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Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results

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Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.
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PERSPECTIVES
Current Practices in Hyaluronic Acid Dermal
Filler Treatment in Asia Pacic and Practical
Approaches to Achieving Safe and
Natural-Looking Results
Niamh Corduff
1
, Lanny Juniarti
2
, Ting Song Lim
3
, Frank Lin
4
, Kavita Mariwalla
5
, Tatjana Pavicic
6
,
Arnelle Quiambao
7
, Tuck Wah Siew
8
, Atchima Suwanchinda
9,10
, Fang Wen Tseng
11
,
Vasanop Vachiramon
10
, Choon Shik Youn
12
, Wilson WS Ho
13
1
Cosmetic Renement Clinic Geelong, Victoria, Australia;
2
Miracle Aesthetic Clinic, Surabaya, Indonesia;
3
Clique Clinic, Kuala Lumpur, Malaysia;
4
Eastern Plastic Surgery, Victoria, Australia;
5
Mariwalla Dermatology, New York, NY, USA;
6
Private Practice for Dermatology & Aesthetics of
Dr. Tatjana Pavicic, Munich, Germany;
7
YouPlus Intelligent Aesthetics Clinic, BGC Taguig City, Philippines;
8
Radium Medical Aesthetics, Singapore;
9
Department of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand;
10
Division of Dermatology, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand;
11
Milano Aesthetic Clinic, Taoyuan City, Taiwan;
12
Yemiwon Dermatologic Clinic, Seoul,
Korea;
13
The Specialists: Lasers, Aesthetic & Plastic Surgery, Central, Hong Kong
Correspondence: Niamh Corduff, Cosmetic Renement Clinic Geelong, T9 400 Pakington St, Newtown VIC, Victoria, 3220, Australia,
Tel +61 407122578, Email niamh.crc@outlook.com
Abstract: Complications such as delayed inammatory reactions (DIRs) and unnatural outcomes can sometimes arise from
hyaluronic acid (HA) dermal ller treatments and can be challenging to address. Given the popularity of HA dermal llers for
aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10
regions in Asia Pacic who administer HA llers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global
experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal llers.
From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA ller, aseptic technique,
and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the
rheological properties and behavior of different HA llers, and being conservative in treatment approach. The panel developed
a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considera-
tions were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA ller, adequate
knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for
education efforts to increase awareness of differential immunogenicity between HA llers and to improve understanding on the
importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support
practitioners in optimizing safety and quality of aesthetic treatment with HA llers.
Keywords: hyaluronic acid dermal ller, consensus, practical approaches, safe, natural-looking outcomes, current practices
Introduction
Hyaluronic acid (HA) dermal llers are one of the most common nonsurgical modalities in aesthetic medicine due to
their ease of administration, quick onset of action and minimal recovery time for patients.
1
Although HA llers are
useful for facial rejuvenation and soft-tissue augmentation,
2–4
complications such as delayed inammatory reactions
(DIRs) and aesthetically unpleasant outcomes can arise, in addition to common side effects like bruising, swelling and
redness.
5,6
While there are discrepancies in the denition of DIRs in the literature, in this article, DIRs are dened as large,
tender, erythematous nodules with surrounding edema presenting ≥14 days after ller placement.
7
Although DIRs are
Clinical, Cosmetic and Investigational Dermatology 2022:15 1213–1223 1213
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Clinical, Cosmetic and Investigational Dermatology Dovepress
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Open Access Full Text Article
Received: 24 February 2022
Accepted: 17 June 2022
Published: 1 July 2022
uncommon and may resolve spontaneously, more often than not, additional interventions are required to promote
resolution; they can be challenging to treat and can lead to permanent sequelae if not managed properly.
5,7
Aesthetically unpleasant outcomes manifest as overlled appearance, surface irregularities, bumps/nodules, dispro-
portionate face, distorted appearance, etc.
5,6
They may be caused by overlling of ller, inappropriate ller choice, and
inappropriate placement of ller.
5,6
While some of these unpleasant outcomes may resolve spontaneously, others require
remedial interventions that may not necessarily restore the original anatomy and patient appearance.
