What is injectible filler and y can it cause blindness? | Safety review

Dermal filler blindness… How common is it? And how safe are injectible fillers?

What are some of the popular types of injectible fillers that you see customers getting in Singapore?

Consumers in Singapore commonly request fillers mainly for either facial volume restoration or contour enhancement.
Common areas include chin fillers, cheek fillers, laugh line fillers and nose fillers.

What are the levels of risks that different injectible fillers carry? Are there some that are riskier than others?

Yes there are. As a general rule of thumb, fillers closer to the midline of the face carry greater risk. Risks can be classified as mild, moderate to high. As per a Polish study in Oct 2020, high risk areas include the glabellar, forehead and nasal area.
Reference: (Witmanowski H, Błochowiak K. Another face of dermal fillers. Postepy Dermatol Alergol. 2020 Oct;37(5):651-659. doi: 10.5114/ada.2019.82859. Epub 2019 Feb 11. PMID: 33240002; PMCID: PMC7675084.)

With any medical procedure, there are risks involved with the use of dermal fillers. Most side effects associated with dermal fillers, such as swelling and bruising occur shortly after injection and many resolve in a few days to weeks. In some cases, side effects may emerge weeks, months, or years later.

As per US FDA website updated 7/7/2023,

Common risks include:

Bruising
Redness
Swelling
Pain
Tenderness
Itching
Rash

Less common risks include:

Inflammation such as swelling or redness may develop near the dermal filler injection site following viral or bacterial illnesses or infections, vaccinations, or dental procedures
Raised bumps in or under the skin
Infection
Allergic reaction
Necrosis (tissue death) | Dermal filler blindness (end organ damage)

How common is dermal filler blindness?

In a systematic review of case reports and case series in 2019, worldwide a total of 190 cases of blindness due to soft-tissue fillers were identified, of which 90 (47%) cases were attributed to autologous fat alone, and 53 (28%) cases were caused by HA. The rest of the cases were attributed to collagen, calcium hydroxylapatite, and other fillers.

The conclusion from that study was that:

Autologous fat was the most common filler associated with blindness despite HA fillers being the most commonly used across the globe. However, the blindness caused by other soft-tissue fillers like collagen and calcium hydroxylapatite was represented. It was also evident through the review that the treatment of HA-related blindness was likely to have better outcomes compared with other fillers due to hyaluronidase use.

Systematic review 2019

Reference: Chatrath, Vandana MSc^*,†; Banerjee, Pooja S. MPharm^‡; Goodman, Greg J. MD, FACD^§; Rahman, Eqram MBBS, MS, PhD^¶. Soft-tissue Filler–associated Blindness: A Systematic Review of Case Reports and Case Series. Plastic and Reconstructive Surgery – Global Open 7(4):p e2173, April 2019.

Based on a study in Germany by Lucaciu et al 2022, there were 2 case reports of dermal filler blindness.

Reference: A., Samp, P.F., Hattingen, E. et al. Sudden vision loss and neurological deficits after facial hyaluronic acid filler injection. Neurol. Res. Pract. 4, 40 (2022). https://doi.org/10.1186/s42466-022-00203-x

In Taiwan in 2023, there was a recent case report of dermal filler blindness in a young lady.

Reference: Wang, I., Lin, HJ., Tsai, YY. et al. Multiple branch retinal artery occlusions following the new facial cosmetic filler (Poly-D, L-lactic Acid) injection a case report. BMC Ophthalmol 23, 86 (2023).

– How does dermal filler blindness happen?

The retinal artery supplies the retina of our eye. If it is blocked, blindness can result. In a meta-analysis by Sito et al in 2019, is understood that blood vessels can be blocked either directly via occlusion or indirectly via external compression.

Reference: Sito G, Manzoni V, Sommariva R. Vascular Complications after Facial Filler Injection: A Literature Review and Meta-analysis. J Clin Aesthet Dermatol. 2019 Jun

How often do injuries from injectible fillers occur?

