Adverse granulomatous reaction after cosmetic dermal silicone injection

A case of recalcitrant silicone granuloma treated with adalimumab: A case report

Liquid silicone is a relatively inexpensive injectable used for soft tissue augmentation. Injection of silicone is associated with a risk of delayed granuloma formation associated with elevated levels of tumour necrosis factor-α. We report a case of recalcitrant silicone granulomas following facial injections of silicone successfully treated with tumour necrosis factor-α blockade. Our case, as well as previous reports, demonstrates the effectiveness of this therapy for the treatment of foreign body granulomas from due to silicone.

Chest Feminization in Male-to-Female Transgender Patients: A Review of Options

Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.

Silicone use among Nepali transgender women: the hazards of beauty

Purpose

It is widely believed that transgender individuals in Nepal inject silicone for face and body manipulation, a phenomenon thought to be common among transgender individuals globally. Therefore, this qualitative study conducted in Nepal explored: (1) awareness of silicone use and sources of information; (2) reasons for using silicone; (3) notion of cost and quality of these procedures; (4) reported negative aspects, including side effects and (5) health seeking behaviors of Nepali transgender women.

Design/methodology/approach

The authors carried out eight focus group discussions (FGDs) with transgender women at four different districts of Nepal, five in the capital Kathmandu and three in different rural areas. We also interviewed three transgender women who preferred not to participate in the FGD but were happy to be interviewed separately. Similarly, six interviews with stakeholders working for sexual and gender minority populations were also conducted.

Findings

Most FGD participants were young (mean age 23.06 ± 3.9 years) and the majority (55%; n = 34) completed grade six to high school level. Peer networks of transgender people and the Internet were the more popular sources of information about silicone. The decision to use silicone was largely influenced by the desire to look beautiful and more feminine. Often they appear not to follow the recommended procedures for silicone use. Their health seeking behavior regarding side effects or complications of these procedures was very poor.

Originality/value

Findings reflect that targeted interventions aimed at transgender individuals should educate them on the use of silicone, as well as explore safe and affordable approaches to meet gender-related appearance needs of Nepali transgender people.

Liquid Silicone-Induced Extensive and Debilitating Granulomatosis Responding to Hydroxychloroquine

In the last two decades, there has been a significant rise in body-image improvement among the American consumers. Cosmetic injectable procedures have increased by 40.6% in the past 5 years. There has also been an increase in nonmedical, illegal, and self-appointed personnel, offering cheaper hazardous procedures. Silicone has been in use since 1965. In 1991, FDA issued guidelines prohibiting the marketing of injectable liquid silicone. However, it is biologically inert, is associated with inflammatory response, and leads to serious complications like granulomatosis, migration, acute pneumonitis, pulmonary embolism, and even death. Here, we present a case of silicone-induced granulomatosis with extensive migration which ended in bilateral mastectomy, multiple anterior chest debulking procedures, and finally peg tube placement due to compression of the esophageal lumen by granulomas. The patient was eventually started on immunomodulatory treatment, hydroxychloroquine with good response.

Granuloma formation secondary to silicone injection for soft-tissue augmentation in facial cosmetics: Mechanisms and literature review

The use of injectable fillers is increasingly popular as an alternative to surgery for facial cosmetic applications. In this regard, silicone is a versatile biomaterial filler that has been used for these purposes, but its use warrants further investigation, especially since it is not clinically approved for such uses. We describe the use of silicone as a facial injectable filler through a scholarly review of the literature for cases of silicone granuloma formation published from September 2007 through September 2017, and we present various contexts in which this complication has been observed. We further review the immunologic etiology of granuloma formation and other complications of silicone injections. We write this report to caution physicians on the use of silicone fillers which, for all their advantages, are associated with significant long-term risks that are frequently overlooked.

Use of a Hyaluronic Acid Soft-tissue Filler to Correct Congenital and Post-traumatic Lip Asymmetry

Background:

The use of hyaluronic acid soft-tissue fillers for enhancement of lip features is a popular and minimally invasive office-based procedure used worldwide due to its relative simplicity and favorable safety profile.

Materials and Methods:

Hyaluronic acid was used in illustrative cases to attempt correction of congenital and acquired lip asymmetries.

Results:

In the cases presented, accurate and cosmetically acceptable results were attained and maintained for the duration of the product life.

Conclusions:

Hyaluronic acid may be used successfully when lip asymmetry is evident and is a relatively simple nonsurgical alternative.

