Identifying and Managing Abscess Formation Related to Soft-Tissue Fillers

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.