5,6
Therefore, it is best to take precautions to avoid these undesirable complications to improve patient safety and the
quality of aesthetic outcomes. This article reports the current practices in HA dermal ller treatment in Asia Pacic
pertaining to the knowledge of practitioners in preventing DIRs and achieving pleasant, natural-looking outcomes. It also
includes relevant recommendations and a concise reference guide to support good practices among aesthetic practitioners
who administer HA llers.
Survey on HA Dermal Filler Treatment and Panel Discussion
An online survey was conducted to understand the current practices in HA dermal ller treatment in Asia Pacic. As
the survey only collected information on treatment practices, ethics approval was not required. Practitioners from 10
regions in Asia Pacic completed the online survey between May and June 2021. A panel comprising 13 clinical
experts with extensive experience in using HA llers, known as the Senior Aesthetics Filler Experts (SAFE) council,
convened in a virtual meeting in July 2021 to review and discuss the survey ndings, and establish a consensus for
safe and appropriate use of HA dermal llers. Specically, they proposed recommendations and practical approaches
to prevent and manage DIRs and achieve natural-looking results. The panel consisted of aesthetic physicians,
dermatologists, and plastic surgeons from Australia, Germany, Hong Kong, Indonesia, Malaysia, the Philippines,
Singapore, South Korea, Taiwan, Thailand, and the United States. The voting results were graded as follows: strong
consensus (>95% agreement); consensus (>75% to 95% agreement); majority consent (>50% to 75% agreement); and
no majority consent (≤50% agreement). The denition of DIR described by Artzi and colleagues
7
was adopted for this
work.
Current Practices in HA Dermal Filler Treatment in Asia Pacic
Two hundred practitioners in Asia Pacic took part in the survey. They had an average of 9.4 (SD 4.8) years of
experience in using HA llers. Practitioners from South Korea (33%), Thailand (20%), and Taiwan (15%) made up 68%
of the survey participants, whereas those from the Philippines (7%), Australia (6%), Indonesia (6%), Hong Kong (5%),
Singapore (4%), Malaysia (2%), and New Zealand (2%) constituted the remaining 32%. The majority were aesthetic
general physicians (64%) and the rest included dermatologists (27%), plastic surgeons (8%), and non-physician practi-
tioners (1%).
Practitioners’ Views and Practices Pertaining to DIRs
Close to three-quarters (74%) of the practitioners reported having encountered patients who had DIRs.
7
When asked to
rate the incidence of DIRs in their practice, 12% rated DIRs as common (1:100 patients), whereas 88% rated the
incidence as low (1:1000 patients) or extremely low (<1:1000 patients). HA cross-linking technology, patients’ health
condition, and break in aseptic technique were identied as the top three risk factors for DIRs (Figure 1A). Choosing an
appropriate HA ller technology and avoiding products that seem to be more prone to DIRs, aseptic technique, and
patient selection were the top three measures to reduce the risk of DIRs (Figure 1B). About half (52%) viewed HA llers
with a higher composition of low molecular weight-hyaluronic acid (LMW-HA) as associated with a higher risk of DIRs
(Figure 2). Half of the practitioners indicated they do not perceive any difference in the risk of DIRs between different
HA ller technologies. Of those who did, two-thirds perceived Vycross
®
technology to have the highest risk of DIRs
(Figure 3).
In terms of the strategies used to manage these delayed reactions, broad spectrum antibiotics, oral corticosteroids, and
intralesional hyaluronidase were most frequently used as early treatment options, whereas surgical excision was used as
a last resort treatment (Figure 4).