Resection of granulomatous tissue resolves silicone induced hypercalcemia

Because of the increasing trend of body contour enhancements with injections, implants, and fillers, clinicians should be on high alert for the possibility of silicone-induced hypercalcemia as one of the differential diagnoses in a patient with history of silicone use. Hypercalcemia as a result of silicone injections has been reported, and there is concern that there will be more cases given the popularity of cosmetic silicone. Cases involved a mother and daughter (70 & 55 years) who presented in 2013 with hypercalcemia after cosmetic silicone injections in 2007. Evaluation showed 1, 25-dihydroxyvitamin D-mediated hypercalcemia and progressive renal dysfunction; lymph node biopsy showed granulomatous silicone lymphadenitis. MRI of the pelvis revealed abnormal signal enhancement within the subcutaneous gluteal adipose tissue and enlarged inguinal lymph nodes. For persistent hypercalcemia and hypercalciuria, surgical resection of silicone material and granulomas is a successful approach to normalize the serum calcium level.

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One of the first reports of resolution of hypercalcemia by surgical intervention

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High possibility of silicone-induced hypercalcemia

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Surgical resection silicone material and granulomas is a successful approach.

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We aim to encourage the awareness of this condition among clinicians.

Oleomas mimicking cutaneous xanthomas following breast augmentation by injection of liquid silicone

BACKGROUND

Oleoma is defined as a foreign body granuloma resulting from the injection of oily substances into the skin or subcutaneous tissue. Liquid injectable silicone has been used extensively over the last five decades for soft tissue augmentation. Although initially considered as a biologically inert material, it has been implicated in a variety of adverse reactions, sometimes with latent periods of decades.

MAIN OBSERVATIONS

We describe the case of a 44-year-old Peruvian woman presenting with multiple painless yellowish papules and plaques limited to the lower half of the breasts, that seemed to be cutaneous xanthomas. A skin biopsy showed granulomatous inflammation with multiple clear vacuoles corresponding to injected liquid silicone particles, diagnosed as oleoma. The patient was then re-evaluated and she reported that she underwent breast augmentation by injection of liquid silicone five prior to presentation in our department. Thus, the diagnosis of oleoma was confirmed.

CONCLUSIONS

We describe a case with yellowish papules on both breasts in a woman that underwent breast augmentation by injection of liquid silicone. Since this unusual presentation of oleomas can be confused with cutaneous xanthomas, a biopsy is essential for diagnosis.

Silicone-induced granuloma after injection for cosmetic purposes: a rare entity of calcitriol-mediated hypercalcemia

Hypercalcemia is often a clue to the presence of unsuspected illness. We present an interesting case of an HIV-positive transgender female with a rare cause of silicone-induced granulomatous hypercalcemia. Although there have been a few case reports of silicone injections in dialysis patients causing hypercalcemia, this metabolic derangement secondary to silicone granulomas continues to be a unique entity with an unclear pathophysiology. We present a 45-year-old transgender HIV-positive female, with extensive silicone injections, who presented with symptomatic hypercalcemia. Workup for malignancy and hyperparathyroidism was negative. 1,25-Dihydroxyvitamin D level and 24-hour urine calcium level were elevated. CT scan showed extensive high-density reticulonodular densities in the buttocks and gluteal muscle fascia extending upwards to the lumbar region, along with prominent external iliac and inguinal lymph nodes. Nuclear imaging showed diffuse heterogeneity and increased uptake in the buttocks, most consistent with granuloma calcifications, and an inguinal lymph node biopsy confirmed a foreign body giant cell reaction. The patient was started on prednisone and this resulted in decrease in serum and urinary calcium levels. Physicians should have a high index of suspicion for silicone-induced hypercalcemia considering the growing prevalence of body contour enhancement with injections, implants, and fillers using this material.

Skin ulcer: a long-term complication after massive liquid silicone oil infiltration

BACKGROUND

Despite scientific literature replete with stories of disastrous results and disfigurement, illicit subcutaneous injections of highly viscous fluids in massive quantities still are performed, often by unqualified persons. The authors present a devastating long-term outcome from a massive volume of silicone oil injected subcutaneously into the buttocks of a 48-year-old transsexual patient and its ulceration treated only through regular medications.

METHODS

The therapeutic protocol consisted of wound disinfection with iodopovidone, washing with saline solution, disinfection with sodium hypochlorite 0.05 %, and application of ointment containing Vibrio alginolyticus collagenase and hyaluronan. The follow-up evaluation was at 1 and 2 weeks and then at 1, 2, and 3 months. Weekly photographs were taken, and measurements of the lesion and evolution were estimated every 7 days.

