Granulomas after fillers: what a cosmetologist should do

Granuloma – a delayed complication of contouring, which is included in the list of phenomena insufficiently studied in aesthetic medicine. From the point of view of histology, these formations are the reaction of the body to a foreign body with tissue infiltration by giant cells and macrophages. There are three types of granulomas that can appear after the introduction of fillers: cystic, nodular and sclerosing. Red firm papules, nodules or plaques may form months or even years after injections of permanent and temporary dermal fillers, most commonly – hyaluronic acid and bovine collagen.

Description of the causes, symptoms, diagnosis and treatment of granulomas after fillers by Dr. Beata Cybulska is given in the article estet-portal.com.

• Glulomas after filler injections
• Diagnosis and treatment of granulomas after fillers
• Clinical and histological features of granulomas after contouring
• Differential diagnosis of granulomas after fillers
• Granuloma treatment after dermal filler injections

Formation of granulomas after filler injections 

A granuloma is formed as a result of a non-allergic chronic inflammatory reaction to a foreign body after the injection of a filler or other foreign material. This tumor is made up of immune cells such as macrophages. They coalesce into chaotically distributed giant cells containing more than 20 nuclei.

Stages of granuloma formation:

• Protein absorption;
• macrophage adhesion;
• macrophage fusion;
• cross interactions.

Patients with chronic sinusitis, dental disease, or other infections are more likely to develop infection after periorbital or central facial fillers. Such patients may also be prone to developing biofilms around or within the implant due to trauma caused by previous injections. Diagnosis and treatment of granulomas after fillers

Diagnosis and treatment of granulomas after the introduction of dermal fillers cause certain difficulties. For successful therapy, it is necessary to collect a comprehensive medical and aesthetic history, as well as conduct a thorough examination of the patient. It is important to differentiate between granulomas and nodules formed by fillers.

  Cystic, nodular, indurated plaques of a bluish tint with congested capillaries, the size of which exceeds the volume of the injected filler. Appear simultaneously in different places.Uniform white-colored masses, firmer than granulomatous nodulesErythema, edema, indurated papules, nodules with or without itchingErythema, swelling, swelling, induration and/or tendernessFiller: type and amount of drug injected.Injectionist: incorrect insertion technique (overcorrection or too shallow insertion), massage not performed.Filler: HA or bovine collagenSubject: Bacterial, viral, fungal, parasitic infections.Months or years after filler injectionEarly – up to two weeks after filler injectionOne month after filler injection with spontaneous resolution one yearImmediate or later

	Granuloma	Filler knot	Late allergic reaction	Infection
Clinical presentation and symptoms
Reason	Subject: infection and biofilm. Injectionist: skin cleanliness and patient choice.	Subject: failed massage (L-polylactic acid).		Injectionist: Wrong choice of patient, inadequate skin cleansing.
Start

Fig

. 1: granuloma differential diagnosis  

In case of late complications

such as granuloma after fillers , you should ask the patient about:

time of onset of symptoms;

• signs of inflammation – pain and redness;
• history of filler injections;
• type, volume and site of filler injection;
• presence of skin infections;
• presence of skin diseases;
• presence of immunodeficiency.
Filler injections are contraindicated in active infections:

bacterial (caused by streptococci and staphylococci causing impetigo);

• parasitic (caused by mites such as
demodex folliculorum
• , causative agents of rosacea); fungal;
• viral, such as herpes simplex virus or papillomavirus infection in the perioral region;
• Pityrosporum folliculitis.

Read also:

 Late allergic reactions to hyaluronic acid fillers Also

before contouring, therapy must be completed

:

sinusitis;

• periodontal diseases;
• ENT infections;
• flux.
There is evidence that such infections can spread to the injected filler and trigger the formation of biofilms, which in turn are a

trigger of allergic reactions. Clinical and histological features of granulomas after contouring

 

Depending on histological properties, there are four types of granulomas after dermal fillers:

cystic (HA, bovine collagen);

• nodular lipogranulomas (silicone, polyacrylamide);
• sclerosing;
• mixed.

Corticosteroids (triamcinolone acitate – Kenalog)Antibiotics Laser removal

Intralesional injections	Systemic Therapy	Surgical methods
Bleomycin 5-fluorouracil	Prednisolone Allopurinol Colchicine Cyclosporine	Opening and drainage Excision and grafting of fat tissue or flap

Fig.

2: Granuloma treatment methods  

Clinically, granulomas appear as red indurated papules, nodules, or plaques that may appear months or years after filler injections.

