It’s a question asked recently by a realself.com patient who explained that after undergoing a filler injection procedure, an at-home traumatic event in the same area caused a large bruise that resulted in a permanent indentation. This patient wants to know, can trauma displace fillers?
With an increase in filler injections by non-core physicians and ancillary staff, as well injections for “off-label” indications, there has been a dramatic increase in reported complications. Expected side effects are most typical of the injection procedure itself rather than the product used, and rare complications are more frequently due to poor technique, lack of experience, or just frank bad luck. As stated in my previous post, Are visual flashes related to injectable fillers around the eyes?, three of the most concerning symptoms after injectable filler treatment are significant pain out of proportion to normal, a change in skin color beyond the typical redness from injection, and/or visual changes. Each of these symptoms has a serious implication; however, most symptoms patients experience after treatment are minor and transitory. In this particular case, here’s why a large bruise and indentation likely happened:
While filler rarely migrates, it has been reported at distant sites and in different planes (superficially) from injection. This may be a result of the technique used, but also at-home management. I have seen inflammatory reactions, product migration, excessive swelling, and extensive bruising from hot yoga, massage table or CPAP machine/mask pressure, and trauma to treatment areas early post-treatment. In addition, a handful of these patients have clinically demonstrated indentations and/or atrophy in the trumatized areas—a condition known as truamatic panniculitis.
Traumatic panniculitis refers to changes in the subcutaneous fat related to physical or chemical agents. As seen in patients from my clinical practice, the picture is that of indurated, warm, red or blue, subcutaneous plaques or nodule. Histologically fat microcysts are surrounded by histiocytes, foam cells, and mixture of inflammatory cells. There may be fibrosis, lipomembranous changes, or calium deposits. The reaction is not necessary related to the intensity of the injury, as even small stimuli such as acupuncturecan elicit a large area of effect.
Treatment Options for Truamatic Panniculitis
The best treatment is avoidence by advising proper at home care:
Supply detailed post-treatment instructions to each patient
Suggest avoidence of manipulation or trauma to treated areas for 24 to 48 hours after treatment
Avoid intese exercise or extremes of temperatures, as well as application of chemicals or irritants to treated areas
In cases with active inflammation, oral antiinflammatories and warm compresses may be helpful to resolve the reaction. It is best to avoid injectable corticosteroids as they can worsen the condition (additional trauma) or exacerbate atrophy (corticosteroid induced). Once the inflammation has subsided, fat grafting or additional filler can be used to treat the irregularity.
What Can We Learn From This Post?
The most important take-home message of this patient query is the need to educate your patients on the potential complications from filler injetions and supply them with comprehensive at-home care guidelines. Truamatic panniculitis can occur in treated areas and it is unlikely due to the filler treatment itself but a result of a subsequent truama.
The prevaling perception is that filler treatments are quick, painless, risk-free and instantly gratifiying; the so-called “lunch time” procedure without any worry. However, it is my view that filler treatments require a more sophisticated methodology:
The technique itself should be treated as any surgical treatment in terms of using a sterile approach, with alcohol and chlorhexidine (Hibiclens) applied to the treatment areas prior to injection.
Patients should be informed and instructed on proper at-home care of the treated areas to limit the more serious consequences of necrosis and infection, as well as migration and asymmetries.
Manipulation of the treatment areas with massage (except for Sculptra) should be avoided for at least 24 to 48 hours after treatent.