Review of Long-Lasting Dermal Fillers

Dr. Lowe: A chronic inflammatory reaction within
the skin. It has a mixture of chronic inflammatory
cells, often surrounding a foreign body (i.e., the filler).
Dr. A. Carruthers: A granuloma has a specific
histological appearance. With permanent fillers,
granulomas are related to the size and nature of
the material injected. Small particles are more likely
to be ingested by macrophages and to produce
this kind of a reaction. There do seem to be other
factors involved, one of which may be foci of infection
elsewhere in the body, such as chronic dental
disease, although that’s not as well established.
Dr. Nicolau: A foreign body reaction is a normal
reaction; a granuloma is an overreaction. The
sheer injection of anything will induce a foreign
body reaction. Any product, including collagen,
hyaluronic acid, and so on can induce a granuloma
or inflammatory reaction.
Dr. Friedland: In essence it is the result of an
injected substance setting up an antigen-antibody
reaction. We call it a granuloma because it has a
granular kind of a texture. It usually appears
where the material was injected.
Dr. Smith: It’s very rare to have a true granuloma.
Nodules are most often technique-dependent and
are not granulomas. Particularly with Artecoll, the
common mistake that doctors make is being too
ambitious; they inject too much filler in one visit or
the visits were too close together. If you do that,
sometimes you can feel it under the skin, and it’s
just excess fullness and not a granuloma or nodule.
granulomas, Alastair and I found that with conservative
management, all the granulomas resolved
within two years. The practice management problem
is that patients with granulomas tend to
oscillate from doctor to doctor, so it is difficult for a
single physician to obtain long-term experience. To
my knowledge, ours is the only recent long-term
evaluation of a cohort of patients with granulomas.
We have thus found that permanent fillers can
cause transient problems, but not necessarily permanent
problems.
How do you recommend treating granulomas?
Dr. Graivier: The main thing is not to excise a
granuloma. Treatment has to be very aggressive
by using both injectable steroids and oral steroids,
and sometimes a mixture of 5-fluorouracil (5-FU)
and triamcinolone. You can even resort to
methotrexate if the granuloma does not respond to
anything else.
Lips with granuloma 3 years
after Artecoll Injection.
Same patient 1 year later. Granuloma
resolved from triamcinolone injections.
Photos courtesy of Alastair Carruthers, MD, FRCP
Dr. Joseph: Most people will never form a granuloma
to bovine collagen, but I’ve seen probably five
of them. Why one person’s body reacts and another’s
doesn’t, you never know.
Dr. A. Carruthers: I inject triamcinolone acetonide
in amounts sufficient to suppress the
lumpiness. It is important to avoid injecting too
much and producing steroid atrophy.
Dr. J. Carruthers Commentary: Complications,
including granulomas, can occur with any filler—
not just permanent fillers. In a study of an
unselected sequential group of patients with
Dr. Smith: Most likely I’d inject Kenalog with a
Becton-Dickinson 31-gauge diabetic needle. We
like Kenalog because it’s a medium-potency, antiinflammatory
steroid with a sustained effect.
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