Inflammatory nodules following soft tissue filler use: a review of causative agents, pathology and treatment options

Late-Onset Reactions after Hyaluronic Acid Dermal Fillers: A Consensus Recommendation on Etiology, Prevention and Management

Hyaluronic acid (HA) dermal fillers, generally considered low-risk, can lead to rare late-onset reactions (LORs) manifesting between 3 and 4 months postinjection, occasionally even as early as 24 h postinjection. The Complication Assessment and Risk Evaluation (CARE) board was established to review these reactions. In this publication, the authors aims to explore the etiological hypotheses underlying LORs, associated risk factors, prevention, and management approaches suggested by the CARE board. The CARE board identified three etiological hypotheses contributing to LORs. Firstly, the physicochemical structure of the filler, particularly low molecular weight HA, which may trigger an immune response. Secondly, infection, potentially introduced during injection or by dormant biofilm activation. Lastly, an imbalance in the host immune system, caused by factors like autoimmune diseases or viral infections, may lead to extended foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions. Based on these hypotheses, the board categorized various risk factors as patient-related (e.g., recent dental treatment, current medical status, active autoimmune disease), product-related (e.g., molecular weight), and procedure-related (e.g., aseptic technique and trauma). To reduce the risk of LORs, the CARE board recommends diligent patient selection, including comprehensive medical history assessment and informed consent. Practitioners should maintain an effective aseptic technique, and choose an appropriate product and injection depth for the anatomical location. Post-procedure, patients should receive education on proper filler care. Management of LORs depends on the suspected etiology, and the CARE board has proposed an algorithm to determine the most appropriate treatment. Hyaluronidase is recommended for noninflammatory reactions in the absence of active infection, while watchful waiting and/or steroid treatment may be preferred for inflammatory reactions. Hyaluronidase is not recommended as a first-line treatment for infections, which require drainage, bacterial culture, and antibiotic treatment. However, the board emphasizes the need for individualized evaluation and treatment in all cases.

Clinical Management With High-Frequency Ultrasound of Recurrent Submental Abscess Formation After Filler Placement: Bacterial Contamination or Immune-Mediated Adverse Event?

The authors present a case of a 29-year-old female patient with a recurrent submental abscess formation after chin augmentation with highly reticulated hyaluronic acid filler. We evaluate the possible cause of this complication and the result after clinical management with ultrasound-guided injection of hyaluronidase. We highlight the prevention, assessment and treatment with real-time imaging of hyaluronidase injection in the affected area, as a predictable approach for both the patient and the physician.

Oral Methotrexate Treatment of Delayed-Onset Inflammatory Reactions to Dermal Fillers

Background

In aesthetic practice, delayed-onset (late) inflammatory reactions (DIRs) to dermal fillers are encountered. The treatment of DIRs can be challenging, with a response to established therapies, including oral antibiotics, intralesional and oral steroids, and hyaluronidase injection, occasionally reported as unsatisfactory.

Objectives

Evaluate the efficacy of low-dose oral methotrexate (MTX) therapy in treating recalcitrant DIRs.

Methods

We retrospectively reviewed cases of recalcitrant DIRs treated with oral MTX. Data collected included individuals' gender and age, medical history, filler type, facial area(s) injected, previous treatments attempted to dissolve the DIR, MTX treatment dosage and duration, and outcome. Adverse events were monitored throughout the treatment.

Results

Thirteen females with a mean age of 52.6 years (range, 31-67 years) who developed recalcitrant DIRs to dermal filler injection are included. Eight reactions were triggered by the injection of hyaluronic acid (HA) fillers, 4 by liquid injectable silicone (LIS), and 1 by polymethylmethacrylate (PMMA). The average starting dosage of MTX was 12.1 mg/week (range, 7.5-12.5 mg/week). Patients were treated for 2 to 3 months in most cases. The average follow-up post-MTX therapy was 11.8 months (range, 2-36 months). A complete response to MTX treatment was observed in 10 patients (6 HA and 4 LIS cases), partial response in 1 (HA case), and an unsatisfactory response in 2 (HA and PMMA cases). Treatment was well tolerated.

Conclusions

A short course of low-dose oral MTX is a possible treatment for DIRs that have not responded to established therapies. The promising results of this report require validation by powered studies.

Level of Evidence 4

Hydrogel Based on Riclin Cross-Linked with Polyethylene Glycol Diglycidyl Ether as a Soft Filler for Tissue Engineering

Hydrogels composed of natural polysaccharides have been widely used as filling materials, with a growing interest in medical cosmetology and skin care. However, conventional commercial dermal fillers still have limitations, particularly in terms of mechanical performance and durability in vivo. In this study, a novel injectable and implantable hydrogel with adjustable characteristics was prepared from succinoglycan riclin by introducing PEG diglycidyl ether as a cross-linker. FTIR spectra confirmed the cross-linking reaction. The riclin hydrogels exhibited shear-thinning behavior, excellent mechanical properties, and cytocompatibility through in vitro experiments. Furthermore, when compared with subcutaneous injection of a commercial hyaluronic acid hydrogel, the riclin hydrogels showed enhanced persistence and biocompatibility in Balb/c mice after 16 weeks. These results demonstrate the great potential of the riclin-based hydrogel as an alternative to conventional commercial soft tissue fillers.

Biofilm formation is a risk factor for late and delayed complications of filler injection

Introduction

Biofilm formation is a major cause of delayed-graft complications. Similarly to implants, dermal fillers carry the risk of biofilm formation, which can lead to the development of nodules, chronic inflammatory reactions, abscesses and other complications. In this study, we investigated the late or delayed complications associated with biofilm formation on dermal fillers.

