Facial granulomas secondary to injection of semi-permanent cosmetic dermal filler containing acrylic hydrogel particles

Abstract

Various reports of long-term complications with semi-permanent fillers, appearing several years after injections have created some concern about their long-term safety profile. We report a case of foreign body granuloma secondary to dermal filler containing a copolymer of the acrylic hydrogel particles, hydroxyethylmethacrylate and ethylmethacrylate, occurring 2 years after the injection. The foreign body granulomas could not be treated satisfactorily with intralesional steroids, and the patient required a surgical excision of her granulomas. The physical and psychological consequences to such patients can be quite devastating.

Migrating Granulomatous Chronic Reaction from Hyaluronic Acid Skin Filler (Restylane): Review and Histopathological Study with Histochemical Stainings

“…Mild to severe reactions have been reported in the literature [9,11,12,14,15]; our case testifies a particularly severe ulcer-fibrotic reaction to the HA filler (Restylane), which persisted over time and displayed a tendency to migrate to territories into which the filler itself had not been injected, such as the subcutaneous fat layer and areas adjacent to the injection point (fig. 1).…”

“…There have been reports of delayed inflammatory skin reactions to HA fillers, occurring mostly after the first and repeat injections [3,4,9,10,11,12]. One retrospective study on the safety of non-animal stabilized HA in European countries spanning the years from 1997 to 2001 reported 34 cases of hypersensitivity - 16 cases of immediate and 18 cases of delayed hypersensitivity - with an overall risk of 0.8%.…”

“…Since 2000, the reported incidence of hypersensitivity reactions has been around 0.6%, half of which are immediate and only 0.3% delayed [13]. Despite the increased safety of non-animal stabilized HA fillers, several cases of significant allergy have been reported [11,12,14,15]. Concerns surrounding such fillers are related to classical granulomatous foreign body reactions.…”

“…In other cases, in whom cystic and macrophagic granulomas are found, biopsies display varying numbers of extracellular microcysts against a background of mononuclear vacuolated macrophages. No bacterial infections are normally associated with such reactions, and surgical toilets as well as corticosteroid injections lead to resolution of the nodules [12,14,15]. …”

Interspecies Differences in Reaction to a Biodegradable Subcutaneous Tissue Filler

“…The time until reaction differs between the various fillers, with a mean of 4.9 months for biodegradable fillers and 18.3 months for nonbiodegradable fillers (Zielke et al 2008). While most of the complications related to fillers are of mild severity and transient, severe reactions have been reported, including tissue necrosis, severe infections, and disfiguring nodules, which are mostly related to the formation of foreign body granuloma (Sachdev et al 2010;Funt and Pavicic 2013). Many of the more severe reactions are permanent and recalcitrant to treatment (Alijotas-Reig and Garcia-Gimenez 2008; Lowe, Maxwell, and Patnaik 2005).…”