To my knowledge, in June 2023, there was a Middle East cross sectional study published in Pubmed June 2023.The most commonly reported complications from fillers were bruising (83.1%), bluish discoloration at the injection site (55.4%), and skin redness due to dermatitis (37.7%). Other reported complications included swelling and accumulation of cells under the skin (24.6%)

Reference: (Al Mashhrawi YM et al  AlNojaidi TF, Alkhaldi RA, Alshami NS, Alhadlaq AS. Awareness and Knowledge of the Adverse Effects of Dermal Fillers Among the Saudi Population: . Cureus. 2023 Jun 12;)

Have you seen an increase in people requesting for injectible fillers over the past few years? If yes, what do you think is the reason for the increasing popularity?

Yes we have seen dermal filler requests increase over the past few years. In my opinion, this is partly due to consumers being more aware of their options, and the alternatives to taking a week long leave just to fly to South Korea for plastic surgery.

K pop wave, and in recent years, social media, ( IG, tik tok) have led to consumers being more image ready. Some would like fillers to improve job prospects, others do so to restore lost volume and addresss facial deficits like a recessed chin, sunken cheeks, flat nose etc.

Clinically, as we age, there are various structural changes that occur in the face due to a combination of factors, including volume loss in soft tissues and changes in bone structure. Dermal fillers can be a valuable tool in addressing some of these age-related concerns and helping to restore a more youthful appearance.

1. Volume Restoration: Dermal fillers are commonly used to replace lost volume in the face. As we age, the fat pads under the skin can shrink, leading to hollowed cheeks, sunken temples, and lines around the mouth. Fillers can be injected into these areas to restore volume and create a more youthful contour.
2. Cheek Augmentation: Loss of volume in the cheeks is a common sign of aging. Dermal fillers can be used to augment the cheeks, providing a lifted and more youthful appearance. This can help restore the appearance of high cheekbones.
3. Nasolabial Folds and Marionette Lines: Dermal fillers can soften the appearance of deep lines and wrinkles that form around the nose and mouth, known as nasolabial folds and marionette lines.
4. Lip Augmentation: Dermal fillers can be used to enhance the fullness and shape of the lips, addressing thinning lips that can occur with age.
5. Under-Eye Hollows: Hollows or dark circles under the eyes are common with aging. Dermal fillers can be carefully injected in this area to reduce the appearance of under-eye bags and improve overall facial harmony.
6. Jawline Contouring: Fillers can also be used to improve the definition of the jawline, which may become less distinct with age-related bone loss.
7. Non-Surgical Nose Job: Dermal fillers can be used for non-surgical nose reshaping (rhinoplasty). They can help to correct minor imperfections in the shape of the nose and provide a more balanced appearance.

It’s important to note that while dermal fillers can provide significant rejuvenation and enhancement, they are temporary and will require periodic touch-up treatments to maintain the results. The choice of filler type and technique should be tailored to each individual’s unique facial anatomy and desired outcome.

Before undergoing any cosmetic procedure, it’s essential to consult with a qualified and experienced healthcare provider who can assess your specific needs, discuss the options available, and provide a personalized treatment plan. Additionally, ensure that you choose a licensed and reputable practitioner to perform the procedure to ensure safety and optimal results.

– What is the difference between injectible fillers and Botox?

While it’s true that both Botox® and dermal fillers are injectable treatments used for cosmetic purposes, there are some important differences between them:

Mechanism of Action:

Botox® (Botulinum Toxin): Botox® is a neuromodulator, meaning it works by temporarily paralyzing or relaxing specific muscles. It contains botulinum toxin, which inhibits the release of acetylcholine, a neurotransmitter that signals muscle contractions. This helps to reduce the appearance of fine lines and wrinkles caused by repetitive muscle movements, such as crow’s feet and frown lines.

Dermal Fillers: Dermal fillers, on the other hand, are primarily used to add volume and fill in wrinkles, lines, and hollow areas of the face. They do not paralyze muscles like Botox®. Dermal fillers are typically made of various substances, including hyaluronic acid, collagen, or synthetic materials, and they work by plumping up the skin and soft tissues.

