what you need to know about covid-19 vaccines and dermal fillers

How long should you wait after your Covid-19 vaccine
to have dermal filler injections?

We are now planning once again to start providing cosmetic treatments, including injections of dermal fillers and botulinum toxin (Botox). Better still, we are doing this while the Covid-19 (SARS-Cov-2) vaccination program in the UK is ongoing and is among the most successful vaccination programs in the world.

Getting vaccinated is, of course, the priority. And as always when planning cosmetic treatment, safety remains my number one concern.

You have probably heard about unwanted side effects with dermal fillers after some of the COVID-19 vaccines, such as facial swelling and inflammation of areas treated with dermal fillers following vaccination. These are rare, but they have been reported.

What we already know from experience with other vaccines and fillers:

Such reactions and side effects after dermal filler injections are not new at all. They are well known to occur when dermal filler treatments are done while the body’s immune system is more active than normal; usually when the immune system is stimulated, whether it is by a vaccine, a viral infection or by “friendly-fire” conditions like auto-immunity. It is also known that our immune system, when stimulated by infection or vaccination, can attack implants and fillers that have been in place for some time before.

The reason we are talking about it more now is because of the vital new vaccination program that is under way for Covid-19. Here, I will talk you through how you may plan your dermal filler injectable treatments in order to minimise the risk of adverse effects or reactions while you have both doses of your Covid-19 vaccine.

The following are some common questions about dermal fillers and COVID-19 vaccines

Not all of us would have asked all these questions. But most of us would have either read reports or wondered any of these could apply to us.

At this time, I would say yes, if you had any vaccine (or infection) within a short time of having dermal filler injection. And vice versa (having filler within a short time of having a vaccine). While reactions like this could seem rather scary in the first instance, if we think about it, it is certainly not limited to dermal fillers, or even to vaccines.

We have known for years that it is unsafe to carry out injectable treatments when there is a chance of infection or inflammation. This is all the more true when we are planning for non-essential or purely cosmetic treatment.

If you are one of my patients reading this, you probably remember the discussion we had before planning your dermal filler treatments, and also when you were going through the consent process. You were asked about whether you are planning to have any dental procedures like implants, root canal treatments, whether you are on any antibiotics for infections elsewhere in your body – and if so, we would have deferred the filler treatment to a time when you were not on any such treatment.

The reason for this, is how our immune system reacts to any foreign substance it encounters: it tries to reject it. Fillers by definition are foreign substances.

If we are currently fighting an infection, there is an increase in number and activity of active immune cells and mediators circulating in our systems. Having a vaccination produces the same stimulation of our immune system (but without the actual infection).

If you have a filler injection at this time, you are more likely to have an immune response to the filler. This response or reaction shows up as swelling, redness, pain and tenderness over the filler. Sometimes the filler forms “nodules” that could be red, hot and tender (inflammatory).

So, the answer is yes, you must plan your injectable treatment safely.

Other than what we know about human physiology, the immune response, and specific properties of fillers, we do not know enough to advise on this with certainty. General safety principles would suggest that we separate the procedures.

We have known for many years that the human body will reject that which is not “self”. Fillers are not “self”. They are foreign particles. If our tissues are recently primed to fight (vaccines, illness, dental infection, inflammation), it is understandable that our immune response and allergic response mechanisms could over-react and actively reject the foreign particles.

Our immune systems include many different cells with specific roles and abilities. The immune response can occur over the short, medium or long term. If a patch of skin was sore or inflamed, we certainly would not inject any dermal filler into it. But what if we have safely injected filler, previously, at some point in time? Can your immune system still attack it? Yes it can. Modern long lasting cross-linked hyaluronic acid fillers are made to last. They remain within the layers of your skin rather like implants. It takes a long while for your body’s natural hyaluronidase enzyme to break down these particles.

If your immune system became very active at any time, in theory, it would still attack the filler – weeks or months after it was injected.

We could apply this understanding of how vaccines and viral illness in general will affect the timing of filler treatments, while considering the existing evidence and the guidelines developed since the covid-19 vaccination program started.

Notice that I did NOT suggest that you delay having the vaccine because you have had a filler treatment: that is because it is vital for you to have the vaccine.

Never delay having the vaccine!

Because this is a new medication, we cannot expect to have a blueprint handed down to us as to what will happen. Instead, we need to understand in more generic terms (for example, how our bodies respond to any foreign substance), and learn from it in order to make future treatments safer and better timed. Our immune systems were designed to protect us from foreign substances, often by rejecting them.