Methods

In this retrospective analysis, we analyzed all cases of complications caused by filler injections at a single center between January 2017 and December 2022, the majority of which comprised nodule formation and chronic persistent inflammatory reactions. The risk of biofilm formation with fillers was summarized and analyzed based on the results of bacterial culture and pathological examination.

Results

Sixty-one patients were enrolled, including 42 cases of nodule formation, 15 of chronic inflammatory reactions, and 4 of active infection. Bacterial culture of the tissue samples obtained from seven patients after surgical treatment were positive, and comprised four cases of Staphylococcus aureus, one case of Staphylococcus epidermidis, one case of Staphylococcus saprophyticus and one case of Mycobacterium abscessus. The corresponding histopathological results indicated extensive mononuclear lymphocyte infiltration, with a giant cell reaction in the fibrous connective tissue.

Conclusion

The results of this study suggest that biofilm formation is a significant risk factor for late and delayed complications following filler injection, and is caused by the contamination of resident bacteria and recessive infection at the injection site.

Efficacy of autologous platelet-rich plasma combined with a non-cross-linked hyaluronic acid compound in the treatment of female androgenetic alopecia: A retrospective, case-series study

BACKGROUND

Female androgenetic alopecia (FAGA) is a condition that affects women and involves the gradual loss of terminal hair in specific areas of the scalp. The limited treatment options for FAGA necessitate the development of new strategies. This study aimed to evaluate the potential benefit of using a combination therapy composed of autologous platelet-rich plasma (PRP) and a non-cross-linked hyaluronic acid (HA) compound in the treatment of FAGA.

METHODS

This was a retrospective, case-series study, which enrolled nine female patients with FAGA between September 2021 and December 2022. The non-cross-linked HA compound (Hearty®, Imeik Technology Development Co., Ltd.) and PRP were implanted into the areas of hair loss over four treatment sessions separated by 4-week intervals. Patients were monitored for overall improvement in their hair loss, hair count, treatment satisfaction, and adverse events at 1, 3, and 6 months follow-up.

RESULTS

The improvement rates, subjectively evaluated by the study physician, were 88.89% at the 1-month and 100% at the 3-month follow-up, relative to baseline. Moreover, the quantitative evaluation results showed that the FAGA patients' hair density increased by 54.51% at the 1-month and by 77.25% at the 3-month follow-up.

CONCLUSION

The combination of PRP and non-cross-linked HA compound appeared to be a certain positive effective procedure for FAGA without serious adverse event. We envisage that this work will contribute to the development of new treatment options for women suffering from this condition.

Imaging Features and Complications of Facial Cosmetic Procedures

Facial aesthetic procedures have become increasingly popular and complex, making knowledge of facial anatomy crucial for achieving desired outcomes without complications. Some of the most common procedures include blepharoplasty, bichectomy, face-lifts, facial implants, thread lifting, and fillers. Blepharoplasty and bichectomy are surgical procedures that respectively aim to restore youthful contours to the periorbita and create a slimmer lower face by removing Bichat fat from the maxillofacial region. Facial implants are used for aesthetic augmentation of the skeletal structure and restoration of facial contour by using biomaterials or autogenous bone grafts. Face-lift surgeries involve incisions and removal of excess skin, and thread lifts involve less invasive procedures performed by inserting threads beneath the skin, with the aim to lift the skin and thus reduce wrinkles and sagging. Fillers improve wrinkles and loss of facial volume, with biologic types made from animal, human, or bacterial sources (such as hyaluronic acid), while synthetic fillers include substances such as paraffin, silicone, calcium hydroxyapatite, polymethylmethacrylate microspheres, polyacrylamide hydrogel, hydroxyethyl-ethyl methacrylate, and poly-l-lactic acid. Synthetic fillers can be classified as rapidly resorbable (<12 months), slowly resorbable (<24 months), or permanent. Imaging modalities such as US, CT, and MRI can help identify and analyze each type of facial aesthetic procedure or filler, as well as their possible complications such as foreign-body granuloma, noninflammatory nodule, late intermittent persistent edema, filler migration, infection, or complications after removal of the buccal fat pad. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center The online slide presentation from the RSNA Annual Meeting is available for this article.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.

Delayed infectious reactions of dermal filler injections in the face: Causes and management

OBJECTIVE

Nowadays, dermal filler injections in the face, are widespread. However, late complications are rarely reported and misunderstood. Moreover, they could be potentially severe, particularly cellulitis which is life-threatening. Reactivation of the biofilm and the hypersensitivity reaction are the main etiopathogenic factors of such unpredictable infections and granuloma reactions. Through four cases of foreign-body cellulitis, this article aims to explain the causality of filler material, and trigger conditions while emphasizes the prompt and adequate solution.

MATERIAL AND METHODS

This work is a retrospective study and chart review which was granted an exemption by the author's institutional review board (IRB). Four women ranging from 27 to 55 years old, presented with onset symptoms of cellulitis of the face and inflammatory swelling of the lip. The hyaluronic acid filler was injected a long date prior. Trigger conditions caused the hatching of such complications which were solved with medical treatment without any filler dissolution or removal.

RESULTS

Improvement of the symptoms was remarkable within the three and fifth days of antibiotic therapy. There was no abscess formation or, recurrence for more than one-year follow-up.

