Adverse Granulomatous Reaction to Artecoll Treated by Intralesional 5-Fluorouracil and Triamcinolone Injections

Adverse effects of fillers

Filler injections belong to the most frequently performed noninvasive beautifying procedures. When done correctly they are generally well tolerated. However, a number of factors, such as poor filler quality, and particularly host as well as user dependent filler reactions may lead to unwanted effects. These may be early, late, or delayed events with characteristics for each of them. Temporary fillers almost invariably cause temporary side effects whereas those of permanent fillers may last forever. Some fillers are notorious for their poor safety profile; for example, silicone is banned in the European Union and the United States but nevertheless used by many practitioners and beauticians. Many fillers can be identified in histopathologic sections allowing specific measures to be instituted.

Managing Complications of Fillers: Rare and Not-So-Rare

Fillers belong to the most frequently used beautifying products. They are generally well tolerated, but any one of them may occasionally produce adverse side effects. Adverse effects usually last as long as the filler is in the skin, which means that short-lived fillers have short-term side effects and permanent fillers may induce life-long adverse effects. The main goal is to prevent them, however, this is not always possible. Utmost care has to be given to the prevention of infections and the injection technique has to be perfect. Treatment of adverse effects is often with hyaluronidase or steroid injections and in some cases together with 5-fluorouracil plus allopurinol orally. Histological examination of biopsy specimens often helps to identify the responsible filler allowing a specific treatment to be adapted.

Foreign body granulomas after the use of dermal fillers: pathophysiology, clinical appearance, histologic features, and treatment

A foreign body granuloma is a non-allergic chronic inflammatory reaction that is mainly composed of multinucleated giant cells. Foreign body granulomas may occur after the administration of any dermal filler. Factors such as the volume of the injection, impurities present in the fillers, and the physical properties of fillers affect granuloma formation. The formation of granulomas involves five phases: protein adsorption, macrophage adhesion, macrophage fusion, and crosstalk. The clinical and pathologic features of granulomas vary depending on the type of filler that causes them. Foreign body granulomas can be treated effectively with intralesional corticosteroid injections. Surgical excisions of granulomas tend to be incomplete because granulomas have ill-defined borders and moreover, surgical excisions may leave scars and deformities.

Inflammatory granuloma caused by injectable soft tissue filler (Artecoll)

Artecoll (Artes Medical Inc., San Diego, CA, USA) has recently been developed as a permanent synthetic cosmetic filler. We experienced an inflammatory granuloma resulting from a previous injection of Artecoll at the upper lip, which was regarded as a rare side effect of this filler. A 50-year-old female patient complained of swelling, dull pain, and heat in the right upper nasolabial fold area, which had started one week before her visit to Kyungpook National University Hospital. The patient received topical steroid therapy at a local clinic, which was not effective. At the injection site, a hard nodule was palpated and erythema was observed with mild tenderness. Antibiotic treatment and subsequent incision and drainage did not result in complete cure of the facial swelling, and the facial swelling and pain persisted. Computed tomography showed a lesion approximately 1-cm in size without clear boundaries and relatively increased nodular thickening. Finally, a subdermal lesion was removed via an intraoral vestibular approach. The lesion was diagnosed as inflammatory granuloma by a permanent biopsy. The patient had healed at two months after the filler injection. Although the soft tissue filler is widely used for cosmetic purposes, there is potential for complication, such as the inflammatory granuloma should be considered before treatment.

Foreign body granulomatous reactions to cosmetic fillers

INTRODUCTION

The use of different facial cosmetic fillers has increased in recent years. The introduction of apparently inert substances in the epidermis can give rise to foreign body granulomatous reactions. Objetives: A literature review is made of the foreign body granulomatous reactions to cosmetic fillers.

MATERIAL AND METHODS

A PubMed-Medline search was made using the following keywords: "granulomatous reactions", "foreign body reactions", "esthetic fillers", "cosmetic fillers". The search was limited to articles published in English and Spanish during the last 10 years. A total of 22 articles were reviewed.

RESULTS

A great variety of substances have been found to give rise to foreign body granulomatous reactions. The most common locations are the upper and lower lip and the nasogenian sulcus. The clinical presentation is variable and can range from single or multiple nodules to diffuse facial swelling of hard-elastic consistency, accompanied by reddening. Most lesions are asymptomatic or cause only mild discomfort. The literature describes different treatments, including systemic corticosteroids, local tacrolimus infiltrations, minocycline, retinoids, allopurinol, 5% imiquimod, and surgical removal.

CONCLUSIONS

In view of the current demand for esthetic treatments, the use of cosmetic fillers can be expected to increase in future, together with the incidence of complications. Key words:Esthetic fillers, granulomatous reactions, foreign body reactions, cosmetic fillers.

ArteFill permanent injectable for soft tissue augmentation: II. Indications and applications

Patients ask for procedures with long-lasting effects. ArteFill is the first permanent injectable approved in 2006 by the FDA for nasolabial folds. It consists of cleaned microspheres of polymethylmethacrylate (PMMA) suspended in bovine collagen. Over the development period of 20 years most of its side effects have been eliminated to achieve the same safety standard as today’s hyaluronic acid products. A 5-year follow-up study in U.S. clinical trial patients has shown the same wrinkle improvement as seen at 6 months. Long-term follow-up in European Artecoll patients has shown successful wrinkle correction lasting up to 15 years. A wide variety of off-label indications and applications have been developed that help the physician meet the individual needs of his/her patients. Serious complications after ArteFill injections, such as granuloma formation, have not been reported due to the reduction of PMMA microspheres smaller than 20 μm to less than 1% “by the number.” Minor technique-related side effects, however, may occur during the initial learning curve. Patient and physician satisfaction with ArteFill has been shown to be greater than 90%.