Here is what we know about how the current covid-19 vaccines influence our immune systems:

Most of the immune activation is related to structure of the spike protein in the envelope of the coronavirus. Some of the response is to the vector which carries the antigenic unit – for example the cold virus.

The level of immune protection and timing of immune response may vary between the different brands. But we know that it takes 2 weeks for the immune system to get fully activated, when it is newly exposed. With prior exposure (previous infection, second dose of vaccine) the activation is more rapid.

Either way, the immune system is likely to be most stimulated after 2 weeks of vaccination, and to reach somewhat stable states of activation after 4 weeks. A full explanation of Covid-19 vaccines, is on the Centers of Disease Control website here.

In Europe and the UK, there are over 200 brands of hyaluronic acid fillers, with various physical properties like lifting capacity, firmness, longevity – hence we use different fillers for different parts of the face. Facial fillers are medical devices. We must be diligent in infection control/ asepsis during these procedures.

So, the answer to this question is: “it depends”: You could have the most premium filler injection in less than ideal hygiene conditions – and cause infection, inflammation, nodules. The injection procedure may have been aseptic, but some aspect of your medical history may make you more susceptible to inflammation and filler reactions.

So, it is more to do with choosing the correct type of filler for that part of the face, and that patient (medical history), and whether it was placed with aseptic technique in the correct layer of the facial skin. (I did say “it depends”).

When you do your own research:

You are probably correct in thinking you should do your own research and learn as much as you can about the process, before choosing a doctor to manage your treatments. And that applies to all medical treatments, not just botox or filler injections. It is preferable for the doctor to be thinking as hard about the treatment as you are, and a good bit more when it comes to risk assessment and safety.

Reputable filler manufacturers would have already done research on inflammatory properties of their fillers, as part of the manufacturing and approval process.

The R&D process is rigorous, and in order to get approval, those fillers have to be proven to be consistently safe and effective. Galderma and Allergan (Restylane and Juvederm manufacturers) have decades of research backing their products. So, they are already able to advise us, who use their products, as to what we can do to keep our patients safe.

When the Moderna vaccine was undergoing clinical trials, two people developed facial swelling after vaccination. Both patients had had dermal fillers injected into their face (cheeks) at different times before they received the vaccine.

One of them had the filler injection a fortnight before the vaccine, and the other had fillers injected about six months before.

A third trial participant had swelling in her lips after the Moderna vaccine. It turned out that she had a history of lip filler treatments (when she had the lip filler injection, or how long before the vaccine, is unclear).

Interestingly, there were reports of a similar response (lip swelling) after receiving the flu jab.

From what is known so far, they are uncommon, and limited to only one of the Covid-19 vaccines. But then, it is early days. We have only just started having the covid-19 vaccine. As with all new medications, it is best to be cautious. We already know that there are immune responses to all vaccines. This is why we defer filler injections if you are flue-ey or unwell. With the covid-19 vaccine being a novel vaccine to a novel virus, I am open to all sorts of interactions over time.

The good thing is that most filler side effects are manageable. We have protocols and effective treatments for most situations.

Depending on the adverse event(s), we may need to use steroids, antibiotics and antihistamines to calm the inflammation, prevent and treat infection. Sometimes it we need to remove the filler to stop it from triggering more reactions over time.

Personally, I prefer to remove the offending filler sooner rather than later, because it will save the patient (and me) from a lot of stress and repeated medication.

Because my clinic is a referral center for complications caused by fillers and other injectables, I see and manage many different adverse events from cosmetic procedures. This means I am reasonably well equipped to anticipate and manage these. But that should not be a reason to be reckless in treating with filler injections while we know there is a degree of risk of side effects in those having the covid-19 vaccine close to the time.

Putting this information in perspective: let us see how this applies to injectable treatments like dermal fillers and botulinum toxin (botox).

Injections cause a break in the skin. This means they have the potential to introduce infection and to cause inflammation. Healthy skin heals rapidly, sealing the breach within a day. This is no different to how a small cut heals – it should be all done in days. Larger cuts take a week or two. If your skin is fragile and you take longer to heal, then you should consider that.

When we inject a dermal filler (or any hyaluronic acid – skin boosters and Profhilo included), they remain in your tissues for a while.

