Anecdotal observations by Kylie Duncan RN (CosMedic Collective) and Dr John Holbrook (Fresh Clinics)*
Summary
A 50-year-old woman presented with an extreme inflammatory response post lip filler treatment elsewhere 4 months previously. The patient had received several immunizations in the immediate period pre and post filler. After the initial swelling started, the patient was treated for infection which, it quickly transpired, was not the cause of the swelling. An immune-mediated delayed onset inflammatory reaction was diagnosed and the patient was treated with Prednisolone, Doxycycline and Aciclovir followed by a hyaluronidase once swelling had largely settled to dissolve the filler.
Timeline
Donna is a 50-year-old patient who had received a lip filler treatment in a cosmetic clinic in Western Sydney on 24 July 2021.
On 21 July 2021, Donna, a registered nurse, had received her flu vaccination and on 28 July she had her first Covid vaccination (Pfizer). On 30 August, Donna received her second vaccination (Pfizer).
In October 2021, Donna had a botulinum toxin lip flip procedure at a local clinic in Orange, NSW. In early November, Donna experienced Covid-like symptoms, however her results came back as negative on a rapid antigen test.
On 19 November, Donna presented to CosMedic Collective with what she had described started as a cold sore-like appearance but had developed into further localised swelling. On examination, it had a nodular feel to it and appeared inflammatory. As the CosMedic Collective team did not yet know her health history and since Donna was not an existing patient, Kylie Duncan, RN, recommended Donna visit her GP for further investigation in order to clear any presence of infection and if the symptoms persisted to return to dissolve the filler.
The GP suspected an infectious reaction and commenced her on antibiotics on 20 November. The antibiotics had minimal effect, and swelling and pain increased over the following days.
Donna presented to the local Emergency Department on 23 November and underwent aspiration to rule out infection which did result in localised bruising but nil infectious process was found. Donna was cleared from having an infection, but high inflammatory markers were present. Donna was discharged from ED to her local GP for further investigation.
Donna presented to her GP on the 24 November with excessive pain and swelling. The GP was unfamiliar with such a presentation and rang CosMedic Collective for consultation. Kylie was familiar with Donna from presenting the previous week when her symptoms had started. Kylie did not claim any expertise in this particular case, however in light of what Donna had already been through, Kylie agreed to review her in conjunction with the medical team at Fresh Clinics.
Upon arrival, Kylie took Donna into a consulting room. What she saw is presented in the first photo. Donna was incredibly distressed and in a lot of pain. Kylie provided reassurance and got permission from Donna to take a photo to send to Dr John Holbrook, co-director of Fresh Clinics for advice.
Kylie called Dr Holbrook over FaceTime. He suspected an immune- mediated inflammatory process and prescribed Prednisolone and Doxycycline to commence immediately. As Donna had mentioned that the initial response looked like a cold sore in appearance, she was commenced on Aciclovir as well. Forty-eight hours post commencement of treatment, her inflammation was visibly reduced.
Donna had an appointment to dissolve the filler with hyaluronidase with CosMedic Collective nurse Sammi on 8 December. After further Facetime consultation with Dr Holbrook, Sammi commenced a hyaluronidase protocol; 1500u of Hyalase was diluted into 2ml saline with 1ml 1% xylocaine. Test patch was administered with no allergic response. Sammi gave 425u via BD syringe and performed massage post treatment.
Donna was rebooked for a second treatment on 13 December with a further 425u planned, however one week post hyalase treatment Donna was feeling much recovered, despite the fact that she could still feel filler present. She was advised to have further sessions of hyaluronidase but was happy with the size. We explained the risk of a recurrent inflammatory response but she accepted the risk and wanted to keep the remaining product in situ.
Points For Discussion
- Over 6 months since her treatment Donna has had no further issues and has fully recovered from her ordeal (picture below) and would like further filler treatment. In discussion with our peers and colleagues, opinion remains divided on whether we should treat Donna with lip filler after such a strong reaction.
- We obtained notes from the clinic where Donna was treated with the filler and were able to get the batch and lot number of the product and reported it to the company. The product is regularly used in our own clinic with good results. The distributors were very receptive and appreciative for the information and followed up on Donna’s case as well as lodged an investigation on their end, with no issues arising from the product itself.
- Immunization dates so close to Donna’s original treatment have been floated as one possible theory for why this occurred. To reiterate the timeline, Donna had her flu vaccination on 21 July, filler on 24 July and her Pfizer Covid vaccination on 28 July, 2021.
- While there have been no documented cases that we can find of delayed inflammatory response as a result of neuromodulator treatment in nearby areas, the fact that Donna had a lip flip with botulinum toxin 6 weeks before the inflammation presented should still be taken into account for consideration as to the cause.
- Educating GPs and emergency room staff as to the potential complications from filler so they can be treated in a timely manner is an important discussion point. It is well noted
- in the aesthetic community that aesthetic complications are often not picked up in a timely manner in general practice or emergency departments – particularly in geographical areas where aesthetic practice isn’t common. On revision of this case, Kylie regrets sending Donna to her GP. Even though she was not originally treated at CosMedic Collective, thanks to the experience of the team and the support of the aesthetic community we feel that clinics such as ours are uniquely placed to help patients with adverse aesthetic outcomes, even if they are from other locations.
- Clinical support is everything!
This case is an excellent example of the importance of establishing a community of clinical support. Fresh Clinics, AMET, clinical trainers, peers and mentors were all involved in Donna’s case (with her permission), allowing the team at CosMedic Collective to treat this adverse outcome confidently and effectively. AMP
*Disclaimer: patient has consented in writing to her name and image being used in this article.
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