Summary Genuine granuloma formation following implantation of injectable dermal fillers is a rare complication, with incidences ranging from one in 100 patients (1 percent) to one in 5000 (0.02 percent). Foreign body granulomas occur several months to years after injection at all implantation sites at the same time. Without treatment, they may grow to the size of beans, remain virtually unchanged for some years, and then resolve spontaneously. Three clinical and histologic types of foreign body granulomas can be distinguished: 1. Cystic granulomas (synonyms: inflammatory, palisading, collagenolytic): these are caused mainly by injected biological gels such as collagens and hyaluronic acids. Their clinical signs are fluctuation (sterile abscess), extreme redness, and induration. Cystic granulomas are small and superficial, occur within the first year, and disappear spontaneously within another year. They are surrounded by a significant number of giant cells. 2. Edematous granulomas (synonym: lipogranuloma): these are caused by artificial fluids such as silicone and polyacrylamides. They appear suddenly years after injection with extensive swelling and are surrounded and infiltrated by mononuclear and inflammatory cells. 3. Sclerosing granulomas (synonyms: sarcoidal and xanthelasmic): these are caused by particulate injectables composed of polymethylmethacrylate, polylactic acid, hydroxyethylmethacrylate, calcium-hydroxylapatite, or dextran microspheres. Sclerosing granulomas occur generally 6 months to 3 years after implantation and are visible, often bluish confined nodules. Histologically, the implant is infiltrated by many macrophages and giant cells, fibroblasts, and collagen fibers but few inflammatory cells. Permanent implants are not characterized by a higher rate of foreign body granuloma per se than temporary implants; however, their clinical appearance is more pronounced and their persistence longer if not treated adequately. (Plast.

Advances in medicine, as any other endeavor, are intimately dependent upon the communication and dissemination of new information among practitioners.Historically, physicians relayed the art of their practice anecdotally-teaching each subsequent generation verbally. Clearly, with the explosion of technology in the later part of the 20th century, the practice of medicine has also been dramatically and irrevocably altered. Concomitantly, the communication landscape, too, has been changed, evolving from the oral and then the written form into the electronic and digital spheres. In this era of a rapidly changing technology and its immediate access, there lies a significant risk of becoming dogmatic and unilateral in the way we learn and practice medicine.In an effort to relay current innovations in an open dialogue with debate and exchange of ideas at the same time as maintaining the tradition of sharing experiences with colleagues, we inaugurate a new feature to Dermatologic Surgery . The section, entitled " Controversies in Dermatologic Surgery ," will allow two authors to present opposing philosophies, techniques, or approaches for the same dermatologic surgical issue. While definitive answers may remain elusive, our goals are to stimulate debate, generate ideas, share pearls and perils, ultimately advance our specialty, and, most importantly, improve the quality of care.The opinions expressed in these dialogues are those of the author(s), and do not reflect the views of the section editors or the Journal . We welcome suggestions, comments, questions, and potential topics.

Linear or macular pigmentation occurs in 10-30% of patients following sclerotherapy of vessels between 0.1 and 5 mm in diameter. Its occurrence is related to solution strength, vessel fragility, injection pressure, and the type of solution used. This adverse sequela of treatment has been assumed, by some, to represent post-inflammatory hyperpigmentation (incontinence of melanin pigment), and has been said to occur in individuals with this tendency. Histologic data presented in this paper suggest that this phenomenon does not represent melanocytic alteration, but is secondary to extravasation of red blood cells into the dermis following rupture of fragile vessels with resulting deposition of hemosiderin. Therapy has included bleaching agents (hydroquinones), trichloroacetic acid, and phenolic peeling agents with variable success. Eighty percent of patients who experience this adverse sequela will clear spontaneously within 6-24 months. The remaining patients will have persistence of pigmentation for up to 5 years, with a small number of patients having pigmentation persisting 5 years after therapy.

Tissue fillers offer patients an opportunity for instant gratification with minimum downtime and, in general, an extremely favorable risk-to-benefit ratio. The best way to minimize complications in both your patients and yourself is to avoid them.

Those patients who had botulinum toxin had significantly less pain toward the end of the first week after surgery. Reduction in spasm within the internal sphincter is the presumed mechanism of action. This is the first reported randomized, controlled trial using botulinum toxin in hemorrhoidectomy.

Pure liquid silicone may be superior to any currently available agent in properly selected patients for permanent correction of certain types of defects. Physicians who use it, however, must be advised that the misuse of this agent or other materials masquerading as liquid silicone have created a pervasive climate of distrust and a veritable minefield of extraordinarily unpleasant medicolegal possibilities.

Both agents provided effective treatment, but HS caused 2.35 times as much pain during injections and resulted in two episodes of tissue necrosis.

Modern sclerosants that have been subjected to rigorous experimental and clinical trials will provide even more efficacious and safer patient treatments.