Treatment Areas:

Botox®: It is commonly used to treat dynamic wrinkles, which are caused by muscle movements, like forehead lines and crow’s feet.

Dermal Fillers: Dermal fillers are used to address static wrinkles and areas with volume loss, such as nasolabial folds (smile lines), marionette lines, and hollowed cheeks. They can also be used for lip augmentation and enhancing facial contours.

Duration of Results:

Botox®: The effects of Botox® are temporary and typically last for about 3-6 months. After this period, the muscle activity gradually returns, and wrinkles may reappear.

Dermal Fillers: The duration of results with dermal fillers varies depending on the type of filler used, but they generally last longer than Botox®. Some fillers can provide results for 6 months to 2 years or even longer.

Safety and Side Effects:
Both Botox® and dermal fillers are generally safe when administered by trained and qualified medical professionals. However, they may have different side effects and risks associated with their use.

Combination Use:
It’s not uncommon for people to use Botox® and dermal fillers in combination to address multiple signs of aging. For example, Botox® can be used to relax forehead lines, while dermal fillers can add volume to sunken cheeks.

– What is the cost of dermal fillers and botox in Singapore?

Fillers can be divided into temporary and semi permanent.
Temporary ones are mainly composed of hyaluronic acid. Prices range between $800- 1000 per syringe. Examples include those from Restylane, Boletero, Teosyal and Juvederm. These can last 6 – 15 months.

Semi permanent ones consist either of polycaprolactone, poly lactic acid, Calcium hydroxyapatite, collagen. Examples include Sculptra, Deusaderm, Radiesse, Ellanse, Aesthefill. These can last 15 – 24 months. Prices range from $1300-1800 per syringe. Price per treatment would depend on the number of syringes required.

Botox prices are at $15-20 per unit. Examples include botox, Dysport, Xeomin. Depending on the number of units needed, prices range from $200-300 per area. Price per treatment would depend on the number of areas injected.

What are some regulations that medical practitioners who administer dermal fillers have to be mindful of, and comply with, when providing this service in Singapore?

Some regulations include the use of approved products and an informed consent. In Singapore, we are governed by The Aesthetic Practice Oversight Committee. We are members of Society of Aesthetic Medicine Singapore, presided by Dr David Loh, which organises regular CMEs (continual medical education) for us to keep abreast with the latest safe and effective aesthetic treatments in the field.

The use of medical products that are both US FDA and Singapore HSA approved.
Informed consent. This  refers to the process through which a healthcare provider, typically a physician, informs a patient about the risks, benefits, and alternatives of a proposed medical treatment or procedure, and the patient voluntarily agrees to undergo the treatment or procedure based on this information.

(Here are the key elements of informed consent in the medical context:

Disclosure of Information: The healthcare provider must provide the patient with clear and comprehensive information about the proposed treatment or procedure. This includes details about the diagnosis, the nature of the treatment, its purpose, the expected benefits, potential risks and complications, and any available alternatives.

Understanding: The patient should have a reasonable understanding of the information provided.

Voluntariness: Informed consent must be voluntary, without any form of coercion or pressure.

Capacity: The patient must have the capacity to make a decision.

Documentation: Informed consent is typically documented in writing.

Ongoing Communication: The process of informed consent is not a one-time event. It is an ongoing dialogue between the patient and the healthcare provider.)

How popular are injectible fillers in Singapore and in Asia?

In our clinical practice, 50% of our cases are from injectibles, namely, anti wrinkle treatments, dermal fillers, collagen stimulators, skin rejuvenation etc.Regionally, the Asia Pacific Dermal Fillers Market size crossed USD 1 billion in 2021 and is projected to showcase around 11.3% growth rate between 2022 and 2028.
reference: (https://www.graphicalresearch.com/industry-insights/1547/asia-pacific-dermal-filler-market)

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