Skin boosters and Profhilo integrate rapidly into your tissues over 2 to 4 weeks. But cross-linked hyaluronic acid fillers do not break down completely for months. We use these in temples, cheeks and lips for their longevity. When a filler is injected into the layers of your skin, it does not remain inert, but interacts with the tissue. Your body will try to use it as scaffolding and build collagen mesh around it. Over time, the filler becomes better integrated into your tissues.

Remember how filler treatments look rather swollen in the first two weeks and then settle down? This is why.

When it comes to planning filler treatments, we need to consider all of these:

  • your personal wound-healing ability and any sensitivities
  • immunological conditions in your medical history
  • the risk from the skin breach by the needle entry
  • possible infections introduced that will trigger local immune response, and
  • the chance of your immune system getting strongly stimulated while the filler is still relatively new, and attacking it.

Things are slightly different for botox treatments. Botox is very short-lived in the tissues, a matter of hours. The skin break, and potential for inflammation due to this are possible concerns. So, there is a concern, but not as much.

We are in a unique situation right now. During the global pandemic, most patients did not have injectable fillers or botulinum toxin BoNTA  for long intervals. There is a novel virus that most of us have been exposed to. There is, of course, a potent new vaccine. I believe this is the time to really understand our treatments, for the better.

This is the opportune time to reassess and plan our management, screen for infection risk, herpes virus risk, counsel about immune reaction risk, anticipate and be more prepared in general.

For my patients, this is nothing new, they have been having such discussions, ad nauseam, with me for years now. All my consultations include a full medical history, treatment history and a detailed enquiry into what was used and when. My patients are among the most well-informed. They often tell me that I tell them more than they expected, but that makes them choose well and get better outcomes from treatment.

Putting this into practice – what are the guidelines and recommendations

Knowledgeable peer groups in the UK such as the ACE group advise clearly to Not undergo soft tissue filler procedures within 2 weeks of your planned vaccination date or within 3 weeks of having received the vaccine. This is excellent advice and must be adhered to as a minimum.

For my patients, I would like to elaborate further. Those who know me know that I try to anticipate and prevent as many complications as possible.

Based on the current research, my professional experience and understanding of human physiology, I recommend to my patients that administration of the Covid-19 (SARS-Cov-2) vaccine, any brand, and dermal filler injections be separated by an absolute minimum of 2 weeks, ideally 4 weeks. It does not matter which is administered first. If you have had your vaccine, it should be relatively easy to schedule your filler treatment after a 4-week gap.

“Filler”, from an immune response perspective, includes any injectable product containing foreign molecules.

The same principles apply, whether it is a non-crosslinked hyaluronic acid like Profhilo or skin boosters, or a cross-linked durable hyaluronic acid like Juvéderm Voluma. Reactions can still occur. It could be argued theoretically that shortlived products would be less likely to cause significant immune reactions. That is because they do not persist long enough to sustain the immune reaction. We do not know this for sure yet.

While this (2-4 weeks) is the minimum between vaccine and filler injections, we are still learning about this. I recommend increasing this window to 8 weeks for patient groups whose medical history suggests a higher risk of reactions, including patients who:

  • have had filler related reactions in the past
  • have auto-immune (friendly fire) conditions
  • suffer with chronic inflammatory conditions
  • experience recurrent infections like sinusitis, dental infections
  • are taking “immunomodulatory” or “biological” treatments (if you were wondering, these are usually drugs whose names are hard to pronounce and end in “-ra” or “-umab”)
  • has a history of more sensitivity and more swelling after fillers than others
  • feel anxious about the possibility of increased risk in general

Of course, if you have had treatments within these windows, and are feeling well in yourself, do not let this worry you – these are extremely rare events as far as we know. As always, I am probably being over-cautious. But this is also why my patients, most of whom had had over 7+ years of treatment with me, have remained looking well, natural, “normal”, and relatively complication-free. If you are reading this, I assume you have thought about the same things that I have.

You should, most definitely, have the COVID-19 vaccine. Big yes. Please do. The benefits of protection from Covid-19 are far more important than the small risk of an immune reaction to a cosmetic injectable. Remember, this could have happened with the flu jab, any travel jab, any viral illness, sinusitis, or a dental infection.

Try to leave 4 weeks between your vaccine and your fillers/ injectables.

If you have appointments booked for filler treatments that fall within this timeframe, please contact me and we will rearrange if required.

I appreciate this timeframe is longer as it is a very cautious one – but worry not, your individual medical history, risk profile, concerns and expectations will be considered before deciding what, if any change is necessary.

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