year were requested via questionnaires.

In all, 47,360 such procedures were evaluated, of which 1,032 had complications (average of 6.45 per year), with more than half of them, 550, caused by procedures performed by non-physicians.

Despite the weak correlation between the total number and complications (about 2.2%), the proportion of damage in cases treated by non-physicians worries researchers, as well as the incorrect use of products.

The average number of procedures performed by each dermatologist was 7.4 per week, and the aggravations resulting from the interviewees’ own procedures represented an index of 1.23 per year. Patients assisted by other types of physicians had an injury rate of 1.79 per year, and those assisted by other types of non-medical professionals reached 3.43 per year.

Excess of product and lack of technique are among the most common causes of complaints, with the main complications reported after a month or more of the procedure. The results were published in the article “Frequency of Complications of Aesthetic Facial Fillers in Brazil”, in the Journal of Plastic and Reconstructive Surgery of the American Society of Plastic Surgeons.

Authors Mayra Ianhez and Marcela Souza, from UFG (Federal University of Goiás), and Hélio Miot, from Unesp (São Paulo State University), studied, in addition to the frequency of complications, the characteristics of products and injection techniques.

“The question that aroused our curiosity was: are the complications more frequent just because there are more people doing it, or is this linked to professionals with a reduced qualification?”, says Miot, who is a professor at the department of dermatology at Unesp .

A second hypothesis evaluated was the type of filling. “It’s one thing to do one that corrects a small wrinkle, it’s another to do the so-called volumization”, says Miot.

The professor says that most of the complications happened due to the volume of the product, which reinforces the thesis that a more natural correction, without excessive injection in places like cheeks, chins and lips, is more indicated.

“The greater the volume of product, the greater the risk of infection, the greater the risk of tissue reaction, [porque] stays longer in the tissue, causing local hypersensitivity reactions.”

Another problem is the regulation of production and sale. Unlike botulinum toxin, fillers and biostimulators used in so-called “facial harmonizations” are not considered medications from a regulatory point of view.

“You don’t have to prove the efficacy and safety equal to the medicine. If I launch a dipyrone, I have to prove the bioequivalence of mine with the reference on the market. If I launch a hyaluronic acid, no”, warns Miot.

According to the professor, although there is quality control during production, for hyaluronic acid, polylactic acid and calcium hydroxyapatite, the three basic substances evaluated in the research, there is no surveillance of adverse effects and safety.

The main complications reported were nodules (63% of the sample), persistent or intermittent edema (swelling) (62%) and late infection (25%). To a lesser extent, there was arterial occlusion (15%), which leads to necrosis, and skin ulceration (8%).

Researcher Ianhez, who is head of cosmiatry at UFG and a physician at the Hospital for Tropical Diseases, also points out that, although adverse effects occur with all types of products, the incidence varies between brands.

Thus, the complication rates of specific brands were tabulated, but the researchers state, however, that a targeted study is necessary for each one of them, mainly regarding the technology of each manufacturer. To better understand the cases, the sensitivity of the patients must also be evaluated in a new ongoing research.

“Probably, patients who have more autoimmunity, that is, who have more reactivity diseases, rheumatological diseases, react more to these foreign bodies and products”, says Miot.

It is also being evaluated whether the presence of a product such as hyaluronic acid after a viral infection can induce a reaction and swelling. “This is quite common and shows that the product is not completely inert, it is well tolerated, very safe, but it can react and become inflamed after an immune stimulus, such as dengue, Covid, tuberculosis”, says Miot.

Plastic surgeon Luís Maatz reinforces that fillers are safe in specialized hands, but errors are usually difficult to treat. “Non-biocompatible materials, such as methacrylate or hydrogel, should not be used, as they are not completely absorbed by the body, presenting a risk of infection and rejection, with a chance of chronicity and sequelae”, he points out.

Maatz also says that superficial applications in certain areas, such as the lower eyelid, can cause edema and change in skin color. “If tissue necrosis occurs, there will be a need for local care with dressings and reconstruction with skin flaps or grafts, depending on the extent”, he describes.

The treatment of deformities, asymmetries and edema, in turn, ranges from massages on the site to the use of injected hyaluronidase to dissolve the applied product.

“There are many doctors or other professionals (such as dentists, biomedical doctors, pharmacists, nurses, physiotherapists) who claim to be specialists in aesthetics, but are not trained to perform the procedures properly and safely. To minimize the risks, ensure that your doctor is really specialist and have experience”, indicates the surgeon.

For José Horacio Aboudib, member of the SBCP (Brazilian Society of Plastic Surgery) and coordinator of plastic surgery at Uerj (University of the State of Rio de Janeiro), the alleged ease of this type of procedure leads to errors and puts patients at risk.

“Any medical procedure must be performed, however simple it may seem, by a specialist in the subject”, he says.

To choose a professional, the recommendation is to search for information on the websites of the SBCP and the SBD (Brazilian Society of Dermatology).