RESULTS

After 3 months of regular medications, the authors succeeded in closing the ulcer, avoiding invasive therapeutic options.

CONCLUSION

In the presence of the cutaneous ulceration above a massively infiltrated area, if the removal of all the injected oil is surgically definitely impossible, other conservative procedures should be considered. Our experience demonstrated how it is possible to manage a so prickly a case with a noninvasive approach such as periodic medications.

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 .

Adverse late reactions after cosmetic implantation of hydroxyethylmethacrylate particles suspended in hyaluronic acid: clinics and complication management

BACKGROUND

The late-stage clinical course, histopathologic analysis, and surgical salvage procedures after eventful cosmetic injection of hydroxyethylmethacrylate particles suspended in hyaluronic acid (DermaLive, marketed through Dermatech, Paris, France and Novamedical GmbH, Langenfeld, Germany) have been studied. The study was designed to present modified treatment guidelines, report results, and draw conclusions regarding the future management of patients with late-stage DermaLive complications.

METHODS

The study consulted and reviewed 21 patients with late-stage complications after facial implantation of DermaLive. Histology samples from excisional biopsies followed by radical surgical excision procedures were obtained and analyzed for nine patients.

RESULTS

The treated zones included nasolabial folds, forehead and glabella, lips, and the perioral and zygoma regions. The late-onset period between injection and first symptoms averaged 17.5 months. Lesions were mostly symptomatic, with discomfort, pain, swelling, and edema. Clinical aspects included bulging, palpable nodules, erythema, and scar formation. A positive correlation between patient age and the delay period was found. All surgically treated patients recovered well. The initial conservative measures achieved only partial success, whereas all nine surgically treated patients (43 %) demonstrated complete relief of their clinical symptoms.

CONCLUSIONS

Soft tissue augmentation with DermaLive led to a series of severe delayed adverse reactions. Sclerosing DermaLive granulomas demonstrated low success rates with conservative measures, whereas early radical surgical excision achieved good results.

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 .

Lip augmentation dermal filler reactions, histopathologic features

Instances of perioral and labial foreign body reactions to a variety of injectable dermal fillers were selected from the oral and maxillofacial pathology and dermatopathology archives at Pacific Pathology Laboratory of San Diego with the objective being to engender a compilation of histopathologic characteristics that allow the pathologist to identify the inciting materials. All cases of foreign body reactions located in the lips and perioral regions were reviewed by four pathologists, retaining those cases with a history of injection lip augmentation as well as those with histologic features previously documented to represent dermal filler substances. In selected cases, Alcian blue pH 2.5 with and without hyaluronidase pretreatment was performed. Immunohistochemical markers for macrophages (CD 68), adipocytes (S-100) and keratinocytes (AE1/AE2) were undertaken. All instances presented as single or multiple submucosal plaques, nodules or swellings. Natural polymers including collagen, hyaluronate, hydroxyapatite, poly-L-lactate and synthetic polymers including carboxymethyl cellulose, dimethylpolysiloxane, and polyethyl methacrylate induce histologically unique features that allow for their identification. Host histopathologic responses included nodule without foreign body reaction, nodule with chronic inflammation, granuloma with epithelioid histiocytic and multinucleated giant cell reaction. Dermal filler foreign body host reactions in conjunction with the morphology of the foreign materials themselves are unique and can be differentiated from one another microscopically.

Conservative Surgical Approach for Reduction of Macrocheilitis Caused by Massive Injection of Liquid Silicone

Cosmetic lip augmentation, regardless of the filling agent, is nowadays one of the most requested aesthetic procedures. Liquid silicone injections were used in the past, but after reports of severe late complications their use has been discontinued, ending with a permanent ban in most western countries. In this report we describe clinical presentation, diagnostic pathways and surgical reconstruction of six patients presenting with macrocheilia due to previous liquid silicone augmentation. Patients showed chronic inflammation of the lower third of the face, lip eversion, various degrees of asymmetry and functional impairment of the lips. All patients underwent preoperative soft tissue High Frequency Ultrasound (HFUS) and Magnetic Resonance Imaging (MRI) of the of the face to obtain evidence of the filler material and to ascertain its diffusion within the soft tissues of the perioral region. Conservative surgery was carried out to remove foreign material and to restore symmetric aesthetically pleasing lips. Histology confirmed the siliconoma diagnosis. HFUS and RMI allowed to clearly identify the silicone within the soft tissues. The conservative surgery restored the harmonious relationship between the lips, with an improvement in lip functionality at long term follow-up. Healing was complete and uneventful in all of the patients.