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Practitioners’ Views and Practices Pertaining to Natural Outcomes
Nearly all practitioners indicated it is very important (92%) or rather important (5%) to create a natural outcome for their
patients. Practitioners viewed overlling (90%), surface irregularities (88%), bumps/nodules (86%), disproportionate face
12%
20%
28%
29%
29%
33%
45%
61%
63%
77%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
Others
Intramuscular implantation
Repeated injections
Site of injection
Perioral injections or injections through oral
mucosa
History of upper respiratory infection
Large bolus injections
Break in aseptic technique
Patients’ health condition
HA cross-linking technology
Percentage of practitioners (n=200)
4%
40%
44%
46%
48%
55%
66%
74%
90%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Others
Limit the number of injection or entry sites
Avoid injections through oral mucosa
Apply an antiseptic/antibiotic cream post-injection
Avoid large bolus (>0.2 mL) injections
Post-treatment care
Patient selection
Thorough cleansing, proper skin preparation and
maintaining aseptic technique
Choosing an appropriate HA filler technology and
avoiding products that seem to be more prone to DIRs
Percentage of practitioners (n=200)
A
B
Figure 1 Practitioners’ views and practices pertaining to DIRs. (A) Risk factors for DIRs. Top three factors are marked by the box. (B) Measures for reducing the risks of
DIRs. Top three measures are marked by the box.
Abbreviations: DIRs, delayed inammatory reactions; HA, hyaluronic acid.
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(81%), and distorted appearance (79%) as unnatural outcomes. They cited poor technique (such as large bolus injections and
wrong layer of injection), and the use of HA llers that do not integrate well into the underlying tissue as the main causes of
unnatural outcomes in treatment with HA ller (Figure 5A). When were asked about the treatment strategies used to achieve
natural outcomes with HA llers, treatment customization, understanding the rheological properties and behavior of different
HA llers, and being conservative in treatment approach were the key strategies reported (Figure 5B).
Yes
52%
(n=104)
No
48%
(n=96)
Higher risk of DIRs with higher
composition of LMW-HA
3%
4%
9%
13%
20%
50%
0% 10% 20% 30% 40% 50% 60%
Others (specify)
Puresense technology
Hylacross technology
NASHA technology
CPM technology
Vycross technology
Percentage of practitioners (n =104)
HA filler technology with the highest % of
LMW-HA
AB
Figure 2 Practitioners’ perception on the association between (A) LMW-HA and risk of DIRs, and (B) LMW-HA and HA llers.
Abbreviations: CPM, cohesive polydensied matrix; DIRs, delayed inammatory reactions; LMW-HA, low molecular weight-hyaluronic acid; NASHA, nonanimal stabilized
hyaluronic acid.
I don’t see any risk
differences between
all the filler
technologies
50%
(n=100)
Vycross technology
33%
(n=66)
Hylacross
technology
8% (n=17)
NASHA technology
5% (n=11)
CPM technology
2% (n=3) Puresense
2% (n=3)
Highest risk of DIRs
Figure 3 Practitioners’ perception on the risk of DIRs among different HA llers technologies.
Abbreviations: CPM, cohesive polydensied matrix; DIRs, delayed inammatory reactions; HA, hyaluronic acid; NASHA, nonanimal stabilized hyaluronic acid.
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Panel Perspectives
Overall, the panel shared that the views and practices of practitioners in Asia Pacic are largely in line with their
experience. The panel added that although choosing an appropriate HA dermal ller and ensuring strict adherence to
aseptic technique are important measures for minimizing the risk of DIRs, it is also essential for practitioners to have an
adequate knowledge of facial anatomy, and to use proper injection techniques. Collectively, these measures are
fundamental for achieving safe and natural outcomes for patients.
5,8–11
The survey revealed limited awareness of differential immunogenicity between different HA llers and the relevant
inuencing factors among practitioners in Asia Pacic despite published evidence.
12–18
Although practitioners recognized the
importance of choosing HA llers that are less prone to DIRs for treatment, close to half did not perceive high composition of
LMW-HA as relating to higher risk of DIRs and half did not seem to be aware of any difference in the risk of DIRs between
different HA ller technologies (Figures 1B,2and 3). The panel acknowledged the need for educational efforts to improve
knowledge on the different HA ller technologies and their associated risk of DIRs among practitioners in Asia Pacic to
support them in making informed decisions when selecting an appropriate HA ller for their patients.