CONCLUSION

The screening for dermal filler deposits must be considered for any inflammatory reaction of the face. Their causality should be discussed as well as the infectious and/or immunologic etiology, ensuring prompt and adequate medical treatment. Thus abscess formation could then not happen, and the resolution of the inflammatory reaction will be obtained. The extraction of filler material or the use of hyaluronidase should not be mandatory and will be done on a case-by-case basis.

Delayed Granulomas as a Complication Secondary to Lip Augmentation with Dermal Fillers: A Systematic Review

Introduction  Lip augmentation with dermal filler is rising in popularity. There are generally minimal side effects that are mild and transient. However, long-term complications may occur and include lumps, bumps, nodules, or granulomas. To better understand this uncommon but challenging outcome, we aim to perform a thorough systematic review of the published literature related to nodule or granuloma formation after cosmetic soft tissue augmentation of the lips.

Methods  A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in April 2021 and included PubMed, ScienceDirect, Embase, Google Scholar, and Cochrane databases. The Medical Subject Headings (MeSH) terms used included the following terms: “lip filler,” “hyaluronic acid,” “lip injection,” “lip augmentation,” “silicone,” “poly-L-lactic acid,” “calcium hydroxyapatite,” “polymethylmethacrylate,” “complications,” “reaction,” “granuloma,” and “nodule.” All studies were reviewed by two independent reviewers. Any discrepancies were resolved by a third reviewer.

Results  The initial search for filler-related nodules or granulomas yielded 2,954 articles and 28 were included in the final analysis containing 66 individual cases of lip nodules. All but one patient was female. The mean age was 50 years. Nodules presented on average 35.2 months or 2.9 years after initial treatment. Thirty-seven nodules underwent histological analysis, the majority of which identified the presence of a foreign-body granuloma. Silicone was the most reported filler used followed by hyaluronic acid. Most cases resolved following multiple treatments including oral antibiotics or steroids followed by surgical excision.

Conclusion  Understanding the sequelae of lip augmentation with filler products allows clinicians to provide safe and effective treatment. Nodules that present months to years following dermal treatment may represent a foreign-body granuloma. A combination of oral antibiotics, intralesional or oral steroids, and surgical excision successfully treated the majority of cases in our study.

Safety of Aesthetic Medicine Procedures in Patients with Autoimmune Thyroid Disease: A Literature Review

Autoimmune thyroid diseases are the most common organ-specific autoimmune diseases, affecting 2–5% of the world’s population. Due to the autoimmune background of thyroid diseases, we analyzed a wide range of cosmetic procedures, from minimally invasive cosmetic injections (mesotherapy) to highly invasive procedures, such as lifting threads. Out of the seven categories of treatments in aesthetic medicine analyzed by us—hyaluronic acid, botulinum toxin, autologous platelet-rich plasma, autologous fat grafting, lifting threads, IPL and laser treatment and mesotherapy—only two, mesotherapy and lifting threads, are not recommended. This is due to the lack of safety studies and the potential possibility of a higher frequency of side effects in patients with autoimmune thyroid diseases.

Clinical Efficacy and Safety of Non-Cross-Linked Hyaluronic Acid Combined with L-carnosine for Horizontal Neck Wrinkles Treatment

Background Horizontal neck wrinkle formation is gaining more attention among cosmetic practitioners and clients. To date, hyaluronic acid products are one of the most common treatment options for this aesthetic concern. However, different therapeutic strategies should be given to solve the problem due to multiple etiological reasons. Given that oxidative damage plays a critical role in neck wrinkle formation, anti-oxidative compounds are now considered by physicians when making a treatment plan. Aims To evaluate the efficacy and safety of a non-cross-linked hyaluronic acid filler in combination with L-carnosine in treating horizontal neck wrinkles. Methods Thirteen patients with a Wrinkle Assessment Scale (WAS) of 2–5 for horizontal neck wrinkles were treated with L-carnosine-containing non-cross-linked hyaluronic acid. Participants were followed-up for 3 months after treatment. The post-treated WAS scores evaluated by physicians were collected when patient satisfaction was surveyed. Any post-treatment adverse events were recorded. Results With a single injection of the above filler, the physician-evaluated WAS scores improved by at least one score at one month and the improvement kept consistent as far as three months after injection. According to the last follow-up visit, 11/13 patients were satisfied with the treatment effect of their neck wrinkle. Moreover, adverse events were rare after filler injection, except for local complications that were considered common reactions to the filler injection procedure. Conclusion The non-cross-linked hyaluronic acid filler containing L-carnosine is safe and effective for treating horizontal neck wrinkles.

Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Aetiopathogenesis of Late Inflammatory Reactions (LIRs) After Soft Tissue Filler Use: A Systematic Review of the Literature

Background

Late inflammatory reactions (LIRs) are the most challenging complications after filler use. The immune system plays a prominent role in its etiology, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for LIRs. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of LIRs.

Methods

We undertook a systematic literature review focused on immunological factors and microbiota in relation to LIRs after filler use. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE and the Cochrane databases were searched from inception up to August 2019. Included studies were assessed for the following variables: subject characteristics, number of patients, primary indication for filler injection, implant type/amount and injection site, type of complication, follow-up or injection duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors.

Results

Data on immunological factors and bacterial contamination were retrieved from 21 included studies. Notably, the presence of histocytes, giant cells and Staphylococcus epidermidis within biopsies were often associated with LIRs.

Conclusion

This review provides a clear overview of the immunological factors associated with LIRs and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with LIRs has been provided. Follow-up research may result in clinical recommendations to prevent LIRs.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors-www.springer.com/00266..