Adverse results with PMMA fillers

BACKGROUND

Various alloplastic materials have been used for filling depressions and for body contouring. Among them, polymethylmethacrylate (PMMA) has provoked many clinical compilations in both the acute and chronic phases. This study shows the correlation between the clinical application of PMMA and the physiopathology of the acute and late complications.

METHODS

Histological studies were performed on biopsy samples from patients who presented with side effects and acute and late complications after PMMA injections given at other health-care centers or aesthetic services.

RESULTS

The histological findings of the samples that were harvested from patients who developed clinical complications or side effects caused by injection of PMMA disclosed not only normal tissues from the implanted areas but also development of capsules that involved individual microspheres of PMMA, and when the capsules were close together they formed concentric capsular groups involving various sets of microspheres and their capsules.

CONCLUSIONS

The injection of PMMA within the tissues can cause severe complications and side effects in both acute and chronic phases. Initially, the complications are related to vascular compromise, but at the late phase they are a consequence of capsular contracture that involves particles of PMMA. The contracture causes local tissue hardening and clinical nodulation of the implanted areas, ending with extrusion of the filler material.

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 at www.springer.com/00266.

The aging perioral region -- Do we really know what is happening?

OBJECTIVES

The perioral region is subject to a myriad of different treatments for rejuvenation, many of which are applied without a clear understanding of the underlying physiological processes of perioral aging. The results of these procedures are therefore sometimes not optimal and do not achieve a natural youthful appearance. The aim of this study was to put the results of three investigations into the perioral aging process into relation to clinical application in aesthetic medicine.

DESIGN

Three different investigations were performed to evaluate the complex 3-dimensional changes during the perioral aging process. Perioral proportions of 182 standardized subject photographs were measured in a photomorphometric study and correlated to age. In cranial MRI scans of 30 women aged 20-35 and 30 women aged 65-80 relevant anatomical dimensions were measured. Histological cross cuts of the upper lip complex of 20 individuals in two age groups, young (< 40 years, n = 10) and old (> 80 years, n = 10), were analysed. The results were then set into relation to today's lip rejuvenation procedures.

RESULTS

All studies showed a statistically significant lengthening of the aging upper lip. The photomorphometric study further showed an increase of prolabium skin at the cost of a decreasing visible upper lip vermilion. The MRI scans showed a decrease in thickness and redistribution towards a length increase but no total volume loss. Histomorphometric analysis revealed statistically significant thinning of the cutis, thickening of the subcutis and a degeneration of elastic and collagen fibers. The orbicularis oris muscle becomes thinner and shows a decrease of the forward curve defining the vermilion border. The results show that the main processes of lip aging are redistribution from thickness to length without total volume loss and a decrease of structural components of the lip, which leads to the decrease of pouting, an inversion of the vermilion and a ptosis of the lip.

CONCLUSION

A new and better understanding of the underlying physiological changes of perioral aging is essential and will lead to a better and more specific implementation of perioral rejuvenation procedures which will lead to more natural results.

Tissue augmentation with fibrin sealant and cultured fibroblasts: a preliminary study

BACKGROUND

Nonoperative subdermal tissue augmentation is one of the most frequently performed procedures in plastic surgery and dermatological practice. Many products, from biological to synthetic filler substances, are currently available. However, none has achieved ideal clinical efficacy, especially regarding volume maintenance and longevity. We examined the use of fibrin sealant as a biological and fully degradable matrix for dermal augmentation in combination with precultured human fibroblasts and hyaluronic acid gel (HYAFF).

METHODS

Four implant preparations were studied: fibrin glue only (F); 1% HYAFF mixed in fibrin glue (FH); 1.8 × 10(6) cells/ml of fibrin glue (FC); and 1% HYAFF and 1.8 × 10(6) cells/ml of fibrin glue (FHC). Each mouse was given two separate subcutaneous injections of implant material. At 1, 3, and 6 weeks two mice from each group were sacrificed, such that there was an n = 4 for each implant group at each time point. The mice were grossly examined for implant retention and the implants were evaluated by means of immunohistochemistry for fibrosis, integration into surrounding tissue, presence of elastin, and blood vessel infiltration.

