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

Safety of esthetic procedures in rheumatic patients: single-center survey of patients

The popularity of esthetic medicine is growing every year, also among patients with autoimmune inflammatory rheumatic diseases (AIRD). The objective of this study was to evaluate the safety of esthetic medicine (AM) procedures in patients with AIRD. A semi-structured, anonymous questionnaire regarding rheumatic and concomitant diseases and AM procedures was distributed among adult patients hospitalized in the rheumatology department or attending outpatient clinic in the National Institute of Geriatrics, Rheumatology, and Rehabilitation, Warsaw. The main outcome was the occurrence of an adverse event. A number of 512 patients took part in the survey and 15 were excluded (AM procedure preceded the diagnosis of AIRD). The study group consisted of 497 patients, of whom 47 had undergone AM procedures. The procedures performed included: tattooing (22 patients), piercing (16 patients), hyaluronic acid (7 patients), botulinum toxin (5 patients) injections, laser procedures (6 patients), plastic surgery (4 patients), mesotherapy (3 patients) and others. The vast majority of patients had these performed during remission or low disease activity. 70.2% of patients received treatment with disease-modifying antirheumatic drugs (DMARDs) during the AM procedure, with TNF-alfa inhibitors being the most common (63.6%). Adverse events occurred in 15% of patients. All were mild and transient site reactions. Most patients would like to repeat the AM procedure in the future. The use of esthetic medicine procedures in patients with AIRD, including those treated with biologic DMARDs, was associated with a risk of mild site reactions. Most of the patients expressed satisfaction with the results of the AM procedure.

Complications following Permanent Filler Injection: A Prospective Cohort Study and Protocol of Management

Permanent filler (PF) substances are increasingly utilized in aesthetic procedures. Concurrently, complications related to fillers have also risen. This study aims to determine the rate of complications secondary to PF injections and develop a therapeutic approach for treating such complications.

METHODS

This cohort study was conducted by distributing a checklist form among all patients aged 18 years or older who arrived for a new cosmetic consultation between 2015 and 2019. The primary outcome was the occurrence of complications, which are defined as symptoms induced by the PF. The demographics, type of PF, injection site, the time for the complication to occur, and signs and symptoms were recorded and followed up.

RESULTS

In this study, 325 out of 503 (64.61%) patients presented with PF-related complications. About 92.8% were women. All patients with PF-related complications presented with a lump (n = 325, 100%). In regard to the anatomical area of injection, the most common areas were the cheeks (66.6%). The time it took for the complication to occur most commonly ranged from 1-5 years (39.2%, P < 0.001). Complications were significantly higher among patients who received the injection in a nonmedical facility (P < 0.0002). Seventy-seven cases (15.3%, P < 0.0001) underwent PF removal.

CONCLUSIONS

PF-related complications in the body exhibit a wide range of onset and adverse events. The best method to prevent complications caused by permanent filling materials is to avoid them altogether. When it comes to permanent filling agents, we suggest extreme caution.

Filler-induced complications of the lips: 10 years experience with intralesional laser treatment and refinements

BACKGROUND

The number of minimally invasive cosmetic procedures has steadily increased every year. In the last decade, the rates of filler injection reactions have also increased. This study presents our experience in the management and treatment of permanent filler complications to the lips. Undoubtedly, in these adverse reactions, the lips are the hallmark that most stigmatizes an unnatural look of the face.

METHODS

One hundred and eighty-one patients (168 female and 13 male) with permanent filler complications to the lips were treated from September of 2009 to September of 2019 at the University Hospital of Modena. One hundred and thirty-five patients underwent intralesional laser treatment (ILT). Forty-six patients underwent a stab incision and drainage and 10 of these patients had solid and calcified nodules and therefore underwent a combined technique. Thirty-three patients underwent further cosmetic procedures.

RESULTS

In 95% of patients there was a clinical improvement of which complete resolution in 38.7% and partial improvement in 34.2% of cases. Nine patients stopped the treatment because they were not satisfied. No patient was considered to have worsened after the treatment. Thirty-three patients underwent further treatments.

CONCLUSIONS

A systematic combined approach between antibiotic therapy and treatments (ILT and a stab incision) represents the best therapeutic approach in dealing with permanent fillers complications to the lips. This treatment modality allows both the removal of the foreign material and the inflammatory reaction with low morbidity and little cosmetic disfigurement. Further cosmetic procedures may be applied to improve aesthetic appearance once most of the non-resorbable substance has been removed.

Dermal fillers do not induce upregulation of NLRP3 inflammasomes or expression of inflammatory cytokines in granulomas

BACKGROUND

Filling materials have increasingly been used in aesthetics over the last decades. Understanding the pathophysiology of granuloma formation as a very relevant unwanted side effect of filler application may be essential to help avoid these adverse events.