Consensus and Practical Approaches to Achieving Safe and
Natural-Looking Results with HA Dermal Fillers
The panel shared their experiences and expertise with HA dermal ller treatment, and established a consensus for the safe
and proper use of HA llers. The consensus statements (Table 1)
12–19
and the panel’s recommendations relating to HA
ller treatment (described in the sections below) are summarized into a concise reference guide (Figure 6). The guide is
not intended to provide detailed instructions on how to prevent DIRs or attain natural-looking results, which are already
available in published literature,
5,6,8–11,20,21
but rather to highlight practical considerations to support practitioners in
customizing their treatment plans based on the unique conditions and needs of the individual patient.
Consensus on HA Dermal Filler Treatment Pertaining to DIRs
The panel expressed high level of agreement with statements 1–6 (Table 1). They recognized that most practitioners will
encounter DIRs in their practice and pointed out that it is important for practitioners to adopt a proactive approach to
avoid these complications, and be able to recognize and manage them when they do occur. The panel noted three
important risk factors for DIRs—llers with higher immunogenic potential, break in aseptic technique, and poor injection
56%
21%
9%
7%
29%
35%
24%
12%
40%
26%
15%
5%
28%
18%
6%
4%
6%
4% 4% 4%4% 3% 4% 4%
10%
13% 13%
4%
1% 3% 4% 4%
1% 3%
11%
24%
0%
10%
20%
30%
40%
50%
60%
Step 1 Step 2 Step 3 Step 4
)002=n(srenoititcarpfo
eg
at
n
ecreP
Broad-spectrum antibiotics Intralesional hyaluronidase Oral corticosteroid
Anti-inflammatory drugs (NSAIDs) Topical therapy Others
Intralesional steroid 5-FU injection Surgical excision
Figure 4 Strategies employed by practitioners to manage DIRs.
Abbreviations: DIRs, delayed inammatory reactions; 5-FU, uorouracil; NSAIDs, nonsteroidal anti-inammatory drugs.
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technique. In addition, the panel acknowledged that any condition or procedure that can cause a systemic or localized
immune response such as known ongoing infections, dental procedures, vaccinations, etc, can also trigger the onset of
DIRs. It was recommended that practitioners consider patients’ medical history and other medical procedures when
creating a treatment plan for their patients
8–10
(Figure 6). In the case of patients with an ongoing infection, ller treatment
should be deferred until the condition is resolved. For patients who have other medical procedures such as dental
procedures, vaccinations (including COVID-19 vaccinations), etc, it was recommended that such procedures be
5%
74%
84%
87%
88%
0% 20% 40% 60% 80% 100%
Others
Site of injection
HA fillers that do not integrate well
Wrong layer of injection
Large bolus injections
Percentage of practitioners (n=200)
3%
77%
84%
88%
90%
90%
0% 20% 40% 60% 80% 100%
Others
Use only HA fillers which integrates well
Master the facial anatomy and the
required support for each compartment
Being conservative, using only adequate
amount of volume and/or undercorrect
when using HA fillers
Understand the unique rheological
properties of different HA fillers and how
they behave post injection
Customize treatment plan according to
individual patients’ needs
Percentage of practitioners (n=200)
A
B
Figure 5 Practitioners’ views and practices pertaining to unnatural outcomes. (A) Causes of unnatural outcomes. (B) Strategies for avoiding unnatural outcomes with HA
llers.
Abbreviation: HA, hyaluronic acid.
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performed at least 2–4 weeks before or after ller treatment to minimize the risk of complications. The development of
a DIR following COVID-19 vaccinations has been postulated to occur via the inactivation of angiotensin-converting
enzyme receptor 2 (ACE2). Published case reports suggest the use of ACE inhibitors as a possible alternative to oral
Table 1 Consensus Statements on HA Dermal Filler Treatment Pertaining to DIRs and Natural Outcomes
Statements Agreement
(%)
DIRs
1. Most doctors will encounter DIRs in their practice, so they should be aware of how to recognize and manage them 100
2. Different HA-cross linking technologies produce HA dermal llers of varying immunogenicity. Using HA dermal llers with high
immunogenicity is the most important factor for the development of DIRs, followed by break in aseptic technique, and poor
injection technique.
100
3. Any condition that can cause a systemic or localized immune response such as viral exposure or dental procedures may trigger
the development of DIRs.
100
4. The SAFE expert panel echoed the assessment by ASDS
19
that DIRs very rarely occur with both HA and non-HA dermal
llers.