Differential diagnosis of granulomas after fillers It is sometimes difficult to differentiate between

granulomas

, nodules that form for other reasons, and abscesses. So, nodules can appear after contouring if the drug was injected using the wrong injection technique, in case of infection or the development of a late allergic reaction. Granulomas should be differentiated from nodules that form as a result of incorrect insertion technique, infection, or a late allergic reaction. Investigations that may help in making a diagnosis:

C-reactive protein;

number of white blood cells;

• erythrocyte sedimentation rate;
• microscopic examination and culture;
• hybridization
in
situ
• ; computed tomography; magnetic resonance imaging;
• biopsy and histological skin examination.
Treatment of granulomas after dermal filler injections
• Treatment of nodules after filler injections is recommended based onthe cause of their appearance
: most often these are infections, improper injection technique, less often – hypersensitivity to material and other product dependent factors.

If the problem occurs after

hyaluronic acid injection

, resort to 6

intralesional hyaluronidase injections;

extraction of the contents of the nodule with a 16G needle under negative pressure;

subsequent intralesional administration of 5 fluorouracil (5 FU);

• laser lysis;
• surgical excision (last resort).
Antibiotic therapy – the first step in the management of complications of presumably infectious origin. Intralesional steroid injections given prior to a course of antibiotics may exacerbate the problem.

Early startGK FillerHyaluronidaseTo

Late start
Other fillers
Massage Lidocaine + Saline	Intralesional steroids in small amounts  5 FU 0.5 ml (50 mg/ml) + 0.3 ml triamcinolone 10 mg/ml + 0.2 ml lidocaine 2% with epinephrine	Fractional laser (eyelids and lips)  Surgical excision Fig. 3: management of non-inflammatory nodules after the introduction of dermal fillers – palpable and visible nodules occurring 2-4 weeks after injections

prevent non-inflammatory nodules from forming

:

avoid overcorrecting;

do not inject fillers too superficially;

Use medicines as directed;

• Massage the treated area to spread the gel evenly.
• Intralesional injections
Treatment of

painless granulomas

that form without an inflammatory response can be done with:

intralesional steroids, then – 5FU;

surgical excision.

Such formations do not require urgent removal, the patient can be examined after 2 weeks.
 

LED

-therapy

Fillers based on polymethylacrylate can be "melted" first; laser and then removed. In some cases, intralesional steroids are needed during the course of antibiotics. Steroid injections are done carefully because of the risk of local atrophy. High doses of triamcinolone (35-40mg) mixed with 2% lidocaine are recommended to be administered with a 0.5-1ml insulin syringe with a 30G intralesional needle. Best Injection Technique – introduction of small amounts from the periphery to the center.

Broad-spectrum antibiotics are given if painful nodules with signs of inflammation are present despite negative cultures. Therapy also includes other substances (bleomycin, colchicine, cyclosporine, immiquimod or etanercept) that are traditionally used in the treatment of rheumatoid arthritis and psoriasis. Isoretinoin can be used alone or in combination with steroids.

Systemic Therapy

Systemic therapy is recommended if local treatment fails. High doses of steroids, such as oral prednisolone 30 mg/day (initial dose) and 60 mg/day (maintenance dose), are given to prevent recurrence of granulomas after fillers. The oral antibiotic minocycline alone or in combination with oral or intralesional steroids is effective in the treatment of inflammatory or silicone granulomas.

Read also:

Filler overcorrection: why it happens and how to fix it

Surgical removal Surgical excision involves the removal of the foreign body and biofilm. But this procedure carries the risk of complications such as scarring and deformities due to potential invasive growth of granulomas and irregular borders that make their complete removal impossible.

In addition, surgical excision of silicone-induced granulomas carries the risk of abscess or fistula formation. Localized sclerosing granulomas can be excised, followed by deformity correction with fat grafts or flaps. Efficacy is demonstrated by incision followed by drainage of a sterile abscess. Follow us on

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Biofilm Broad Spectrum Antibiotics:Ciprofloxacin or clarithromycin 500mg po twice a day + moxifloxacin 400mg po once a day x 4 weeks.If no response, consider surgical excision with flap technique or fat grafting. 4:

Erythematous indurated area appearing anytime after filler injection Granuloma

Sterile abscess, redness, indurated area after a few months – years after filler injections

If no result, switch to clindamycin 600 mg twice daily po + tetracycline 500 mg twice daily po. If improved, remove the nodule material with a 16G negative pressure needle. Consider: injections of 0.5 ml of 5FU monthly x 4; laser lysis, incision and irrigation of the cavity with antibiotics or surgical excision. Intrafocal or systemic steroids: triamcinolone, betamethasone, or prednisolone. If no response, add 5 FU, bleomycin, colchicine, ciclosporin.

Fig.

management of inflammatory nodules after dermal fillers

 

Thorough cleansing and disinfection of the skin, sterile insertion technique, prophylactic antibiotic therapy, and the use of small-gauge needles to minimize trauma and bacterial entry reduce the risk of granuloma formation after fillers. It is equally important to avoid overcorrection with dermal fillers, misuse of drugs and uneven distribution of the product in the tissues. As for the patients, it is not recommended to wear make-up immediately after the contouring procedure.Adapted from Aesthetics.Subscribe to our

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