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Dermal Fillers and COVID 19 Vaccine

Why You Should Still Get the COVID-19 Vaccine Even If You Have (or Plan to Get) Dermal Fillers

After headlines linking COVID-19 vaccines to filler swelling shook the beauty world, dermatologists and plastic surgeons flooded social media with a resounding message: The risk is rare; get vaccinated.

BY JOLENE EDGAR

January 20, 2021


In the wake of sensationalized headlines grossly overstating the rare risk of transient filler swelling associated with Moderna's COVID-19 vaccine, dermatologists and plastic surgeons are being inundated with calls, texts, emails, and direct messages from concerned patients. "These articles have created so much chaos — I have patients calling to cancel their March and April filler appointments because they're worried, they won't be able to get the vaccine," board-certified New York City plastic surgeon Umbareen Mahmood shared with Allure via DM.

"The press spin was really a public health tragedy," adds Lara Devgan, a board-certified plastic surgeon in New York City, who reached out with a far more disturbing report: "[I have] patients saying they're too scared to get the vaccine because they like their fillers," says Devgan via DM, who, like scores of her peers, got the Moderna vaccine in December (and, yes, she does have filler in her face — not that it's any of our business). When she later polled her 410,000 Instagram followers asking if they'd do the same, 27 percent of those who replied admitted that they would refuse the vaccine — a result she found rather shocking.

"I think the science behind the vaccine studies is of excellent quality," she says. "The study arms themselves are much larger, with much greater scientific power, than [those of] a traditional vaccine-approval study. And the data is extremely clean. So, from a scientific standpoint, it's a no-brainer. It's really surprising that people are not lining up for it as quickly as I did" — particularly at this time, she adds, when as of the end of December, the New York Times reported one in 1,000 Americans has died from Covid-19.

Board-certified New York City dermatologist Shereene Idriss — who was also recently vaccinated and presently has fillers — contracted COVID-19 in November and says the virus brought "some of the worst days of [her] life." She too has fielded a number of calls from confused patients — many spurred by alarming media coverage — but says she's been able to defuse panic by clarifying the facts and giving them "a better understanding of what the statistics mean."

Following her lead, we're dissecting the circumstances surrounding the filler reactions seen in the Moderna trial to help you make sensible decisions about your upcoming COVID-19 vaccinations and injectable procedures.

What we know — and don't know — about the filler reactions seen in the Moderna vaccine trial

As first reported by Stat News on December 17, during a meeting of the Vaccines and Related Biological Products Advisory Committee, Rachel Zhang, a Food and Drug Administration (FDA) medical officer charged with presenting the trial data, disclosed that three study participants — all with a history of dermal fillers — experienced localized swelling around pre-existing fillers after receiving the vaccine and that all cases resolved with treatment. The panel went on to recommend that the FDA grant an emergency use authorization for Moderna's COVID-19 vaccine as it previously did for Pfizer's technologically similar shot. The FDA briefing document, detailing the clinical safety and efficacy of the Moderna mRNA vaccine, was subsequently posted online — including this snippet, under the heading, "Non-Fatal Serious Adverse Events or SAEs":

There was one event of lip angioedema two days after vaccination in a 29-year-old female participant in the vaccine group which was classified as medically significant but not considered an SAE. The participant has a history of dermal filler injection in the lips (unknown how long prior to vaccination). She reported having a similar reaction after receipt of an influenza vaccine in the past. Taken in context with the SAEs of facial swelling which occurred in two participants who had previous history of cosmetic filler injections, it is possible the localized swelling in these cases is due to an inflammatory reaction from an interaction between the immune response after vaccination and the dermal filler. This phenomenon has been reported after natural infection (e.g., after an influenza-like illness). In FDA's opinion following a review of the narratives, three SAEs are considered likely related, including the...two reports of facial swelling.

After parsing the facts from the FDA document and the advisory panel meeting, our experts supplied a bit more backstory:

Three subjects out of the 15,184 Phase 3 participants who received at least one dose of the mRNA vaccine (not the placebo) developed facial or lip swelling one or two days after vaccination.

