Foreign body reaction to injectable hyaluronic Acid: late granuloma formation

Are Delayed Dermal Filler Granulomas More Common Since COVID-19?

PURPOSE

Granuloma and delayed inflammatory reaction to hyaluronic acid facial esthetic fillers occurs rarely. More recently, these reactions have been reported with increasing frequency and have been associated with COVID-19 infection. The purpose of the study is to determine if delayed filler granulomas are more common after the start of the COVID-19 pandemic.

MATERIALS AND METHODS

A retrospective cohort study including of all patients treated with dermal filler at 4 offices of a single cosmetic surgery practice between August 1, 2018 and October 31, 2021 was performed. The primary outcome variable was granuloma formation. The primary predictor variable was time period, either pre-COVID (8/1/18 to 2/29/20) or post-COVID (3/1/20 to 10/31/21). Other study variables recorded were age, amounts of dermal fillers used, and types of dermal filler used. Data were analyzed using chi-squared test, t-tests, and logistic regression.

RESULTS

Over the study period, 3,255 patients receiving 8,067 syringes of filler over 6,800 sessions were reviewed. The average patient age was 46.8 ± 13.7 years and 2,583 sessions were performed in the pre-COVID time period and 4,217 sessions in the post-COVID time period. There were 11 granulomas in 9 subjects receiving filler in the post-COVID time period and 0 granulomas in the pre-COVID time period (0.3% vs 0.0%, respectively, P = .009). Juvederm Vollure was used in 64% of patients who developed granulomas but only accounted for 26% of filler administrations in the post-COVID time period and 28% in the cohort overall (P = .02).

CONCLUSIONS

Granuloma formation is a rare complication of hyaluronic acid filler injection that appears to be occurring with more frequency following the COVID-19 pandemic. Practitioners who administer dermal fillers should be aware of this complication and its apparent increased incidence.

Hyaluronic Acid-Glycine-Cholesterol Conjugate-Based Nanoemulsion as a Potent Vaccine Adjuvant for T Cell-Mediated Immunity

Clinical cases of allergic reaction that are due to excipients containing polyethylene glycol (PEG), a hydrophilic molecule commonly used in drug/vaccine formulations, has attracted much attention in recent years. In order to develop PEG-free adjuvants, we investigated the feasibility of natural ingredients in the human body such as hyaluronic acid in the form of hyaluronic acid-glycine cholesterol (HACH) conjugate as an excipient for vaccine formulation. Interestingly, HACH grafted with ~13 wt.% cholesterol has good water dispersity and can serve as an emulsifier to stabilize the squalene/water interfaces, yielding a milky white and isotropic emulsion (SQ@HACH) after being passed through a high-shear microfluidizer. Our results show that SQ@HACH particles possessed a unimodal average hydrodynamic diameter of approximately 190 nm measured by dynamic light scattering and exhibited good stability upon storage at 4 °C and 37 °C for over 20 weeks. The results of immunogenicity using a mouse model with ovalbumin (OVA) as the antigen revealed that SQ@HACH significantly enhanced antigen-specific immune responses, including the polarization of IgG antibodies, the cytokine secretions of T cells, and enhancement of cytotoxic T lymphocyte (CTL) activation. Moreover, SQ@HACH revealed lower local inflammation and rapidly absorbing properties compared with AlPO₄ after intramuscular injection in vivo, indicating the potential functions of the HA-derived conjugate as an excipient in vaccine formulations for enhancement of T cell-mediated immunity.

An unusual and delayed complication of hyaluronic acid filler injection: a case report

48-year-old female with facial granulomatous nodules and fungal/bacterial infection after hyaluronic acid injection. She underwent anti-fungal/antibacterial therapy and local excision. The proposed mechanisms include inflammatory foreign body reaction and pathogen contamination. Providers must exercise caution with the use of facial fillers and demonstrate expertise in avoiding and managing potential complications.