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02306-3.

Multiple Knoten am Handrücken infolge einer kosmetischen Behandlung mit Hyaluronsäure

Bei einer 47-jährigen Frau erfolgte eine kosmetische Behandlung zur Faltenreduktion beider Handrücken in Form einer Unterspritzung der Falten mit Hyaluronsäure. Wenige Tage später trat eine Schwellung beider Handrücken mit Hitze- und Spannungsgefühl auf. Unter Kühlung und topischer Pharmakotherapie war die Schwellung rückläufig, jedoch traten deutliche Knötchen im Bereich beider Handrücken an den vorher injizierten Arealen auf, die trotz regelmäßiger Unterspritzungen über mehr als 2 Jahre nicht abheilten. In einer dermatologischen Begutachtung wurden Fremdkörpergranulome diagnostiziert, deren Auftreten nach Fillerinjektionen mit Hyaluronsäure in die Handrücken, wenn auch selten, beschrieben wurde. Ein Behandlungsfehler konnte daher nicht bejaht werden, da es sich bei den Granulomen um die Verwirklichung eines seltenen, aber typischen Risikos des Eingriffs handelte. Jedoch blieb offen, ob eine rechtswirksame Einwilligung auf der Basis einer Aufklärung über sämtliche für die Einwilligung wesentlichen Umstände vorlag. Im Falle kosmetischer Eingriffe stellt die Rechtsprechung an die Aufklärung besonders hohe Anforderungen; sie sollte „schonungslos“ sein, damit der Patient entscheiden kann, ob er ggf. bleibende Entstellungen oder gesundheitliche Beeinträchtigungen in Kauf nehmen will, selbst wenn diese auch nur entfernt als eine Folge des Eingriffs in Betracht kommen. Die Beweispflicht für die Aufklärung trägt der Arzt; kann er dieser Pflicht nicht genügen, tritt für die Folgen der Behandlung eine Beweislastumkehr ein, d. h. dem Arzt werden eventuelle Schäden zugerechnet, auch wenn der Eingriff lege artis erfolgte.

Complications after cosmetic periocular filler: prevention and management

Soft tissue fillers are a mainstay in contemporary, minimally invasive facial rejuvenation procedures owing to timely results and minimal recovery period. Although associated with a low complication rate, soft tissue fillers are not without risk. Complications range from mild superficial skin irregularities to granuloma formation to vascular occlusion leading to skin necrosis or even blindness. Fillers vary in composition, elasticity, hydrophilicity and duration of effect that is tailored to specific cosmetic indications. Selecting the right product for the desired effect can cut down on unwanted outcomes. Severe adverse events can be avoided with safe injection technique, early recognition of symptoms and a thorough knowledge of the local anatomy. This review outlines several complications all providers should recognize and discusses strategies for their prevention and management.

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

Global Approaches to the Prevention and Management of Delayed-onset Adverse Reactions with Hyaluronic Acid-based Fillers

BACKGROUND

Delayed-onset adverse reactions to hyaluronic acid (HA) fillers are uncommon but have received increased attention, particularly with regard to late-onset nodules. Globally, there is a need for comprehensive prevention and management strategies.

METHODS

Experts with clinical practices in diverse regions of the world and extensive experience in managing complications related to HA fillers convened to propose and evaluate approaches to prevent delayed-onset adverse reactions after HA filler administration and manage late-onset nodules.

RESULTS

The expert panel agreed to define delayed-onset adverse reactions as those presenting more than 4 weeks posttreatment, with swelling, induration, and nodulation being the most common clinical signs. The panel recommended 5 general key approaches for the prevention of delayed-onset reactions (patient selection, anatomic location of injection/product selection, aseptic technique, injection procedure/filler, and posttreatment care). Strategies recommended for managing late-onset nodules included oral antibiotics, oral steroids, nonsteroidal anti-inflammatory drugs if needed, hyaluronidase for noninflammatory nodules (recognizing the limitations and regional availability of this treatment), intralesional antibiotics, intralesional immunosuppressive drugs such as steroids and fluorouracil, and surgical excision as a last resort. The panel noted that late-onset nodules may vary in both clinical presentation and etiology, making them challenging to address or prevent, and stressed individualized treatment based on clinical presentation. Regional differences in aseptic protocols, antibiotic selection, and steroid formulations were described.

CONCLUSION

Insights from global experts on approaches to prevent and manage delayed-onset adverse reactions following HA filler administration, including late-onset nodules, support clinicians worldwide in optimizing patient outcomes and safety.

Retrospective review of delayed adverse events secondary to treatment with a smooth, cohesive 20-mg/mL hyaluronic acid filler in 4500 patients

BACKGROUND

Recent publications have suggested an increased risk of delayed adverse events (DAEs) with a smooth, cohesive 20-mg/mL hyaluronic acid filler, Juvéderm Voluma (HA-V).

OBJECTIVE

To examine the occurrence of HA-V DAEs and identify patterns and characteristics.

METHODS

Charts from patients who received HA-V between February 1, 2009, and February 28, 2018 from 2 clinics were analyzed.

RESULTS

In 4500 patients who received 9324 treatments with HA-V, 44 DAEs were identified, for a combined incidence of 0.98% per patient, 0.47% per treatment, and 0.23% per syringe. Patients with DAEs received a slightly larger cumulative amount of HA-V than those who did not. Delayed swelling and nodule formation were the most common reactions and occurred a median of 4 months after treatment, with an increase in frequency between October and January. About a third were preceded by an identifiable immunologic stimulus. DAEs were transient and resolved without incident.