  • "All three of the cases had filler prior to vaccinations," according to Kavita Mariwalla, a board-certified dermatologist in West Islip, New York. One woman with facial swelling had filler placed two weeks earlier; the other, six months before the vaccine. In the lip-swelling case, it was unknown how long prior to the vaccination she received the filler. This type of swelling is considered "delayed" — and is distinct from the normal puffiness filler can breed in the hours and days directly after injection.

  • The lip swelling wasn't considered a serious adverse event. Rather, it was classified as a "medically significant" angioedema, which is a unique type of "soft tissue swelling usually related to an adverse drug reaction or allergic reaction," explains Gilly S. Munavalli, a board-certified dermatologist in Charlotte, North Carolina. This subject "had a similar reaction to the influenza vaccine, so she may just be a reactive person," adds Mariwalla.

  • Investigators determined that the facial swelling was due to the vaccine. "The vaccine initiated an immune response in the body, which it’s supposed to do," Mariwalla explains. "Dermal fillers can sometimes get caught up in the immune response and become firm or hardened or even swell." Viral and bacterial infections, which fire up the immune system in a similar fashion, can also cause fillers to flare. In short, "when your immune system gets turned on, it can hone in on things that are not native to your body and cause a temporary and treatable inflammation in that region," says Amelia K. Hausauer, a board-certified dermatologist in Campbell, California.

  • While not included in the FDA document, Zhang did note at the advisory panel meeting that all three cases of swelling were completely resolved with oral steroids and antihistamines.

Despite Moderna's transparency regarding adverse events, certain facts remain elusive. "We don’t know the true denominator — how many in the treatment group had fillers [at the time of the trial]," says Hausauer. This figure, if available, could tell us how many folks with filler got the vaccine without incident. Also absent from the report are the specific types and amounts of filler in play — both highly relevant to the topic of swelling. "Many questions still remain," Idriss says. "Did the patients who developed reactions have underlying immune disorders?" for example. "Are [they] even the right candidates for receiving fillers?"

The situation is still very much evolving.

In the weeks since the FDA hearing, Allure has learned of additional anecdotal instances of COVID-related swelling in people with fillers. Munavalli shared with us details of a dozen cases — reported to him via multiple physician-only Facebook groups — involving doctors (dermatologists, plastic surgeons, primary care providers) who saw short-term swelling around their fillers after receiving either the Moderna or Pfizer COVID-19 vaccine. Beyond the inoculated set, "there were several more who [developed reactions] after COVID itself," he adds.

In all of these instances, swelling surfaced somewhere between 24 hours and two to four weeks following the instigating vaccine or illness. And in most scenarios, the filler was placed at least six months prior to vaccination or infection. "The products ranged across the board," Munavalli says.

While researchers haven't yet proven the precise interplay between fillers and immunological triggers, Munavalli theorizes that, in the case of COVID-19, it might have to do with "the spike protein binding to ACE receptors in the dermis and resident skin cells, such as the fibroblasts and keratinocytes, and creating a proinflammatory environment around areas with higher concentrations of T-cells," which includes the dermis adjacent to old filler. Backing up to connect these dots: The spike protein on the surface of the COVID-19 molecule is what latches onto our cells to gain entry. The mRNA vaccines from Moderna and Pfizer provide our bodies with instructions to make copies of these proteins, so that we can, in turn, produce antibodies to defend against the SARS-CoV-2 virus that causes COVID-19. ACE receptors act as doorways for spike proteins — and exist on various cells throughout the skin, including those in the dermis and fatty adipose tissue, "where fillers are typically targeted," Munavalli explains.

Even with the small uptick in filler complications seen separate from the Moderna trial, "I'd still say this [side effect] is very, very rare," says board-certified Denver dermatologist Joel L. Cohen. And given the record number of COVID-19 cases being tallied daily, he adds, "We also can't rule out the possibility that some of these patients had simultaneous asymptomatic COVID-19 infections coinciding with receiving the vaccine — in which case, the facial swelling could have been related to COVID-19 infection itself. We have seen this type of rare, transient, and treatable filler reaction after other vaccines, as well as after infections, like the flu, and after dental abscesses and sinus infections."

The good news, according to Munavalli: "The [incidents] I've seen so far have been controlled without any big interventions — they've been self-limited or controllable with oral medications," he says. He's written up several of these cases for a paper that's currently pending publication.

