The term delayed (or late) onset nodules (DONs) isn’t a diagnosis as much as simply a descriptive term for nodules or areas of induration which occur at least two weeks after a dermal filler treatment. These nodules can occur with the use of any type of dermal filler. However, they may be more common with biostimulators and traditional collagen fillers.

While delayed onset nodules are a risk with any filler procedures, there are several practices that may help reduce this reaction.  Our long-standing approach or protocol at Medical Day Spa for minimizing this risk includes:

  1. Patient selection and education.  We screen patients with a consultation and good faith exam with our physician, doctor of nurse practitioner, or physician assistant before approving patients for dermal filler treatment.  Patients with underlying immune issues may not be good candidates for dermal filler.  Patients with recent illnesses, vaccinations, or recent invasive procedures, including dental work, surgery, tattoo procedures, or brow microblading, should refrain from having dermal filler for at least two weeks before and after. Pre-treatment assessment and screening must be done consistently and without exception to minimize risk.
  2. Technique: We pay careful attention to skin disinfection before treatment. At Medical Day Spa of Chapel Hill, this involves triple cleansing the skin with alcohol, chlorhexidine, and Puracyn (hypochlorous acid). This protocol is highly effective against a range of bacterial pathogens, including those identified in biofilms. Smaller needles are typically associated with minimal tissue trauma.  We use the smallest needle possible that is appropriate, change the needle several times during injections, and perform small injections slowly to help prevent tissue trauma.  Puracyn-soaked gauze is used throughout treatment to disinfect the skin as it is touched.  Gloves are changed as needed.
  3. Type of Filler: We only use hyaluronic acid fillers in our practice.  This means any potential adverse event can more easily be treated. In contrast to calcium-based fillers and collagen, hyaluronic acid fillers can be dissolved with an enzyme in case of an adverse reaction.
  4. Anatomical Knowledge: We are constantly undergoing continuing education and training which focuses on anatomy. Most late-onset nodules occur when the filler is inadvertently placed in the fascia or muscle.  Thorough knowledge of anatomy helps to ensure injections are performed in the correct layer of the face which minimize risk.
  5. Post-Treatment Care: What patients do – and do not do – after injections is also very important.  Dermal fillers are similar to implants.  It is essential for the skin to be kept clean and makeup and other products avoided for 24 hours following dermal filler injections.

The practitioner must be knowledgeable in differentiating between inflammatory and non-inflammatory nodules.  Is the “nodule” simply a filler lump?  Inflammatory nodules will often be tender to palpation.  If you check their medical history, have they had a recent illness that was not disclosed?  Ascertaining whether the lump is tender or came on immediately after the filler was injected vs. weeks/months later helps differentiate inflammatory versus non-inflammatory nodules. A cautious approach is typically the best approach with nodules.  The use of steroids and antibiotics is a safe course of action with reassessment after a reasonable time has been given for the patient to respond to treatment.  If this course is not successful, dissolving the filler with hyaluronidase may be necessary.

There are risks with any procedure.  It is important for patients to be educated on the risks, for providers and patients to do everything possible to minimize the risks, and for the practice to have follow-up with patients to ensure a successful outcome.

If you have questions or concerns about late-onset nodules following dermal filler, please call Medical Day Spa of Chapel Hill at (919)-904-7111.

If this sounds like something you could benefit from, we would love to have you come into Medical Day Spa of Chapel Hill to be assessed and given a regimen that would be specifically catered to you. Please call 919-904-7111 to schedule your consultation today and meet with one of our medical professionals.

If you live in Raleigh, Durham, Chapel Hill, Cary, Apex, Morrisville, Hillsborough or anywhere in the Triangle area of North Carolina come on in and experience our 5 star MedSpa !