AIMS

Our aim was to investigate the role of the inflammasome in the formation of filler granuloma, as a central column of the innate immune response.

METHODS

RPMI 1640 medium was used for growth of THP-1 cells and the induction of THP-1 macrophages. Sonication was applied in order to crush the acrylic particles of the filler. ELISA was the method of analysis for the specific cytokines. Biopsy specimens of filler granuloma were analyzed by various immunohistochemical methods. GraphPad Prism 5 software was used for the statistical data analysis.

RESULTS

Neither was the sensor NALP3 overexpressed, nor could an elevated expression of cleaved IL-1β, IL-18, or IFN-γ be detected. Furthermore, no increased expression of IL-8 or IL-1β was detectable in vitro.

CONCLUSION

No increased inflammasome activation could be observed; however, filler granulomas were infiltrated with granulocytes and macrophages. Therefore, we speculate that an unspecific immune response might be the key player in the formation of filler granuloma.

Another face of dermal fillers

Potential complications related to dermal fillers depend on the type of the fillers and the site of their application. The classification of dermal filler complications can be divided into early and late, and into minor and major events. According to their mechanism, they can be divided into non-ischaemic and ischaemic complications. The aim of this study is to present possible complications related to dermal fillers, to explain their aetiology and to propose preventive management and treatment. Non-ischaemic complications can be technique-dependent and include the reactions at the site of the injection, contour irregularities, and inflammatory and infectious reactions. They are usually resolved as a matter of course after 2-7 days. Arterial or venous occlusion leads to ischemia, with subsequent necrosis of the skin and/or vision loss.

Dermalive Facial Filler Granulomas Masquerading as Neurofibromas

A 56-year-old woman presented with periocular nodules that were clinically suspected to be neurofibromas. Histopathologic examination of excised nodules revealed a pronounced granulomatous reaction to a foreign material that was composed of glossy polygonal palely eosinophilic fragments. These fragments were outlined in red with Masson trichrome, stained gray with the elastic stain, and were uniformly red with Gomori methenamine silver staining. The histopathologic appearance was consistent with a granulomatous reaction to Dermalive facial filler. Postoperatively the patient admitted that she had filler injections many years earlier in another country, and that nodules appeared 1 year after injection. Treatment with steroids, intralesional immunosuppressive agents and surgery had been previously attempted to eradicate the nodules. The literature pertaining to granulomatous reactions to Dermalive and related hybrid facial fillers is reviewed and treatment options are discussed. This report is the first to illustrate the unique histopathologic staining characteristics of Dermalive, which may be useful to ophthalmic pathologists in identifying this uncommon foreign material.

Consensus Recommendations for Treatment Strategies in Indians Using Botulinum Toxin and Hyaluronic Acid Fillers

BACKGROUND

Indians constitute one of the largest population groups in the world. Facial anthropometry, morphology, and age-related changes in Indians differ from those of other ethnic groups, necessitating a good understanding of their facial structure and the required aesthetic treatment strategies. However, published recommendations specific to Indians are few, particularly regarding combination treatment.

METHODS

The Indian Facial Aesthetics Expert Group (19 dermatologists, plastic surgeons, and aesthetic physicians with a mean 15.5 years' aesthetic treatment experience) met to develop consensus recommendations for the cosmetic facial use of botulinum toxin and hyaluronic acid fillers, alone and in combination, in Indians. Treatment strategies and dosage recommendations (agreed by ≥ 75% of the group) were based on results of a premeeting survey, peer-reviewed literature, and the experts' clinical experience.

RESULTS

The need for combination treatment increases with age. Tear trough deficiency is the most common midface indication in Indian women aged 20-40 years. In older women, malar volume loss and jowls are the most common aesthetic concerns. Excess medial soft tissue on a relatively smaller midface precedes age-related sagging. Hence, in older Indians, fillers should be used peripherally to achieve lift and conservatively in the medial zones to avoid adding bulk medially. The shorter, wider lower face requires 3-dimensional correction, including chin augmentation, to achieve increased facial height and the oval shape desired by most Indian women.

CONCLUSIONS

These recommendations give physicians treating Indians worldwide a better understanding of their unique facial characteristics and provide treatment strategies to achieve optimal aesthetic outcomes.

Dermal fillers in aesthetics: an overview of adverse events and treatment approaches

BACKGROUND

The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.

OBJECTIVE

To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance.

METHODS

Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors' extensive experience, recommendations for avoiding and managing complications are provided.

RESULTS

Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique.

CONCLUSION

For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.

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.

Dermal fillers: facts and controversies

Dermal fillers have been used for decades in soft tissue augmentation. Currently, filler implementation is among the most common minimally invasive procedures for rejuvenation and body sculpturing. There is a broad variety of filler materials and products. Despite immense experience, a number of controversies in this topic exist. Some of these controversies are addressed in this review, for example, who should perform filler injections, the difference between permanent and nonpermanent fillers, the off-label use of liquid silicone, and the role of pain reduction. Implementation of guidelines and restriction of filler use by trained physicians can improve safety for patients.