Meanwhile, the aesthetics community is closely monitoring the situation. Both The Aesthetics Society and the American Society for Dermatologic Surgery (ASDS) have carefully analyzed the data and released statements (here and here) aiming to contextualize these rare reactions and give guidance on how to manage them, should they arise. Here, the key takeaways:

These reactions are not new or unique to the COVID-19 vaccine.

These side effects are hardly unprecedented. "Delayed dermal events with both hyaluronic acid and non-hyaluronic acid fillers have been documented extensively throughout the literature, even prior to the COVID vaccine," Idriss tells us. "Although relatively rare, infections and vaccinations have been known to trigger potential immune responses that have previously been linked to dermal filler swelling."

She points to a 2019 study in the journal Clinical, Cosmetic and Investigational Dermatology exploring delayed hypersensitivity reactions to HA fillers following flu infections. (Again, delayed is the keyword here: this is not the ordinary puffiness you see immediately after getting your lips or chin augmented.) "Delayed hypersensitivity may manifest from weeks to months after an uneventful HA filler injection," the study authors note. "Hence, it is impossible to predict the probability of occurrence."

Indeed, the same can be said for COVID-19-induced filler complications. What doctors find reassuring though is that "this swelling does not appear to be anything out of our experience with fillers over the past 15 years," says board-certified Boston dermatologist and ASDS president Mathew Avram. "It seems to be consistent with what we've seen with other vaccinations, with a viral illness, and with dental procedures, like cleanings." To minimize risk, dermatologists have long advised filler patients to schedule their injections around vaccines and dental work — putting two weeks on either side — and to postpone filler when sick.

The most commonly cited data on these types of filler reactions comes from two retrospective studies, one published in 2015 and the other in 2020, looking at delayed adverse events associated with the hyaluronic acid gel Juvéderm Voluma. In both papers, reactions were found to occur about four months after treatment — at rates of less than one percent per patient. "Of those reporting this side effect, immunologic triggers prior to swelling were reported in 39 percent and 34 percent, respectively, and included flu-like illness, dental work, and vaccines," explains Katie Beleznay, a board-certified dermatologist in Vancouver, BC, who co-authored both studies. "So, this complication is not unique to the Moderna vaccines and it should not deter someone from getting the COVID vaccine — or any vaccine for that matter." Moreover, she notes, "It also doesn't mean that someone can't get filler if they're planning to get or have already received the vaccine."

Certain fillers may be more fickle than others

While the FDA document doesn't disclose the specific types of filler used by the three trial subjects, "many of us who are quite familiar with the cases [believe it was] hyaluronic acid fillers," says Mariwalla, which are essentially water-binding sugar-derived substances. There are several brands of HA, and under those umbrellas, various subsets of gels, classified by their physical properties.

While there's been speculation in the aesthetics community that some longer-lasting fillers could be more prone to flaring, the reality is, "we're seeing this issue with all kinds of fillers, across the board," reiterates Munavalli.

There does seem to be a common thread among these products, however. Our experts agree that older fillers and poorly placed fillers tend to be more reactive than freshly injected gels delivered via proper technique. "I think it takes time to set up this reaction in the body," says Munavalli — "and this reactivity is influenced by the body's metabolism of previously-placed filler. We haven't seen anybody who has had the vaccine, then had filler a week or two later, and then reacted," he adds.

It's also worth noting that higher volumes of filler — any filler — have also been linked to swelling, notes Hausauer, which is why savvy injectors generally dose conservatively, favoring a slow-and-steady approach to volumization and avoiding big bolus-style shots.

Expert injectors are trained to manage filler complications.

While Hausauer tells us we're more likely to be struck by lightning than to see our filler balloon post-vaccine, "it's important for people to know this is something that can occur — and [that] it usually resolves on its own, but can also resolve with physician intervention," adds Avram.

If ever your filler behaves oddly, call your doctor right away. "We can get you through this," Hausauer says. When swelling doesn’t subside on its own within a few days, oral antihistamines and steroids, which tamp down inflammation, are generally first-line treatments. There has been some debate, however, as to whether or not giving systemic steroids on the heels of vaccination could potentially dampen the vaccine’s efficacy. According to Edward Charles Jones-Lopez, an infectious disease specialist with Keck Medicine of USC, there isn’t data to definitively answer this question — but he speculates that "the amount of steroids you would use in these situations is not high enough or prolonged enough to really change the vaccine's response."

