The new guideline appears in the February 2021 issue of Dermatologic Surgery.

The American Society for Dermatologic Surgery (ASDS) Multispecialty Soft-tissue Fillers Guideline Task Force has released its evidence-based recommendations for physicians performing injectable filler procedures including best practices for preventing and treating vascular occlusion, nodules, and other potential complications.

The new guidelines appear in the February 2021 issue of Dermatologic Surgery.

“Evidence-based clinical guidelines provide a critical resource for physicians, and ASDS strives to be recognized as the authoritative source on the science of surgical interventional treatments of skin aging and skin disease,” says Derek Jones, MD, Chair of the ASDS Soft-tissue Fillers Guideline Task Force, in a news release. “We have gathered the best available evidence within the scientific literature to form the basis for best practices in patient care for soft-tissue filler injections.” 

Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the task force identified six critical questions to focus the guidelines and inform the literature research. The questions gauged risk factors for vascular occlusion; treatments for blindness; treatment of vascular occlusion of the skin without blindness; risk factors for nodules and inflammatory events with hyaluronic acid fillers; treatments for nodules and inflammatory events; and risk factors for nodules and inflammatory events from non-hyaluronic acid fillers.

ASDS commissioned the Mayo Clinic Evidence-based Practice Center to conduct systematic reviews to extract the data and summarize the relevant evidence. The guidelines specify recommendations for the:

• Prevention of vascular occlusion, blindness, stroke.
• Treatment of filler related vascular occlusion with blindness.
• Treatment of vascular occlusion (skin) without blindness.
• Treatment of nodules and inflammatory events from hyaluronic acid fillers.
• Treatment of nodules caused from permanent and semi-permanent fillers

Practice-changing Implications

Reducing risk of vascular occlusion, blindness, or stroke starts with thorough knowledge of facial anatomy including blood vessels and relevant cutaneous landmarks, the new guidelines state.

“Vascular occlusion, blindness and stroke are certainly huge fears,” says task force member Chapel Hill, NC-based dermatologist Sue Ellen Cox, MD (pictured).

The nose, glabella, forehead, and maybe the temples, to a lesser extent, are extra high-risk areas for these complications.

“The guidelines have really outlined the facial anatomy incredibly well including where Important blood vessels are and where they connect,” she says.

Some individuals with deeply etched glabellar lines may seek filler on top of neuromodulators, but Dr. Cox is no longer planning to use filler in this area due to heightened risks. “It is such a high-risk location that we urge great caution even for the most expert physicians,” she says. “I will now just do laser resurfacing, microneedling, or another technology where I can affect and improve these static lines without sticking filler in them,” she says.

To avoid nodules and inflammatory events after hyaluronic acid injection, the task force suggests using the smallest bolus possible such as 0.1 to 0.2 mL and making sure patients have not had dental procedures or invasive diagnostic and surgical procedures for more than two weeks before or after fillers.

Nodules may be related to a heigtened immune response or infection, and doctors often have to play detective to figure out the precise etiology, Dr. Cox says.

Treatment options for hypersensitivity reactions include oral steroids, hyaluronidase, intralesional triamcinolone with or without 5-fluorouracil, or a watch-and-wait approach, she says.

Feel the nodule, she suggests. “If it is tender and red that often times relates to hypersensitivity, but if it is fluctuant, soft, and warm, we put a needle in and see if there is pus and if there is, we culture it and put the patient on broad-spectrum antibiotics, she says.  Biofilm infection around the filler can be more challenging to treat, she notes. 

Sometimes it’s OK to hedge. “If I suspect some hypersensitivity, but am not 100 percent sure there isn’t an underlying infection, I will prescribe doxycycline with steroids to cover both things."

(Watch this video to find out how dermal fillers may affect risk of facial swelling after COVID-19 vaccination.)

The multidisciplinary task force was assembled in 2018 and consisted of ASDS member physicians (eight board certified in dermatology, two in plastic and reconstructive surgery, one in ophthalmology), two patient representatives and a methodologist:

• Derek Jones, MD, Chair
• Murad Alam, MD, MBA
• Kimberly Butterwick, MD
• Jean Carruthers, MD (Oculoplastic Surgery)
• Sue Ellen Cox, MD
• Steve Dayan, MD (Facial Plastic Surgery)
• Lisa Donofrio, MD
• Rebecca Fitzgerald, MD
• Shannon Humphrey, MD, FRCPC
• Nowell Solish, MD
• Jackie Yee, MD (Plastic Surgery)
• M. Hassan Murad, MD, MPH, Methodologist
• Shari Weiss, Patient Representative
• Lisa O’Keefe, Patient Representative