RESULTS

Only the implants in the cell-containing groups, FC and FHC, remained after 6 weeks. Moreover, with the exception of a mild inflammatory response, no adverse affects of the cell-seeded implants were noted.

CONCLUSION

Presence of fibroblasts increases implant durability. Further studies should evaluate the ideal hyaluronic acid and fibroblast concentration for long-term longevity.

Fillers: contraindications, side effects and precautions

Fillers are generally considered safe. However side effects may happen and hence a practicing dermatologist need to be aware of such side effects, contraindicatons and precaution to be adopted while using fillers.

A systematic review of dermal fillers for age-related lines and wrinkles

BACKGROUND

Dermal fillers are gaining popularity for rapid aesthetic improvement. Long-term efficacy and safety have not been well documented. The aim of this systematic review was to assess the safety and efficacy of injectable dermal fillers compared with other facial augmentation techniques for the management of age-related lines and wrinkles.

METHODS

Studies including patients receiving injectable semi-permanent or permanent dermal fillers for age-related lines and wrinkles were included in this review. Efficacy outcomes (including changes in skin thickness and patient satisfaction) and safety outcomes (including mortality, lumps and infections) were examined.

RESULTS

Three randomized control trials and six case series were included. Permanent and semi-permanent dermal fillers improved subjective ratings of appearance and resulted in higher patient satisfaction than temporary fillers. Long-term efficacy appeared good in the few studies that reported it. Short-term safety appeared favourable. Lumps were reported in all but one study but received little follow-up. Long-term safety data were limited.

CONCLUSIONS

The treatment of age-related lines and wrinkles with permanent and semi-permanent dermal fillers is more efficacious compared with temporary fillers in those studies that compared them. Case series evidence suggests that these fillers achieve their objective, which is to decrease the visible effects of age-related changes. These fillers appear at least as safe as temporary fillers in the short term in those studies that compared them. Long-term safety could not be determined.

Granulomatous foreign-body reaction involving oral and perioral tissues after injection of biomaterials: a series of 7 cases and review of the literature

PURPOSE

Injectable implants used for soft-tissue augmentation may lead to a granulomatous foreign-body reaction. The aim of this report is to present 7 new cases of foreign-body granulomas involving the oral and perioral tissues, after injection of biomaterials to achieve soft-tissue augmentation. In addition, the clinical and epidemiological profile of this condition is summarized, based on a review of the English-language literature of all previously described cases.

PATIENTS AND METHODS

We report on 7 new cases of granulomatous foreign-body reaction involving the oral and perioral tissues after the injection of biomaterials. A comprehensive literature review is also presented.

RESULTS

The literature search revealed 49 cases of this condition affecting the oral and perioral tissues. Our 7 patients were female, with a mean age of 52.8 years (range, 34 to 70 years). The lower lip was affected in 4 cases, 1 case was located in the upper lip, 1 case in the buccal mucosa, while 1 case involved 2 different sites (upper lip and buccal mucosa). Histopathologic examination revealed numerous cells with clear, often multiple, cytoplasmic vacuoles, bearing a resemblance to lipoblasts. Immunohistochemistry revealed diffuse positivity for the histiocytic marker CD68.

CONCLUSIONS

The diagnosis of granulomatous foreign-body reactions may be challenging because of their microscopic resemblance to liposarcoma, and because of the occasional reluctance of patients to report the previously performed esthetic procedure. A clinical history, histopathologic examination, and immunohistochemical analysis (as needed) are essential in achieving an accurate diagnosis.

Skin rejuvenation without a scalpel. I. Fillers

Fillers are an important tool in the armamentarium of the physician combating aging phenomena. A wide variety of filler substances are now available that meet many, but by far not all, needs in aesthetic medicine. The most commonly used substances now are hyaluronic acid and collagen preparations that have slightly different indications, but collagen requires pre-use testing to rule out inflammatory complications. Poly-L-lactic acid has gained its place in the filling of adipose tissue wasting in HIV-infected patients. Autologous fat is easy to harvest and inject and has virtually no risk of adverse side effects. Permanent fillers may be of advantage but carry the risk of permanent adverse reactions. Skillful combination of different fillers as well as with botulinum toxin injections and other cosmetic procedures may give optimal results.