[Facial manifestations of granulomatous diseases]

Clinical manifestations of granulomatous diseases are a recurring challenge in everyday dermatological practice. Clinical presentation and histological patterns are variable, depending on the particular disease. Knowledge about the differential diagnosis of granulomatous changes in the face is of decisive importance for making a rational diagnosis and therapy considering the patient's well-being. Therefore, histological and clinical characteristics of important granulomatous diseases that typically manifest on the face are presented here.

Skin bacterial flora as a potential risk factor predisposing to late bacterial infection after cross-linked hyaluronic acid gel augmentation

Introduction

Cross-linked hyaluronic acid (HA) gel is widely used in esthetic medicine. Late bacterial infection (LBI) is a rare, but severe complication after HA augmentation. The aim of this study was to determine whether patients who underwent the HA injection procedure and developed LBI had qualitatively different bacterial flora on the skin compared to patients who underwent the procedure without any complications.

Methods

The study group comprised 10 previously healthy women with recently diagnosed, untreated LBI after HA augmentation. The control group comprised 17 healthy women who had a similar amount of HA injected with no complications. To assess the difference between the two groups, their skin flora was cultured from nasal swabs, both before and after antibiotic treatment in the study group.

Results

A significant increase in the incidence of Staphylococcus epidermidis was detected in the control group (P=0.000) compared to the study group. The study group showed a significantly higher incidence of Staphylococcus aureus (P=0.005), Klebsiella pneumoniae (P=0.006), Klebsiella oxytoca (P=0.048), and Staphylococcus haemolyticus (P=0.048) compared to the control group.

Conclusion

The bacterial flora on the skin differed in patients with LBI from the control group. The control group’s bacterial skin flora was dominated by S. epidermidis. Patients with LBI had a bacterial skin flora dominated by potentially pathogenic bacteria.

Update on injectables in the nose

PURPOSE OF REVIEW

The use of injectable fillers for nonsurgical rhinoplasty has increased tremendously over the past decade. This review describes the most commonly used fillers and their indications in the context of recent reports of both their successes and failures.

RECENT FINDINGS

Hyaluronic acid and calcium hydroxylapatite are the two most commonly used fillers for injection. Recent studies have found that most injectable fillers are met with success and patient satisfaction, but vascular complications are still a serious problem of which physicians should be wary.

SUMMARY

Injectable fillers should continue to be considered for patients on a case-by-case basis, but physicians should be knowledgeable of the various filler types, their indications, and injection technique to prevent serious complications.

Effective new membrane for preventing postthoracotomy pleural adhesion by surface water induction technology

Background

After thoracic surgery, adhesions between the pleura can cause substantial complications. This study investigated the effectiveness of a novel membrane utilizing surface water induction technology to prevent adhesions.

Methods

Eight beagles were divided into an experimental group (five males) and a control group (three females). The experimental group underwent thoracotomy on both the left and right sides of the chest. Both sides received the membrane, and the membrane on one side was glued to the pleura using tissue adhesive. The control group underwent thoracotomy only on the left side. Two weeks postoperatively, all dogs were sacrificed and adhesions were evaluated macroscopically and microscopically.

Results

Severe adhesion was seen between the parietal and visceral pleura in all control dogs, whereas the experimental group showed minor adhesion in only one dog on one side.

Conclusions

Our novel anti-adhesive membrane appeared highly effective in preventing postthoracotomy pleural adhesions.

Late-Onset Complication of Fillers: Paraffinoma of the Lower Eyelids Clinically Mimicking Xanthelasma

Injectable poly-L-lactic acid (PLLA) is world-famous filler used in lipoatrophy and facial rejuvenation because of its collagen neogenesis effect which leads to gradual volume restoration. Until recently, quite a number of unwanted adverse events of PLLA have been reported. However, to the best of our knowledge, paraffinoma as a complication of PLLA has never been reported. We herein describe the first case of paraffinoma after Sculptra® injection and propose its possible mechanism.