He also failed to tell the woman about the risk of her developing growths known as granuloma, the findings said.
The woman, known as Mrs A, started developing swelling and inflammation on her cheeks about two weeks after receiving the injections.
By October a large granuloma was about to erupt on her face. She had to see a GP to get it drained, which left a hole by her cheekbone.
She received steroid injections and laser therapy after going back to the original doctor for a follow up consultation.
Despite the treatments, she was left with "obvious swellings" of about 10 to 20 centimetres on her face.
She was forced to receive care from two specialists, after which she alleged the doctor ignored her phone calls.
The Health and Disability Commissioner criticised the doctor for failing to ensure Novielle Gel Plus was safe and for not providing appropriate follow up care.
He did not tell the woman about the risk of granuloma forming or that the filler was not an approved medicine in New Zealand, the HDC said.
The doctor was ordered to apologise to the woman in writing and to review Medical Council of New Zealand good practice guidelines.
- Herald Online