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

Late inflammatory reactions (LIRs) in patients with soft tissue fillers after SARS-CoV-2 infection and vaccination: A systematic review of the literature

INTRODUCTION

Soft tissue fillers are used for cosmetic and reconstructive purposes, and soft tissue filler procedures are among the most common nonsurgical procedures in the USA. Although soft tissue filler procedures are relatively quick and safe, adverse events such as late inflammatory reactions have been reported with every filler product. Infections and vaccinations have been proposed as potential triggers for late inflammatory reactions (LIRs), and it is therefore not surprising that these adverse events have been reported after SARS-CoV-2 infection and vaccination. Therefore, this review aims to give a detailed overview of these cases.

MATERIALS AND METHODS

A literature search was undertaken on LIRs in patients with a history of soft tissue filler use after SARS-CoV-2 infection or vaccination. This systematic review was reported according to the PRISMA guidelines. We searched the electronic database PubMed from January 2020-August 2021. Data on patient characteristics, filler characteristics, clinical findings and treatment options were included.

RESULTS

This review included 7 articles with a total of 19 patients with LIRs after SARS-CoV-2 infection or vaccination. Three patients with postinfection LIRs and 16 patients with postvaccination LIRs were reported. These LIRS mainly occurred in females who had HA injections for cosmetic purposes. Three patients with postinfection LIRs had symptoms of facial swelling and/or lip angioedema in a matter of weeks. Sixteen patients reported reactions after SARS-CoV-2 vaccination (13 following Moderna vaccination and 3 after Pfizer vaccination, after both the first and second doses) from 13 hours up to three weeks. These patients presented with similar clinical symptoms as patients with postinfection LIRs. All patients were treated in a conservative manner.

DISCUSSION

This review shows a relationship between LIRs and SARS-CoV-2 infection and vaccination. In the case of vaccination, these adverse events have been reported only after Moderna and Pfizer vaccinations. The reported adverse events are generally minor and self-limiting, and we encourage patients with soft tissue fillers to participate in vaccination programs.

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.

Histopathologic features of noninfectious granulomatous disorders involving the skin

Granulomatous dermatoses may represent primary skin inflammation or can serve as the harbinger of a multitude of underlying systemic disorders or drug reactions. Taken together with clinical findings, the microscopic features from skin biopsy can allow recognition of various patterns and facilitate a precise diagnosis. Accurate classification of entities in this category of inflammatory dermatoses may prompt clinicians to investigate for underlying systemic problems, thereby allowing the pathologist to add considerable value in the care of affected patients. This review article categorizes clinical and microscopic features of common and uncommon causes of noninfectious dermal and subcutaneous granulomatous inflammation.

Novel injectable gallium-based self-setting glass-alginate hydrogel composite for cardiovascular tissue engineering

Composite biomaterials offer a new approach for engineering novel, minimally-invasive scaffolds with properties that can be modified for a range of soft tissue applications. In this study, a new way of controlling the gelation of alginate hydrogels using Ga-based glass particles is presented. Through a comprehensive analysis, it was shown that the setting time, mechanical strength, stiffness and degradation properties of this composite can all be tailored for various applications. Specifically, the hydrogel generated through using a glass particle, wherein toxic aluminium is replaced with biocompatible gallium, exhibited enhanced properties. The material's stiffness matches that of soft tissues, while it displays a slow and tuneable gelation rate, making it a suitable candidate for minimally-invasive intra-vascular injection. In addition, it was also found that this composite can be tailored to deliver ions into the local cellular environment without affecting platelet adhesion or compromising viability of vascular cells in vitro.

Plasmacytoid dendritic cells in granulomatous variant of mycosis fungoides

INTRODUCTION

Granulomatous mycosis fungoides (MF) is a rare variant in which granulomas are associated with other typical signs of MF. Its prognosis is worse than that of classical MF. Plasmacytoid dendritic cells (PDCs) are a subset of interferon-producing dendritic cells that link the innate and the adaptative immune responses. They have also been related to tolerance to certain tumors such as melanoma.

MATERIALS AND METHODS

In this article, we examined for the presence of CD123+ PDC in six cases of granulomatous MF from our archives.

RESULTS

We found clusters of 10 or more positive cells in three of six cases of granulomatous MF (two women and a man, in their sixth and seventh decade). Although in two of these three cases the granulomatous response was extensive, in the other, it only represented 10% of the infiltrate of the biopsy. In all three cases, the granulomas were epithelioid, sarcoidal type.

CONCLUSIONS

CD123+ PDC can be identified in granulomatous MF. The pathogenic and prognostic role of this finding requires further clarification.

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Intralesional Laser Treatment for Dermal Filler Complications

BACKGROUND

For complications caused by filler treatments, in general, two treatment regimens are advised: systemic drugs and surgical removal of the material. Another possible treatment option would be removal of the material by intralesional laser treatment.

METHODS

Two hundred forty-two patients with complications caused by fillers were treated with intralesional laser treatment.

RESULTS

In the majority of patients, an improvement was achieved (92 percent), in 9 percent the complication was resolved, and in 3 percent it was not improved (unknown in the rest).