92
5. The SAFE expert panel agreed with the ASDS recommendation
19
that patients who have received dermal ller treatment
should not be discouraged or precluded from receiving vaccines of any kind, and vice versa.
100
6. Patients who have received COVID-19 vaccination should be advised to delay HA dermal ller treatment for at least 2–4
weeks post vaccination.
100
7. HA dermal llers with a higher composition of LMW-HA (<1000 KDa) are associated with a higher risk of DIRs.
12,13
100
8. Published evidence suggests increased incidence of DIRs with Vycross
®
technology HA dermal llers.
12,16–18
One hypothesis
for the greater inammatory response relates to the high composition of LMW-HA in Vycross
®
llers.
12,16–18
100
9. As LMW-HA is associated with increased proinammatory activity which could trigger DIRs,
14,15
practitioners should consider
choosing a HA dermal ller containing a lower percentage of LMW-HA for treatment.
100
10. Choosing HA dermal llers that are more immunologically inert, ensuring strict adherence to aseptic technique, and using
proper injection technique are key measures that can be taken to reduce the risk of DIRs.
100
11. DIRs can present as a spectrum of reactions that require physician assessment and appropriate tailored responses, which can
range from the use of broad-spectrum antibiotics, oral steroids, and/or intralesional hyaluronidase to surgical excision to
manage these reactions.
100
12. For severe DIRs, a combination of broad-spectrum oral antibiotics, intralesional hyaluronidase, and oral steroids can be used
to manage the symptoms.
85
13. The approach for managing recalcitrant DIRs can include intralesional hyaluronidase injection under ultrasound guidance or
a combination of intralesional hyaluronidase and 5-FU, with surgical extraction reserved as a last resort.
100
Natural outcomes
14. Unnatural outcomes are characterized by overlling, surface irregularities, bumps/nodules, disproportionate face, and
distorted appearance.
100
15. Attaining natural outcomes is a very important consideration when performing HA ller treatment. 100
16. Poor technique (large bolus injections, wrong layer of injection, etc) and inappropriate selection of HA llers are causes of
unnatural outcomes in HA ller treatment
100
17. Filler treatment plan should be individualized, respecting patient’s anatomical structure and avoiding one-size-ts-all treatment
approach that can produce unnatural outcomes.
100
18. Safety and natural outcomes are more important factors to consider when choosing a HA dermal ller than longevity of
a ller.
100
19. Using HA dermal llers with excellent tissue integration leads to a more natural outcome. 100
20. Treatment customization, understanding the HA dermal ller rheological properties and behavior, and being conservative in
treatment strategy are important measures to avoid unnatural outcomes.
100
21. Proper education to improve the understanding of the importance of preserving aesthetic individuality is vital for achieving
optimal outcomes.
100
22. As physicians, we have a non-malecence duty of care to educate patients on the importance of safe injection procedures and
avoiding unnatural treatment outcomes.
100
Abbreviations: ASDS, American Society for Dermatologic Surgery; DIRs, delayed inammatory reactions; 5-FU, 5-uorouracil; HA, hyaluronic acid; LMW-HA, low
molecular weight-hyaluronic acid; SAFE, Senior Aesthetics Filler Experts.
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steroids for managing the reaction should it arise.
22,23
The panel concurred with the recommendations from the ASDS
guidance that was issued in response to reports of COVID-19 mRNA vaccine-related adverse events in patients with
dermal ller.
19
The majority of the panel members agreed that the risk of developing DIRs following ller treatment is
rare. Hence, there was a strong consensus that such potential complications should not hinder patients from taking
vaccines (including COVID-19 vaccines).
The panel pointed out that although HA llers are generally well tolerated and have a favorable safety prole, there is
differential immunogenicity between different HA llers, which is inuenced by several factors including the molecular
weight of HA, crosslinking and manufacturing technologies, etc.
24
The incidence of DIRs to HA ller treatments has
been reported to range from around 0%–4.3% across different HA ller products.
