Hyaluronic acid side effects and risks — what is common, what is rare and what is an emergency

Common: the normal companions of the first few days

Every injection is a small injury, and the skin reacts to it. Swelling occurs almost always, noticeably on the lips, subtly on the cheeks or chin. It is strongest on the first and second day and subsides within about a week; on the lips it can look quite impressive for the first few days. Redness at the injection sites usually fades within hours. A bruise (haematoma) occurs when the needle or cannula grazes a small vessel — despite all care, this can never be entirely avoided, and it lasts one to two weeks. In addition, there is tenderness to pressure and a slight feeling of tightness. All of this is unpleasant but harmless and needs no treatment other than cooling and patience. What you can do yourself is in the Aftercare after hyaluronic acid filler.

Occasionally: asymmetry, nodules, Tyndall effect

A slight asymmetry in the first few days is usually due to swelling, which is rarely exactly the same on both sides. If it persists after two weeks, it can be corrected at the follow-up check by careful topping up or, if necessary, targeted dissolving. No face is naturally symmetrical; the goal is harmony, not a mirror image.

Small lumps form when gel collects in one place, was placed too superficially or shifts through muscle movement. Early lumps can often be dispersed by gentle massage; if they persist, hyaluronidase helps.

The Tyndall effect is a bluish shimmer that occurs when hyaluronic acid lies too close beneath thin skin — typically in the tear trough or on the lips. The light is scattered in the gel and appears blue. It is not dangerous, but it is visible and one reason why the tear trough is treated with thin products, deeply and sparingly. Here too, dissolving is the solution.

Rare: infection and granuloma

An infection after filler is rare, because we work under sterile conditions and on disinfected skin. It announces itself through increasing redness, warmth, pain and sometimes fever after the second or third day — in other words, at the point when the normal reaction should actually be subsiding. Early antibiotic treatment almost always resolves the problem. A special case is a herpes reactivation on the lips: if you are prone to cold sores, we give you prophylaxis before the treatment.

Granulomas are inflammatory nodules that the immune system forms around foreign material, sometimes only months after treatment and often triggered by an infection in the body. They are very rare with modern, certified hyaluronic acid products and can be treated with hyaluronidase and, if necessary, with anti-inflammatory medication. Products of unclear origin significantly increase this risk.

Very rare, but serious: vascular occlusion

The case that every honest consent discussion must address: if filler enters a blood vessel or presses on it from outside so firmly that it closes, the tissue beyond it is no longer supplied. This is a vascular occlusion. Untreated, it can lead to skin necrosis; if it affects vessels connected to the ophthalmic artery — especially in the nose, forehead and frown-line region — in extremely rare cases it can also lead to visual disturbances. According to the available data, the frequency is well below one in a thousand treatments, but it is not zero.

You know the warning signs best yourself:

• Severe, persistent or increasing pain that does not fit the treatment — or, deceptively, no pain at all together with unusual skin colour.
• Whitish pallor of the skin directly after the injection, later blotchy, net-like, blue-grey or dark discolouration.
• Cool skin compared with the other side, delayed return of blood flow on finger pressure.
• Visual disturbances, eye pain, double vision of any kind — an immediate emergency.

The immediate measure is hyaluronidase (Hylase): the enzyme dissolves the filler within minutes to hours and frees the vessel again. The earlier, the better — the first hours are decisive. That is why Hylase is always in stock at our practice, and why you receive a number after every filler treatment on which you can reach us. How dissolving works is explained under Filler dissolving in Wiesbaden. With visual disturbances, every minute counts: call immediately or, outside consultation hours, call the emergency services.

Risks differ by zone

Not every region carries the same risk. At the lips, swelling and bruising are most pronounced, but the vascular anatomy is well known; nodules occur here when filler is placed too superficially or in too great a quantity — more on this at Lip augmentation in Wiesbaden. The tear trough is the zone with the highest risk of the Tyndall effect and persistent swelling, because the tissue is thin and attracts water; it is not suitable for every anatomy, see Tear trough in Wiesbaden. The nasolabial fold lies close to a large facial artery, which is why cannula and deep placement are particularly important here. Cheeks, chin and jawline are considered comparatively safe zones with few side effects, because the work is done deep on the bone. Nose, forehead and frown line are high-risk zones for vascular complications, and we treat them with fillers only after very careful consideration or advise against it.

What you can contribute yourself

Part of the risk is in your hands. In the week before the treatment, as far as medically acceptable, stop blood-thinning painkillers such as acetylsalicylic acid or ibuprofen and avoid alcohol and high-dose fish-oil or vitamin E supplements — this noticeably reduces bruising. Do not come with an incipient infection or a cold sore. Tell us about all medications, pre-existing conditions and previous treatments, even if they seem unimportant to you. After the treatment: do not press, do not massage, no heat and no sport for 48 hours. And if something does not fit the course described, call us before you search the internet.

When we do not treat: contraindications

• Pregnancy and breastfeeding — not because of known harm, but because there are no studies.
• Acute infection or herpes in the treatment area, active acne at the injection site.
• Known allergy to components of the product, for instance the lidocaine it contains.
• Autoimmune diseases in an active phase, blood clotting disorders or use of blood thinners — here we decide individually and, where appropriate, in consultation with your treating physicians.
• Permanent fillers in the same region from earlier treatments — placing hyaluronic acid on top is risky.
• Unrealistic expectations or the wish for amounts that are not anatomically sensible. That too is a medical reason to advise against treatment.

How we minimise risks

Anatomy. The vessels of the face run along known paths with individual variations. Anyone who knows them and keeps them in mind with every injection avoids the dangerous planes. That is why regions such as the nose, forehead and frown lines are demanding for fillers, and why we are particularly restrained in the tear trough.

Cannula instead of needle. A blunt cannula pushes vessels aside instead of piercing them. In many areas — cheeks, jawline, nasolabial, tear trough — it is the safer instrument and also reduces bruising.

Aspiration and slow injection. Before injecting, the plunger is briefly drawn back to check whether blood is aspirated. This is not one hundred percent reliable, but it is an additional safety step. Small amounts, placed slowly and with low pressure, leave time to recognise reactions.

Certified products. We use exclusively CE-certified medical products from established manufacturers, document batch numbers and give you the product details in writing. We do not perform follow-up treatment on fillers of unknown origin placed elsewhere.

Medical administration. Treatment with fillers requires experience and in Germany may only be carried out by a doctor — not least because only a doctor may use hyaluronidase in an emergency and treat complications. All zones, products and procedures can be found on Hyaluronic acid fillers in Wiesbaden.

And afterwards: the follow-up

About two weeks after the treatment, the swelling has subsided and the result can be assessed. We offer a check-up in which asymmetries or small irregularities can be addressed and corrected. Make use of it — and get in touch beforehand if anything does not fit the course described above. Better one call too many than one too few.

Frequently asked questions