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Are facial filler microcrystalline porcelain complications caused by dermatologists or dentists?

Hey guys, cervicofacial subcutaneous emphysema is a rare sequela of dental and head and neck surgeries caused by air entering the soft tissues. It is rarely reported in the dermatologic literature. It is important for dermatologists to recognize this complication, as it can occur with dental procedures following skin projects on the head and neck.

Case Details

A 42-year-old woman underwent soft tissue filler injections at a US facility for aging. A total of 3.0 mL of calcium hydroxyapatite (microcrystalline porcelain) was injected into the subperiosteum of the patient's temples, zygomaticomandibular cheeks, mandibular line, and premandibular sulcus on both sides. During the informed consent period and prior to the procedure, the patient was advised to avoid any dental work for 2 weeks before and 2 weeks after the soft tissue filler procedure to prevent biofilm-related infections. The patient waited 15 days after the facial injections before her dentist placed a temporary crown on her upper left tooth.

During dental treatment, the patient felt vague pain and a tingling sensation on the left side of the face. Within minutes, unilateral left-sided facial swelling in the left cheek rapidly worsened and extended to the periorbital region (Figure 1). Her dentist thought she had angioedema due to a potential allergic reaction to the anesthetic she used during crown placement. After an intramuscular injection of 0.3 mg epinephrine (0.3 mL, 1:1000) and 50 mg oral diphenhydramine, her response was inadequate and her symptoms did not improve. Crown placement was discontinued, and the patient was immediately returned to the authors' dermatological clinic for evaluation of a potential soft-tissue infection associated with the filler injection.

Figure 1: Rapid onset of left facial swelling

Physical examination revealed that the patient had no fever and stable vital signs. There was extensive swelling in the left periorbital, zygomatic and mandibular subcutis. Palpation revealed a murmur in the affected area (Figure 2). There was no overlapping erythema, palpable nodules, or skin tenderness. The patient denied shortness of breath, neck pain, chest pain, hoarseness or wheezing. The diagnosis was subcutaneous emphysema in the neck and face, and computed tomography (CT) of the head and neck was required to better determine the degree of involvement and guide the further nursing plan.

Figure 2: papules and swelling in the left periorbital area

The CT film shows extensive soft tissue airways throughout the left face and neck, extending into the thoracic inlet but not significantly into the superior mediastinum. Soft tissue gas extends along the buccal surface and into the left parapharyngeal space. The smallest soft tissue gas crossed the midline into the anterior vascular plane of the anterior neck (Figures 3 and 4).

Imaging findings were consistent with the authors' clinical impression that the cervicofacial subcutaneous emphysema had no sequelae to her airway or involvement of the mediastinum. Amoxicillin/clavulanate 875 mg/125 mg twice daily for 10 consecutive days was used to cover any potential oral flora that may have traveled down along the fascial planes into the critical spaces of the head and neck. The patient was closely monitored through daily visits to the author's clinic. Her condition improved daily, and after 7 days, she was in remission with no adverse sequelae and no change in soft tissue enlargement enhancement.

Figure 3: Head CT showing air in the parapharyngeal fat and areas of hyperdensity in the soft tissue of the premaxilla associated with previous soft tissue filling with hydroxyapatite.

Figure 4: Cervical CT showing air entering the thoracic inlet but not the anterior cervical space connecting the mediastinum


Cervicofacial subcutaneous emphysema is a well-recognized clinical condition caused by the introduction of air or gas into soft tissue planes. It is a rare complication of various dental procedures and is more common in head and neck surgery and maxillofacial trauma. Typically, this condition is caused by the use of high-velocity pneumatic instruments in the oral cavity during dental procedures (e.g., surgical extractions, endodontics, and trauma). Surgical procedures, especially those involving third molars, may increase susceptibility to soft tissue emphysema. These high-speed air heads discharge high pressures that can disrupt the oral mucosa and cause air to travel subcutaneously into the fascial planes of the head and neck. Entry of air into the prevertebral and retropharyngeal spaces connected to the mediastinum can lead to very rare but potentially serious and fatal complications such as mediastinitis, airway injury, air embolism, and necrotizing fasciitis of the neck.

With the rise and increasing popularity of several dermatologic procedures, many patients will undergo dermatologic procedures in close proximity to dental procedures, which can be performed with pneumatic instruments. Awareness of this medically induced dental complication is critical in order to distinguish it from complications arising from dermatologic procedures and to allow for proper evaluation and prevention of the rare but potentially life-threatening respiratory sequelae.

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