16,17
Hence, the panel recommended
that practitioners be aware of the immunogenicity of different HA llers and the inuencing factors when selecting an
appropriate ller for their patients. Reports have shown that HA dermal llers with a higher composition of LMW-HA
(<1000 kDa) are associated with a higher risk of DIRs.
12,13
Published evidence suggests increased incidence of DIRs
with Vycross
®
technology HA dermal llers.
12,16–18
One hypothesis for the greater inammatory response relates to the
high composition of LMW-HA in Vycross
®
llers, which is proinammatory and could trigger DIRs.
12,14–18
Hence, it
was recommended that practitioners consider a ller product containing a lower percentage of LMW-HA for treatment
(Table 1).
The panel recommended three measures that are fundamental for avoiding DIRs—choosing an appropriate HA
dermal ller with low immunogenic potential, ensuring strict adherence to aseptic technique, and using proper injection
technique which requires an adequate knowledge of facial anatomy, in particular of deep spaces, different fat compart-
ments, and muscle–bone relationship
8–10
(Figure 6) (Table 1). The panel stressed that strict adherence to aseptic
technique is important for minimizing the risk of DIRs. Injections can increase the chance of bacteria passing through
the skin and causing a biolm infection, which can induce the development of chronic nodules and granulomatous
inammation.
25
Hence, it was recommended that patients’ skin be thoroughly cleaned and disinfected before injection.
Aseptic technique should be adhered to throughout the procedure and practitioners should exercise continuous vigilance
against possible contamination. Patients should be advised to delay putting on makeup and avoid touching the treated
area for at least 12 hours after injection. The panel also addressed the importance of proper injection technique to avoid
DIRs. Due to high numbers of bacteria in the perioral areas, practitioners are advised to take additional precaution when
Figure 6 Practical considerations for creating an individualized treatment plan to achieve safe and natural-looking results.
Abbreviation: HA, hyaluronic acid.
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injecting these areas, and avoid injecting through the oral mucosa. Studies show that large bolus ller injections can
trigger the occurrence of DIRs, and multiple injections can increase the risk of bacterial contamination,
25,26
hence the
panel recommended limiting ller volume and the number of injection sites, according to patient’s aesthetic needs,
treatment area, and product selected. In line with published guidance,
5,8
the panel pointed out that it is pertinent for
practitioners to have a thorough knowledge of facial anatomy and a clear understanding of the appropriate depth and
plane of injection. It is also important to understand how each ller intercalates with the skin at different depths.
27–32
For
example, what can be placed supercially and what will easily intersperse with fat in areas like the mid face.
The panel recognized that DIRs can present as a spectrum of clinical manifestations with varying etiology that require
distinct treatments (Table 1). It was recommended that practitioners rst assess patients to differentiate DIRs from non-
inammatory nodules. The development of DIR-related nodules can be attributed to biolm and granulomatous
reactions.
25
The panel agreed that the strategies for treating DIRs can include broad-spectrum oral antibiotics, oral
steroids, and/or intralesional hyaluronidase, with surgical excision used as a last resort.
5,7,9,33,34
Oral antibiotics should be
prescribed rst, before oral steroids or intralesional hyaluronidase are considered. For severe DIRs, the majority of the
panel recommended using a combination of broad-spectrum oral antibiotics, intralesional hyaluronidase, and oral steroids
to manage the symptoms. However, a few panel members noted that they prefer to separate the use of oral antibiotics and
oral steroids to distinguish pure hypersensitivity reaction from bacterial biolm. For recalcitrant DIRs, it was agreed that
intralesional hyaluronidase alone or in combination with 5-FU can be used for treatment. Triple combination including
intralesional hyaluronidase, 5-FU, and triamcinolone can also be used, with surgical extraction reserved as a last resort.
The panel recommended using ultrasonography to determine the location of the injected ller and to guide the precise
delivery of hyaluronidase.
35
The panel recommended treatment with broad-spectrum antibiotics for a week. Treatment
duration with oral steroids is recommended to be between 1 and 2 weeks, depending on the severity. If intralesional
steroid is administered, it is recommended to be given at every 3–4 weekly interval. Most of the panel members
recommended weekly intralesional hyaluronidase injection.
