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Dermal Filler — Cross-Linked Hyaluronic Acid (Medical Device Class III) Pregnancy: Avoid — elective cosmetic procedures should not be performed in pregnancy; insufficient safety data.

Hyaluronic Acid Dermal Filler

Brand names: Juvederm (Allergan), Restylane (Galderma), Belotero (Merz), Teosyal

Adult dose

Dose: Facial augmentation: 0.3–2 mL per anatomical region per session (lips: 0.5–1 mL; nasolabial folds: 0.5–1.5 mL; tear troughs: 0.3–0.7 mL; jawline: 1–3 mL). Volume tailored to desired correction
Route: Intradermal / subdermal / supraperiosteal injection via needle or blunt cannula
Frequency: Repeat every 6–18 months as effects diminish
Max: Typically 2–4 mL per session; no absolute maximum, but excess risks vascular occlusion
Cross-linked HA is not a drug — it is a Class III medical device (CE marked). Included as it is commonly administered by plastic surgeons/aesthetic practitioners and has important pharmacological considerations (particularly hyaluronidase antidote). HA naturally occurs in human tissue — degraded by hyaluronidase; this provides the key safety feature. Regulated by CQC and MHRA as medical device.

Paediatric dose

Route:
Not for use in persons under 18 years — UK law since 2021 (Cosmetic Procedures Act) prohibits non-surgical cosmetic procedures including filler in under-18s.

Dose adjustments

Renal

Not applicable.

Hepatic

Not applicable.

Clinical pearls

  • Vascular occlusion — emergency protocol: if skin blanching, pain, or vision changes occur immediately during injection → STOP immediately; inject hyaluronidase (Hyalase) 150–1500 units into affected area within minutes; warm compress; aspirate HA if accessible; 2-hourly hyaluronidase if no improvement; refer immediately to ophthalmology for visual symptoms. Blindness from HA filler is irreversible once established — speed is critical
  • MHRA 2020 alert: UK has seen multiple cases of serious complications from HA fillers including blindness and stroke. JCCP (Joint Council for Cosmetic Practitioners) standards now mandate: thorough anatomy knowledge, emergency training including hyaluronidase, and standardised consent process
  • Hyaluronidase as antidote: Hyalase (hyaluronidase) 1500 units/mL — dilute 1:10 in normal saline and inject immediately around vascular occlusion site; HA filler degrades and vascular perfusion restored. All practitioners administering HA fillers must have immediate access to hyaluronidase and be trained in its emergency use

Contraindications

  • Active skin infection or inflammation at injection site
  • Bleeding disorders or anticoagulant therapy (relative — increased bruising/haematoma risk)
  • Hypersensitivity to HA or lidocaine (most fillers contain lidocaine 0.3%)
  • Under 18 years (UK law — Cosmetic Procedures Act 2021)
  • Pregnancy (insufficient safety data — avoid elective cosmetic procedures)

Side effects

  • Bruising and haematoma (common; advise discontinuing aspirin/NSAIDs 1 week prior)
  • Swelling and erythema (expected — resolves within days)
  • Nodule formation (irregular cross-linking or placement)
  • Vascular occlusion (rare but catastrophic — MHRA critical alert): accidental injection into or embolism from facial arteries → skin necrosis, blindness (retinal artery occlusion); ophthalmic artery retrograde flow → stroke
  • Tyndall effect (subdermal placement of superficial product — bluish discolouration)
  • Delayed hypersensitivity granuloma (rare)

Interactions

  • Anticoagulants and NSAIDs/aspirin (increased bruising — advise cessation 1 week before if clinically safe)
  • Hyaluronidase (intended antidote — dissolves HA filler)

Monitoring

  • Skin perfusion and blanching during and immediately after injection
  • Vision (any change = visual emergency — stop and inject hyaluronidase immediately)
  • Pain (pain out of proportion suggests vascular compromise)
  • Follow-up at 2 weeks (nodule, asymmetry, persistent swelling assessment)

Reference: BNFc; BNF 90; MHRA Medical Device Alert 2020 (HA Filler Vascular Complications); JCCP Guidelines 2022; Beleznay et al. Dermatol Surg 2015 (vascular occlusion review); UK Cosmetic Procedures Act 2021. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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