LIMITATIONS

The retrospective nature made it difficult to capture time to resolution or remember potential triggers.

CONCLUSION

In this large, long-term, retrospective review, HA-V DAEs occurred at a rate of 0.98% per patient. Although the exact cause has yet to be elucidated, we hypothesize that an increase in fragmentation during the HA-V degradation process may trigger an inflammatory response after an immunologic trigger.

PMMA Safety for Facial Filling: Review of Rates of Granuloma Occurrence and Treatment Methods

PMMA is composed of microspheres suspended in bovine collagen. Once injected in a dermal area, the carrier is absorbed, giving place to collagen that gives volume and maintains the spheres in the place. This process may give origin to exacerbate foreign body reaction and granuloma. The frequency of such complication is not clear. The primary objective was to review and compare the frequencies of granuloma between the published studies. The secondary aim was to compare the therapies and efficacies. The series of cases in which PMMA was used as facial filler were reviewed, and the rate of granulomas was compared; the case report studies describing those complications were also reviewed, and the therapies and outcomes were quantified. The data showed general frequency of PMMA-related complications of 4.9% and granulomas 1.9%; the incidence of granuloma was 1/2075 patients-year, and the time to development ranged from 6 to 180 months. The most used therapies were steroid, surgery or both, with satisfactory results. In conclusion, considering the actual risks and benefits of PMMA, we may affirm that it is a safe filler; doctors and patients must be conscious of potential risks when deciding for its use. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Delayed sclerosing granulomatous reaction to dermal filler injection of poly-hydroxyethyl-methacrylate suspended in hyaluronic acid: Histochemical and confocal laser scanning microscopical analysis

Re-absorbable dermal fillers of poly-hydroxyethyl-methacrylate suspended in hyaluronic acid are considered overall safe and well tolerable because of biocompatibility; nevertheless, rarely, late, or early adverse reactions may occur.

Management of Lip Complications

This article discusses complications that may occur after procedures on the lips, specifically focusing on injectable fillers. Evidence-based guidelines and suggested methods to manage these complications are presented in a systematic format.

A Cross-sectional Analysis of Adverse Events and Litigation for Injectable Fillers

Importance

Injectable fillers are increasing in popularity as a noninvasive option to address concerns related to facial aging and volume loss. To our knowledge, there have been no large-scale analyses of adverse events and associated litigation related to filler injections.

Objectives

To determine risks of injectable fillers and analyze factors raised in litigation related to injectable fillers.

Design, Setting, and Participants

In this cross-sectional review, the US Food and Drug Administration's (FDA) manufacturer and user facility device experience (MAUDE) database was evaluated for complications from the use of the following fillers: Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill, and Juvederm Voluma from 2014 to 2016. The Westlaw Next database was used to identify jury verdicts.

Main Outcomes and Measures

Complications were organized by type of filler used, location of injection, and severity. Intra-arterial injections without sequelae and those resulting in blindness or necrosis were considered severe complications. Factors raised during the litigation process were also analyzed.

Results

Of 1748 adverse events analyzed, most cases stemmed from cheek (751 [43.0%]) or lip (524 [30.0%]) injection. Commonly reported adverse events reported included swelling (755 [43.2%]) and infection (725 [41.5%]). Among FDA-reported complications, blindness was significantly associated with dorsal nasal injections (P < .001). Vascular compromise with and without sequela of dermal necrosis and blindness were significantly associated with Radiesse injections P < .001. Of the 9 malpractice cases identified, two-thirds involved allegations of inadequate informed consent, and the median award in cases resolved with payment was $262 000.

Conclusions and Relevance

Although specific complication profiles vary by material and injection site, common adverse events associated with injectable fillers include swelling and infection. More serious events include vascular compromise, resulting in necrosis and blindness; these events are also raised in cases involving litigation. This analysis illustrates the importance of outlining these risks in a comprehensive preoperative informed consent process.

Level of Evidence

NA.

Complications and Litigation Associated With Injectable Facial Fillers: A Cross-Sectional Study

PURPOSE

Soft-tissue injectable fillers are a popular treatment option for patients seeking minimally invasive facial rejuvenation. The use of soft-tissue fillers has increased significantly in the past 10 years. In 2017 alone, clinicians administered nearly 2.7 million soft-tissue fillers, up from 1.3 million in 2007. Although injectable fillers have a relatively high safety profile compared with more invasive rejuvenation procedures, serious adverse events, including intra-arterial injections, necrosis, and visual symptoms such as blindness, have been documented. Complications from injectable fillers have also been a source of litigation, which has been shown to be associated with a perceived lack of informed consent. We sought to document the reported complication rates associated with injectable facial fillers from a national database and to report on the available cases of malpractice litigation.

MATERIALS AND METHODS

The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was used to collect the reported complications from 2013 to 2017 for the following injectable fillers: Artefill, Bellafill, Belotero, Juvederm, Radiesse, Restylane, Sculptra, and Kybella. Complications were organized by filler type, injection location, and complication type. The Thomson Reuters Westlaw Edge database was used to collect the reported jury verdicts and settlements from 2008 to 2017 for injectable facial fillers.