Interspecies Differences in Reaction to a Biodegradable Subcutaneous Tissue Filler

Soft tissue filler products have become very popular in recent years, with ever-increasing medical and aesthetic indications. While generally considered safe, the number of reported complications with tissue fillers is growing. Nevertheless, there is no specific animal model that is considered as the gold standard for assessing safety or efficacy of tissue fillers, and there are very little data on interspecies differences in reaction to these products. Here, we report on interspecies differences in reaction to a subcutaneous injectable co-polyester, composed of castor oil and citric acid. Comparison of the histopathological local tissue changes following 1-month postimplantation, indicated that in rats the reaction consisted of cavities, surrounded by relatively thin fibrotic enveloping capsule. In contrast, an unexpected severe inflammatory granulomatous reaction was noticed in Sinclair minipigs. To our knowledge, this is the first report on significant interspecies differences in sensitivity to tissue fillers. It emphasizes the importance of using the appropriate animal model for performing preclinical biocompatibility assays for biodegradable polymers, tissue fillers, and implanted medical devices in general. It also makes the Sinclair minipig subject for scrutiny as an animal model in future biocompatibility studies.

Dermal fillers in aesthetics: an overview of adverse events and treatment approaches

Background

The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.

Objective

To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance.

Methods

Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors’ extensive experience, recommendations for avoiding and managing complications are provided.

Results

Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique.

Conclusion

For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.

Semipermanent volumization by an absorbable filler: onlay injection technique to the bone

BACKGROUND

Hyaluronic acid (HA) fillers have become the most popular tool for wrinkle treatment and volumization, although HA is generally absorbed within 6-12 months and requires repeated treatments to maintain the effects.

METHODS

HA was injected onto the bone for volumization with a small 30-gauge needle to examine the long-lasting effects. Of the 63 Japanese patients with 97 treated sites followed up more than 12 months, 51 had HA injections for cosmetic purposes and 12 were treated for reconstructive volumization of facial deformity such as localized scleroderma and postsurgical bony deformity. Treated sites included the forehead, temple, nasal root, mentum, tear trough, and infraorbital sulcus.

RESULTS

After long-term follow-up (12-93 months, mean = 21.6), persistent volumizing effects were observed in most patients. In fact, 86.6% of the treated sites showed >50% volume retention and 49.5% showed >75% retention. Magnetic resonance imaging analyses revealed that the injected space was well maintained, capsulated, and filled with heterogeneous content. Magnetic resonance imaging quantitative T2 maps indicated that much of the injected HA was replaced with other materials. Together with clinical inspection, these findings suggest that onlay injection of HA on the bone induced formation of capsule, fibrosis, and/or calcification/ossification, which contributed to persistent volumization.

CONCLUSIONS

Semipermanent volumizing effects can be achieved by HA injection if the target area has an underlying bony floor. Periosteal stem cells may be activated by HA injection and may contribute to persistent volumizing effects. This treatment may be a much less invasive alternative to fat or bone grafting.

Complications of injectable fillers, part I

Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.

Dermal filler complications from unknown biomaterials: identification by attenuated total reflectance spectroscopy

BACKGROUND

In the last decade, an increase in complications related to dermal filler injections has been reported, especially in patients who underwent multiple treatments with different products. Imaging or histological examinations may suggest what kind of substance was used, but none can precisely identify the biomaterial. The aim of this study was to evaluate the use of Fourier transform infrared spectroscopy, using an attenuated total reflectance cell, in the identification of unknown dermal fillers.

METHODS

In the preclinical study, samples from different manufacturers were analyzed according to attenuated total reflectance spectroscopy using the Nicolet 8700 FT-IR spectrophotometer (resolution, 0.125 cm; Thermo Fisher Scientific, Inc., Madison, Wis.). Spectra of each biomaterial were collected and included in a reference database. In the clinical study, seven patients affected by severe complications due to multiple injections with unknown fillers provided a sample of the pathological tissue for the analysis.

RESULTS

Two granulomas, two infiltrated tissues, and three abscesses were studied. Attenuated total reflectance/Fourier transform infrared analysis of pathological tissues revealed the presence of absorption bands absent in the healthy tissue. Comparison of these bands to the filler database made it possible to identify the dermal fillers injected.

CONCLUSIONS

This pilot study has demonstrated the absolute validity of the application of infrared spectroscopy in attenuated total reflectance for the determination of infiltrated biomaterial. The knowledge of the previously injected fillers may be crucial to selecting the appropriate medical or surgical treatment as well as to solving medical-legal issues.