The histological aspects of fillers complications

The histological aspects of resorbable heterologous fillers (bovine collagen, acid hyaluronique), autologous fillers (lipofilling, dermis-fat graft), biodegradable fillers (New-Fill), and permanent fillers (silicone, Artecoll, Evolution, Aquamid, DermaLive, DermaDeep, Bioplastique, Paraffin) are described. This article relates the morphological aspect of these materials, the normal tissue reaction after injection, and its chronological evolution as the morphological aspects from the different side effects, more frequently observed for the permanent fillers. They mainly consist of granulomatous reactions which may appear long after injection.

Secondary Lymphoedema of the Lower Leg as an Unusual Side-Effect of a Liquid Silicone Injection in the Hips and Buttocks

We report an unusual case of secondary lymphoedema of the lower extremities as a result of injections of liquid silicone. A 30-year-old transsexual had received large-volume injections of silicone in the hips and buttocks for cosmetic purposes in order to obtain a female body form. Painful silicone granulomas developed in both the treated areas and areas outside the original injection location, and a progressive lymphoedema of feet and legs developed during a period of 5 years.

Mycobacterium abscessus cellulitis and multifocal abscesses of the breasts in a transsexual from illicit intramammary injections of silicone

We report the case of a 29-year-old transsexual who developed Mycobacterium abscessus infection after receiving intramammary liquid silicone injections in the nonphysician office setting. Our patient represents 1 of 14 confirmed and 11 suspected cases in New York City of M abscessus infection after illicit cosmetic procedures. As injectable cosmetic procedures are becoming increasingly popular, dermatologists should be aware of both the common and unusual complications. Furthermore, all physicians should be alerted to the current cluster of M abscessus infections after injections for cosmetic purposes by nonmedical practitioners in New York City.

Abscess formation after lip augmentation with silicone: Case report

This paper describes the development of an abscess after injection of an alloplastic preparation (silicone) for enhancement of the lower lip. The 56-year-old woman presented with a painful swelling of her lower lip which was incised. Pus drained from the incision. A biopsy was taken. Histology revealed homogeneous foreign body inclusions (silicone) with fibrosis, chronic inflammation and multinuclear giant cells. Healing was uneventful with little deformation of the lower lip. Since the number of persons seeking aesthetic lip augmentation is increasing, oral surgeons and dentists should be familiar with adverse effects to filling agents.

Management of complications after implantation of fillers

Soft tissue augmentation is widely practised by a variety of different practitioners. A new classification of filler substances and procedures, taking into account long-term safety and reversibility of side effects, is proposed: i non-permanent and biodegradable, ii semi-permanent and biodegradable, iii permanent and reversible, iv permanent and non-reversible. Complications and adverse effects occur with all fillers and all filler procedures. Insufficient experience is an important contributory factor. Underreporting is probably common. Commonest are haematomas, ecchymoses, infections, papulopustular or acneiform lesions, non-hypersensitivity related swelling and oedema, erythema, changes in pigmentation, palpability of the implant and necrosis of overlying tissue. Specific therapeutic approaches for these complications and practical recommendations to minimize or avoid them are discussed. Hypersensitivity reactions and granuloma formation are the most distressing adverse effects. They can occur with most fillers. Mostly these hypersensitivity reactions are local granulomas but, rarely, generalized reactions also occur. Case reports of systemic reactions after injection of hyaluronic acid are documented. Treatments include steroids, minocycline and immunomodulatory agents, such as cyclosporin, tacrolimus and ascomycin. In selected cases, surgical procedures are necessary to elimirate granulomatous reactions. Implant migration and facial lipoatrophy are encountered with certain compounds. Extreme caution is therefore advocated before using permanent and non-reversible products for soft tissue augmentation. Those who use fillers need to be familiar with the complications of fillers and with the treatment of those complications.

Lip silicone granulomatous foreign body reaction treated with aldara (imiquimod 5%)

We report a case of a lip granulomatous reaction after injection of silicone being treated successfully with topical Aldara (Imiquimod 5%). Silicone granulomas and the inflammatory foreign body reaction that can occur are some of the complications that arise from using silicone for cosmetic enhancement. The inflammatory reaction of this patient first appeared shortly after silicone injection of both the upper and lower lips. Histopathologic examination revealed a foreign body inflammatory reaction that is consistent with silicone granuloma. Although this reaction has been described extensively in the dermatologic literature as one of the disfiguring side effects of silicone injection, its treatment has plagued cosmetic dermatologists. We report the use of an immunomodulatory cream Aldara (Imiquimod 5%) to treat this type of reaction.