RESULTS

A total of 2813 adverse events were analyzed. The most common locations for complications were the cheek (915 [32.5%]), lips (503 [17.9%]), and nasolabial fold (412 [14.6%]). The commonly reported adverse events were swelling (1,691 [60.1%]), nodule (948 [33.7%]), and pain (636 [22.6%]). Severe complications included intra-arterial injections resulting in necrosis and visual symptoms (eg, blurred vision and blindness). Forehead and dorsal nasal injections were significantly associated with intra-arterial complications resulting in necrosis and visual symptoms (P < .01). Injections with Radiesse were significantly associated with intra-arterial injections resulting in necrosis and visual symptoms (P < .01). A total of 11 malpractice cases were analyzed. The median award in the cases resolved by a verdict in favor of the plaintiff or settlement was $600,000. In 10 of the 11 cases, a lack of informed consent had been alleged.

CONCLUSIONS

The complications associated with injectable facial fillers varied greatly, depending on factors involved with their application. The most common adverse effects were swelling, nodule formation, and pain. Serious complications stemming from intra-arterial injections included necrosis and visual disturbances, including blindness. These complications have been raised in legal cases, in which the lack of informed consent was frequently alleged. The present analysis has documented some of the potential risks involved with injectable facial fillers and demonstrated the need for a thorough informed consent process before their administration.

A prospective study comparing topic platelet-rich plasma vs. placebo on reducing superficial perioral wrinkles and restore dermal matrix

Introduction: The goal of our prospective study was to assess the efficacy of the topical Platelet-rich plasma on reducing superficial perioral wrinkles and restoring the dermal matrix. Materials and methods: 50 women with moderate to severe perioral wrinkles were treated on the perioral area by a single session of fractional CO2 laser skin resurfacing plus intradermal injection of prp. 25 patients (group 1) applied topically prp twice a day for 12 weeks as post laser treatment. 25 (group 2) applied gentamicin and betamethasone twice a day for the first 7 days and then hyaluronic acid gel for the following 12 weeks. Results: In group 1, moisture (p < 0.001), amount of collagen fiber (p < 0.001) skin elasticity (p < 0.001), PSAl (p < 0.001) and SSAl (p < 0.001) improved significantly. In group 2 all the parameters investigated improved but did not reach significant difference. Discussion: Our medical device with a plasma-like formulation is able to maintain prp active for a period of 7 days so patients are able to apply topically growth factors at home. Conclusions: Our prospective study proves that the use of topical prp reduces superficial perioral wrinkles and restore dermal matrix when used at home for 12 weeks.

Injection Rhinoplasty Using Filler

Rhinoplasty is a commonly performed cosmetic surgery in Asia. Rhinoplasty using filler is preferred because has fewer side effects and shorter down time. The part of external nose between the skin and bone or cartilages consists of 4 layers. To prevent vascular compromise, the injection should be into deep fatty layer, preventing embolization. Filler is usually injected in the order of radix, rhinion, tip, and the supratip area. To minimize asymmetry, the surgeon should always mark the midline on the nasal bridge and perform the procedure without deviating from it.

[Cutaneous foreign body granulomas following cervico-facial arterial embolization: Three cases]

BACKGROUND

Foreign body granuloma is an inflammatory tissue reaction to exogenous material. Classically it appears on the face after aesthetic procedures. Herein we report for the first time three cases of facial granulomatous reactions to microbeads after arterial cervico-facial embolization.

PATIENTS AND METHODS

Three patients underwent embolization of the facial arteries using Embogold^® microbeads in a setting of epistaxis or tumoral hemostasis. Within 10 to 45 days painful, inflammatory, subcutaneous nodules appeared on the homolateral side of the face. Histological samples showed an inflammatory response with giant cells as well as the presence of microbeads in the skin. A favorable outcome was achieved with colchicine in one patient and with surgery in another; the third patient was lost to follow-up.

DISCUSSION

The embolizing microspheres produced a local inflammatory reaction, with destruction of the vascular wall and bead migration to facial tissue leading to a granulomatous reaction. The occurrence of three cases within a period of few weeks, with several different operators and batches of products, is surprising considering the long-standing use of the product. There was no common comorbidity in the patients and no suggestion of trauma. Retrospective analysis of the product batches was normal. Gold staining could play a role in severe inflammatory response to Embogold^® particles.

CONCLUSION

These three cases illustrate the value of discussing potential foreign body granulomatous reaction in cases of facial nodules following cervico-facial embolization. Colchicine may offer a valuable therapeutic alternative.

Cutaneous Granulomatosis: a Comprehensive Review

Cutaneous granulomatosis is a heterogeneous group of diseases, characterized by a skin inflammatory reaction triggered by a wide variety of stimuli, including infections, foreign bodies, malignancy, metabolites, and chemicals. From a pathogenic point of view, they are divided into non-infectious and infectious granulomas. Pathophysiological mechanisms are still poorly understood. Non-infectious granulomatous skin diseases include granuloma annulare, necrobiosis lipoidica, rheumatic nodules, foreign body granulomas, cutaneous sarcoidosis, and interstitial granulomatous dermatitis. Necrobiosis lipoidica is more frequent in diabetic patients. Infectious granulomas of the skin are caused by mycobacteria, in particular Mycobacterium tuberculosis or atypical mycobacteria; parasites, such as Leishmania; or fungi. Pathogenic mechanisms of M. tuberculosis-related granuloma are discussed. From a clinical point of view, it is useful to divide cutaneous granulomatosis into localized and more disseminated forms, although this distinction can be sometimes artificial. Three types of localized granulomatous lesions can be distinguished: palisaded granulomas (granuloma annulare, necrobiosis lipoidica, and rheumatoid nodules), foreign body granulomas, and infectious granulomas, which are generally associated with localized infections. Disseminated cutaneous granulomas can be divided into infectious, in particular tuberculosis, and non-infectious forms, among which sarcoidosis and interstitial granulomatous dermatitis. From a histological point of view, the common denominator is the presence of a granulomatous inflammatory infiltrate in the dermis and/or hypodermis; this infiltrate is mainly composed of macrophages grouped into nodules having a nodular, palisaded or interstitial architecture. Finally, we propose which diagnostic procedure should be performed when facing a patient with a suspected cutaneous granulomatosis.