CONCLUSION

Considering the large number of patients treated until now and the efficacy and good safety profile of this treatment, the authors plead that intralesional laser treatment may be considered as a treatment option before surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Plasmacytoid dendritic cells in cutaneous sarcoidosis

While absent from normal skin, plasmacytoid dendritic cells (pDCs) infiltrate the skin in several infectious, inflammatory, and neoplastic entities. In addition to providing anti-viral resistance, pDCs link the innate and adaptive immune responses. Sarcoidosis is an idiopathic multi-system granulomatous disease characterized by epitheliod granulomas. Its underlying immunopathogenesis involves hyperactivity of cell-mediated immune system with involvement of CD4+ T-helper cells of the Th1 subtype. Recently, pDCs have been shown to contribute to other cutaneous granulomatous disorders such as granuloma annulare (GA). Here, we intend to investigate pDC occurrence and activity in cutaneous sarcoidosis. Twenty cutaneous sarcoidosis cases and a comparable group of 20 cases of GA were retrieved from our database and were immunohistochemically tested for pDC occurrence and activity using anti-BDCA-2 and anti-MxA antibodies, respectively. Fifteen cases of cutaneous lupus erythrematosus (LE) were used as a comparison group. A semi-quantitative scoring system was used. pDCs were present in all cutaneous sarcoidosis in peri-vascular and/or peri-adnexal location admixed with lymphocytes. pDC numbers in sarcoidosis were comparable to those in GA, while pDCs were significantly more abundant in LE. MxA expression was mostly patchy in cutaneous sarcoidosis and GA cases, while LE cases showed diffuse and strong MxA expression. In conclusion, we have shown that pDCs are recruited into the skin lesions of sarcoidosis and GA. Despite the diminished type I IFN production demonstrated in our study, the consistent presence of pDCs in all cutaneous sarcoidosis cases speaks in favor of some role of these cells in the pathogenesis of granulomatous disorders. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 55-61).

Calcium hydroxylapatite: A review on safety and complications

BACKGROUND

Radiesse^® , or calcium hydroxylapatite (CaHA), is a biodegradable, biostimulatory soft tissue filler suitable for deeper folds and wrinkles. In the literature, good results have been documented with the use of CaHA and patient satisfaction scores are high. This study reviews the current literature on safety and complications of CaHA.

METHODS

A literature search in MEDLINE/PubMed electronic database was conducted. A total of 21 articles were included and screened for reports of adverse events (AEs).

RESULTS

Twenty-one peer-reviewed articles, published between 2004 and 2015, were included. A total of 5081 treatments with CaHA were performed on 2779 patients. A total of 173 (3%) AEs were reported. The assessed types of AEs consisted of nodules (n=166, 96%), persistent inflammation/swelling (n=4, 2%), persistent erythema (n=2, 1%), and overcorrection (n=1, 1%).

CONCLUSION

Based on the results in this study, CaHA appears to have a good safety profile. Nodules are by far the most common AE. Of the reported nodules, 49% occurred in "dynamic" areas currently known for having a higher tendency for nodules. Several treatment approaches exist for managing CaHA nodules; however, in most cases, CaHA nodules are not visible and resolve without intervention.

Adipose stem cell-laden injectable thermosensitive hydrogel reconstructing depressed defects in rats: filler and scaffold

Facial depressed defects are a common cosmetic problem. Temporary fillers need to be re-injected frequently to maintain the desired outcomes. Here, the feasibility of a novel type of injectable hydrogel for persistent effect is demonstrated. We first useed agmatine to synthesize a poly(amidoamine) (PAA) to form a cell-attachable crosslinker and then the crosslinker was co-polymerized with N-isopropylacrylamide to obtain an injectable and temperature sensitive hydrogel. ¹H NMR showed the successful synthesis of the crosslinker. In vitro tests, CCK-8 assay and live/dead viability test showed that the hydrogel was non-toxic to adipose-derived stem cells (ASCs). SEM images also confirmed that ASCs could adhere to the hydrogel. Then we constructed a novel depressed defect model in rats and injected four different fillers in the depressed defects: (1) the hydrogel with ASCs, (2) the hydrogel only, (3) hyaluronic acid, and (4) PBS. After 4 weeks, gross and histological analyses showed the defects in hydrogel, hydrogel + ASCs, and HA groups improved significantly and there were no significant differences among them. Significant differences in thickness from skin to muscle in the defect was found between the hydrogel + ASCs group and the other groups after 6 months. The hydrogels degraded completely in defects in both the hydrogel group and the hydrogel + ASCs group, and were filled with adipocytes and multilocular immature adipocytes. Immunohistochemical study using s-100 and perilipin staining revealed adipocyte differentiation in the defect sites. We also used green fluorescent protein (GFP)-ASCs for tracing and found that exogenous added ASCs were involved in adipogenesis. In conclusion, such a cell attachable thermosensitive hydrogel has definite potential not only as a filler but also as a scaffold, and has a persistent effect for small depressed defects. It might ultimately become a new material in plastic and reconstructive surgery.