Jones-Lopez adds, for the record, that swelling, however unwelcomed, is "a good sign that the patient is developing antibodies against the vaccine." In fact, like vaccines in general, both COVID-19 vaccines are known to be reactogenic — meaning that, as they stimulate the immune system and begin to work, they produce symptoms, "ranging from local, mild injection site arm pain, redness, or swelling to systemic fever, lethargy, and muscle aches, all of which usually resolve by five to 10 days, with most actually resolving in three to five days," explains Cohen.

If puffiness around fillers is especially persistent or dramatic, doctors may inject an enzyme called hyaluronidase to melt the gel. This shot works for HA fillers only, however, and cannot dissolve Sculptra or Radiesse.

Munavalli also believes that rapid-acting, low-dose ACE inhibitors, commonly used to control hypertension, can limit or halt facial and lip filler swelling following COVID-19 vaccines. "We tried the drug in two people, both dermatologists who recognized the inflammation pretty quickly, and it completely stopped the reaction within six to eight hours."

Neuromodulators, like Botox and Dysport, are a nonissue

A quick word about toxins, because injectables are so often conflated, and doctors want to be crystal-clear on this point: Neurotoxins, which temporarily weaken muscles to smooth wrinkles, have not been implicated in COVID-provoked swelling. This issue pertains only to dermal fillers, largely because "they're an injectable implant of sorts — they're space-occupying and stay in your body for a protracted amount of time," says Devgan. Toxins, on the other hand, don't linger. "They do their thing — chemically altering the action of neurotransmitters — and dissipate away."

Ask your doctor how best to coordinate fillers and vaccines

"Vaccines and fillers are not mutually exclusive," Hausauer reiterates. If you have fillers in your face, you can absolutely still get the COVID-19 vaccine. As the ASDS spells out in its statement, "Given currently available data, patients already treated with dermal fillers should not be discouraged or precluded from receiving vaccines of any kind. Similarly, patients who have had vaccines should not be precluded from receiving dermal fillers in the future."

If you choose to get fillers, go to an experienced injector whom you trust — a board-certified dermatologist, plastic surgeon, facial plastic surgeon, or oculoplastic surgeon, who is up on the latest safety protocols and knows how to minimize and manage complications, particularly those connected to COVID-19. "Now is probably not the time to get injected by a random person in a salon," Mariwalla says. (Don't ever do this, actually.)

The doctors we interviewed don't plan on changing the way they inject in response to potential COVID-19 vaccine- or virus-fueled swelling, because they're already familiar with this phenomenon, and it's exceedingly rare and easy to reverse. "You are super unlikely to have this happen," Devgan assures us. "And if it does happen, it resolves, and there are no long-term sequelae [or consequence]. It's not something that warrants changing our clinical practice."

For those wanting to be extra-cautious, our experts say it may make sense to wait a few weeks after your second dose of the COVID-19 vaccine before getting filler, though there's no ironclad evidence supporting this recommendation, and hiccups can still happen. Still, according to Cohen, based on what's currently known about the vaccines' reactogenicity — namely, that immune-mediated symptoms commonly resolve by 10 days and that, in the case of Moderna, they may be more severe after dose two — it's fair to say that by two-plus weeks out from your final shot, "the immune surge typically seen with the vaccines should have subsided enough to at least really minimize the rare risk of delayed filler swelling," he says.

Of course, if you've experienced filler side effects from other vaccines or illnesses, be sure to tell your physician, notes Mahmood, and ask "whether taking an antihistamine prior to vaccination may be beneficial."

Bottom line: Don't let the minuscule risk of fleeting facial swelling stop you from taking your shot. "This is the largest worldwide vaccination effort medicine has ever seen," says Mariwalla — and our participation in it is vital to ending the COVID-19 pandemic.

Reference

Edgar, J. (2021, January 20). Why You Should Still Get the COVID-19 Vaccine Even If You Have (or Plan to Get) Dermal Fillers. Allure. https://www.allure.com/story/covid-19-vaccine-side-effects-dermal-fillers-injectables.


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