Unusual Aspergillus Infection After Dermal Filler Injection

According to a great desire for facial rejuvenation, dermal filler is promising for improving people's appearance without surgery. In a society of plastic surgery, injection of dermal filler is one of the most common procedures for a younger appearance. An increase in patients who have filler injection has been paralleled by a rise in various adverse reactions. Formation of inflammatory or infected nodules is one of the most common long-term complications. Infections can be increased because of improper disinfection of the patient's skin, a poor injection technique, decreased general immunity, and the presence of pathogens. The majority of bacteria are aerobic or facultative aerobic bacteria. This expectation of pathogens is critical for deciding on the antibiotic treatment before confirming the pathogen by microbial culture. The authors experienced unusual culture results in a patient with a chronic inflammatory nodule with abscess formation. The authors report a unique Aspergillus-cultured infection after filler injection.

Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations

Background

Dermal fillers have been increasingly used in minimally invasive facial esthetic procedures. This widespread use has led to a rise in reports of associated complications. The aim of this expert consensus report is to describe potential adverse events associated with dermal fillers and to provide guidance on their treatment and avoidance.

Methods

A multidisciplinary group of experts in esthetic treatments convened to discuss the management of the complications associated with dermal fillers use. A search was performed for English, French, and Spanish language articles in MEDLINE, the Cochrane Database, and Google Scholar using the search terms “complications” OR “soft filler complications” OR “injectable complications” AND “dermal fillers” AND “Therapy”. An initial document was drafted by the Coordinating Committee, and it was reviewed and modified by the experts, until a final text was agreed upon and validated.

Results

The panel addressed consensus recommendations about the classification of filler complications according to the time of onset and about the clinical management of different complications including bruising, swelling, edema, infections, lumps and bumps, skin discoloration, and biofilm formation. Special attention was paid to vascular compromise and retinal artery occlusion.

Conclusions

Clinicians should be fully aware of the signs and symptoms related to complications and be prepared to confidently treat them. Establishing action protocols for emergencies, with agents readily available in the office, would reduce the severity of adverse outcomes associated with injection of hyaluronic acid fillers in the cosmetic setting. This document seeks to lay down a set of recommendations and to identify key issues that may be useful for clinicians who are starting to use dermal fillers. Additionally, this document provides a better understanding about the diagnoses and management of complications if they do occur.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Injectable facial fillers: imaging features, complications, and diagnostic pitfalls at MRI and PET CT

Injectable fillers are widely used for facial rejuvenation, correction of disabling volumetric fat loss in HIV-associated facial lipoatrophy, Romberg disease, and post-traumatic facial disfiguring. The purpose of this article is to acquaint the reader with the anatomy of facial fat compartments, as well as with the properties and key imaging features of commonly used facial fillers, filler-related complications, interpretation pitfalls, and dermatologic conditions mimicking filler-related complications. The distribution of facial fillers is characteristic and depends on the anatomy of the superficial fat compartments. Silicone has signature MRI features, calcium hydroxyapatite has characteristic calcifications, whereas other injectable fillers have overlapping imaging features. Most fillers (hyaluronic acid, collagen, and polyalkylimide-polyacrylamide hydrogels) have signal intensity patterns compatible with high water content. On PET-CT, most fillers show physiologic high FDG uptake, which should not be confounded with pathology. Abscess, cellulitis, non-inflammatory nodules, and foreign body granulomas are the most common filler-related complications, and imaging can help in the differential diagnosis. Diffusion weighted imaging helps in detecting a malignant lesion masked by injected facial fillers. Awareness of imaging features of facial fillers and their complications helps to avoid misinterpretation of MRI, and PET-CT scans and facilitates therapeutic decisions in unclear clinical cases.

KEY POINTS

• Facial fillers are common incidental findings on MRI and PET-CT scans. • They have a characteristic appearance and typical anatomic distribution • Although considered as safe, facial filler injections are associated with several complications • As they may mask malignancy, knowledge of typical imaging features is mandatory. • MRI is a problem-solving tool for unclear cases.

Current Applications of Facial Volumization with Fillers

LEARNING OBJECTIVES

After reading this article and watching the accompanying videos, the participant should be able to: 1. Assess patients seeking facial volumization and correlate volume deficiencies anatomically. 2. Identify appropriate fillers based on rheologic properties and anatomical needs. 3. Recognize poor candidates for facial volumization. 4. Recognize and treat filler-related side effects and complications.

SUMMARY

Facial volumization is widely applied for minimally invasive facial rejuvenation both as a solitary means and in conjunction with surgical correction. Appropriate facial volumization is dependent on patient characteristics, consistent longitudinal anatomical changes, and qualities of fillers available. In this article, anatomical changes seen with aging are illustrated, appropriate techniques for facial volumization are described in the setting of correct filler selection, and potential complications are addressed.

An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment

PURPOSE

The purpose of this study was to provide an overview of infections associated with facial soft tissue fillers.