Consensus on HA Dermal Filler Treatment Pertaining to Natural Outcomes
The panel agreed to dene unnatural outcomes as overlled appearance, surface irregularities, bumps/nodules, dispro-
portionate face, and distorted appearance that manifest after ller treatment (Table 1). Considering patients can be
distressed with such unpleasant outcomes and the potential risk of permanent sequelae,
5,6
the panel stressed the
importance for practitioners to adopt proactive strategies to achieve natural outcomes for their patients when using
HA llers in aesthetic procedures. They noted two key causes of unnatural outcomes—poor technique and inappropriate
selection of HA llers—which practitioners should be aware of.
5,6
The panel recommended three important measures that practitioners should adopt for achieving aesthetically pleasant
outcomes for their patients: choosing an appropriate HA dermal ller, having adequate knowledge of facial anatomy, and
using proper injection technique
5,8–11
(Figure 6). The panel stressed that ller treatment plans should be individualized,
respecting the patient’s unique anatomical structure and avoiding a one-size-ts-all treatment approach, which can
produce unnatural outcomes (Table 1). When choosing a HA dermal ller for treatment, the panel advised prioritizing
product safety and effectiveness in achieving natural outcomes over durability of the ller product. Use of incorrect
products for an indication may result in noninammatory nodules.
8
Hence, it is recommended that practitioners have
a good understanding of the rheological properties and behavior of different HA llers to aid them in selecting the
appropriate product to address the unique aesthetic needs of the individual patient. The panel recommended selecting
products that have better tissue integration for more natural results. The panel added that it is essential for practitioners to
have detailed knowledge of facial anatomy, and a thorough understanding of the appropriate depth and plane of injection
to ensure correct placement of the product into the appropriate tissue layer.
8
The panel also addressed the importance of
proper injection technique for achieving natural results. It is recommended to limit ller volume and inject slowly to
introduce the product gently and evenly.
8
The panel advised physicians to take a conservative approach to undercorrect to
avoid an overlled appearance.
11,20
It is noted that while drastic results may be desired by patients, it is important to
increase awareness on the possibility of irreversible distortion of the original tissue structure and facial contours with
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overcorrection.
6
The panel acknowledged the need for educational efforts to improve understanding on the importance of
preserving aesthetic individuality and proper injection procedures for optimal results.
Conclusions
This is the rst report describing the current practices of HA dermal ller treatment in Asia Pacic on preventing DIRs
and achieving natural-looking outcomes. The report also includes a concise reference guide for creating an individualized
treatment plan aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes with HA llers. More
clinical evidence may still be needed to support the recommendations for the prevention of DIRs and unnatural results.
Nonetheless, the current ndings from the survey and the practical insights from the experts can raise awareness of these
complications in clinical practice and support practitioners in optimizing the safety and quality of aesthetic treatment
with HA llers.
Acknowledgments
Medical writing and editorial support were provided by Tech Observer Asia Pacic Pte Ltd and was funded by Merz
Aesthetics.
Disclosure
Dr Corduff serves as a lecturer and clinical advisor for Merz Aesthetics. Dr Lim, Dr Suwanchinda, Dr Tseng, and
Dr Ho serve as speakers and advisory board members for Merz Aesthetics. Dr Lin serves as a speaker and advisory
board member for Merz Aesthetics, BTL, and AbbVie. Dr Pavicic serves as a speaker and a member of advisory
boards for Merz Aesthetic, AAT, J&J, and BTL, as well as conducts clinical studies for Merz Aesthetics, LG, AAT,
Galderma, and AbbVie. Dr Quiambao has received honoraria from Merz Aesthetics and Teoxane Laboratories and
serves as a speaker and regional advisory board member for Merz Aesthetics. Dr Siew serves as a trainer and lecturer
for Merz Aesthetic. Dr Vachiramon serves as a speaker for Merz Aesthetic, LG Chem, Leo Pharma, and Biersdorf,
L’Oreal, as well as a member in advisory boards for Merz Aesthetic, AbbVie, and L’Oreal. All authors have received
honoraria from Merz Aesthetics for their contributions at the advisory board meeting and subsequent manuscript
preparation.
The authors report no other conicts of interest in this work.
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