MATERIALS AND METHODS

A literature review was performed which evaluated infections associated with facial soft tissue fillers.

RESULTS

Infection rates with soft tissue fillers are low and are estimated at 0.04 to 0.2%. Most of these infections arise when skin contaminants infiltrate the injection site at the time of injection. These infections can occur early, up to several days after treatment, or delayed, occurring weeks to years after treatment. Reactions vary based on the filler absorbability and duration. Early recognition and treatment are important factors in managing our cosmetic surgery patients.

CONCLUSION

Although facial fillers are safe and predictable, infections can still occur. Oral and maxillofacial surgeons need to be able to prevent, recognize, and properly manage infections related to these popular injections.

Use of Fillers in Rhinoplasty

Surgical rhinoplasty is the one of the most common cosmetic procedures in Asians. But there are limitations, such as down time, high cost, and a steep learning curve. Most complications are implant related. A safer and less invasive procedure is rhinoplasty using fillers. Good knowledge of the nasal anatomy is essential for rhinoplasty using fillers. Knowledge of nerves, blood supply, and injection plane allows avoiding complications. There are several planes in the nose. The deep fatty layer is recommended for injection, because it is wide and loose and there are less important neurovascular structures. Botulinum toxin also can be used for noninvasive rhinoplasty.

Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers

BACKGROUND

Although the use of filling agents for soft-tissue augmentation has increased worldwide, most consensus statements do not distinguish between ethnic populations. There are, however, significant differences between Caucasian and Asian faces, reflecting not only cultural disparities, but also distinctive treatment goals. Unlike aesthetic patients in the West, who usually seek to improve the signs of aging, Asian patients are younger and request a broader range of indications.

METHODS

Members of the Asia-Pacific Consensus group-comprising specialists from the fields of dermatology, plastic surgery, anatomy, and clinical epidemiology-convened to develop consensus recommendations for Asians based on their own experience using cohesive polydensified matrix, hyaluronic acid, and calcium hydroxylapatite fillers.

RESULTS

The Asian face demonstrates differences in facial structure and cosmetic ideals. Improving the forward projection of the "T zone" (i.e., forehead, nose, cheeks, and chin) forms the basis of a safe and effective panfacial approach to the Asian face. Successful augmentation may be achieved with both (1) high- and low-viscosity cohesive polydensified matrix/hyaluronic acid and (2) calcium hydroxylapatite for most indications, although some constraints apply.

CONCLUSION

The Asia-Pacific Consensus recommendations are the first developed specifically for the use of fillers in Asian populations.

CLINCIAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

One-pot synthesis of highly mechanical and redox-degradable polyurethane hydrogels based on tetra-PEG and disulfide/thiol chemistry

A series of tetra-PEG polyurethane hydrogels with tunable redox-degradability and a high compressive fracture strength has been synthesized by a one-pot method.

Granulomatous foreign-body reactions to permanent fillers: detection of CD123+ plasmacytoid dendritic cells

BACKGROUND

Soft-tissue augmentation with permanent fillers can lead to severe granulomatous foreign-body reactions (GFBRs), but the immune pathomechanism of this complication is still unknown. We performed conventional histologic examination and immunostaining for plasmacytoid dendritic cells (pDCs) in skin sections from patients with GFBR to 4 permanent filler agents, which have been widely used in recent decades.

METHODS

Twenty-one skin biopsies were studied from 19 patients with GFBR to polyalkylimide 4% gel (PAIG, n = 10), polyacrylamide 2.5% gel (PAAG, n = 2), hydroxyethyl methacrylate/ethyl methacrylate in hyaluronic acid (HEMA/EMA, n = 4), or liquid injectable silicone (n = 5). GFBRs were analyzed in hematoxylin and eosin stained sections and pDCs detected using CD123 antibodies. Anti-CD11c immunostaining was performed for comparison.

RESULTS

Grading of the inflammatory infiltrates observed histologically did not correlate with the clinical features of inflammation. Immunostaining for CD123 did not detect pDCs in 8 of 10 polyalkylimide gel, 1 of 2 polyacrylamide gel, and the 5 liquid injectable silicone biopsies. In contrast, all 4 HEMA/EMA biopsies contained collections of pDCs in lymphocytic infiltrates close to filler particles and adjacent sarcoidal granulomas.

CONCLUSIONS

Our data suggest that pDCs contribute to the sarcoidal granulomas associated with injected HEMA/EMA. Recruited pDCs may exert their pro-inflammatory effects by the release of interferon-α at the site of these filler deposits.

Patient factors influencing dermal filler complications: prevention, assessment, and treatment

While rare, complications do occur with the esthetic use of dermal fillers. Careful attention to patient factors and technique can do much to avoid these complications, and a well-informed practitioner can mitigate problems when they do occur. Since cosmetic surgery is usually an elective process, requested by the patient, clinical trials are complex to organize and run. For this reason, an international group of practicing physicians in the field of esthetics came together to share knowledge and to try and produce some informed guidance for their colleagues, considering the literature and also pooling their own extensive clinical experience. This manuscript aims to summarize the crucial aspects of patient selection, including absolute contraindications as well as situations that warrant caution, and also covers important considerations for the pre- and posttreatment periods as well as during the procedure itself. Guidance is given on both immediate and long-term management of adverse reactions. The majority of complications are related to accepting patients inappropriate for treatment or issues of sterility, placement, volume, and injection technique. It is clear that esthetic practitioners need an in-depth knowledge of all aspects of treatment with dermal fillers to achieve optimal outcomes for their patients.