Foreign Body Granuloma Formation after Dermal Fillers – A Review & Comparison of Literature

Dr. Tahreem Kashif^*, Dr. Aneela Arooj¹, Dr. Zartaj kashif², Dr Fareena Kanwar³, Dr Rozina Kanwar⁴, Dr. Ayesha Kashif⁵, Dr. Anum Kashif⁶

1. MRCP London, Clinical research fellow in University hospital of wales , Cardiff.
2. Professor of Histopathology Department of Pathology, Multan.
3. GP, Department of Aesthetic/Dermatology- Dubai.
4. Clinical assistant at Mississauga (Toronto), Canada.
5. Department of Public health- Oxford Brookes Uk.
6. Department of medicine- Mulan

Corresponding Author: Dr. Tahreem Kashif, Aesthetic physician- Department of Dermatology/Aesthetic Medicine- Aster hospital Dubai.

Copy Right: © 2023 Dr. Tahreem Kashif, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: January 17, 2023

Published Date: February 01, 2023

Abstract

Hyaluronic acid based dermal filler injections  to correct skin deformities, volume loss, facelift and countering is a common practice in aesthetic medicine. (1) although these fillers are considered safe because of their biodegradability but advanced reactions can occur. (2) Here, we discuss and compare a rare case of foreign body granulomas formation in the parotid and submandibular region presented as painful subcutaneous nodules, following injection of hyaluronic acid performed 1 year ago for strengthening of jawline. A review of 16 publications in literature presenting with similar presentation or formation of granulomas after filler injection, who underwent a biopsy for confirmation, was conducted to determine the diagnosis, presentation and management of the nodule after derma filler injections.

Introduction:

Dermal fillers are gel like substances mostly hyaluronic acid, calcium Hydroxyl apatite (CaHA) or Poly-L- lactic acid that are injected beneath the skin to restore the lost volume, smoothen lines and soften creases, or enhance facial contouring. (3) Among them the most widely used filler is hyaluronic acid based  fillers. Dermal fillers are gaining in popularity and frequently use to treat aging skin. Although, a large variety of fillers is present in the market to achieve satisfactory results if injected with accuracy and guidelines, however adverse reactions can also be observed and complications can happen. (4) All dermal fillers carry a risk of adverse reactions ranging from transient reactions like erythema, redness, swelling, bruising and inflammation that disappear after a short time to vascular occlusion, chronic inflammation and infection, filler migration and foreign body granulomas that are challenges for the physicians. (5)(6).

Methods & Materials:

An Extensive manual literature search was performed to review the complications that can happen with dermal fillers. Specifically, the occurrence of foreign body granuloma after dermal fillers.

A complete review of articles published upto 2022 on pubmed, Science direct, Embase, Google Scholar, Cochrane database and Medline database was conducted to correctly describe the proposed mechanism of actions, the factors involved in Granuloma formations, its presentation and correct treatment options. The initial search for filler- related nodules or granulomas yielded 2,955 articles and 16 cases with complete case reporting in which the confirmation was made with histopathological examination were manually searched for other potential eligible studies.

Case Analysis:

A 26 years old otherwise healthy Arab women presented with history of tenderness and swelling in her jawline, complaining about multiple subcutaneous lumps in her jawline that has been presented for almost 1 month.

On physical examination, multiple small to large firm, round to symmetrical nodules were noticed in the parotid & Submandibular area on Palpation. The nodules were tender, firm in consistency and not fixed. She exhibited neither lymphadenopathy nor fever. Her medical history was unremarkable. In the same area, she had a history of taking 5 ml of hyaluronic acid based filler for straightish for her jawline 1 year ago that had been injected by a physician in a private medical clinic. On investigations, routine laboratory examination, CBC, liver function test, renal function test, erythrocyte sedimentation rate, C- reactive protein all were within normal range. On MRI scan, there were numerous fluid filled low intensity well circumscribed rounded lesions in the parotid and submandibular area. Patient was referred for histopathological examination of these nodules & Incisional biopsy was performed and histopathological analysis showed a well circumscribed granulomatous reaction without central necrosis, characterized by an epithelioid histiocytic organization, numerous multinucleated giant cells with peripheral disposition of nuclei, PAS positive stain suggesting hyaluronic acid with the granuloma.

The patient was treated with hyaluronidase and intralesional steroidal injections followed by antibiotics. The nodules disappear after 2 weeks complete remission was confirmed by soft tissue ultrasound. patient was fully explained about the long term adverse effects of filler and the follow up was made to check  further reoccurrence and relapse. 

Discussion

Hyaluronic acid-based fillers are widely used to correct facial deformities, enhancement of volume and facial counter, loss of volume in hands and lip enhancement in aesthetic medicine. (1) they are generally considered Safe. Though adverse reactions can happen. Swelling, redness, inflammation, erythema, tenderness can occur an immediate side effect after procedure, these adverse effects go shortly without leaving any trace. however late complications like foreign body granulomatous, inflammatory reactions, fillers displacement can happen even after many months and years. (2) (6)

Delayed reaction due to dermal filler injection have appeared in various studies in the past even until recent times previously silicon fillers were considered the culprit but HA fillers are also causing this complication.

A review of 16 publications in literature presenting with similar presentation of formation of granulomas after filler injection who underwent a biopsy and radiological assessment for facial nodule formation from the period of 4 months to 6 years after filler injections, was conducted to determine the diagnosis presentation and management of the nodule after filler injection and to determine type of filler used.

All patients were women (mean age 60.6 years) some patients suffered from different localizations lip 09; glabella 02; cases nasolabial folds 04; cheeks 04; the parotid region 1; and arms 1; case 90% patients know the type of filter used and in other cases histopathological findings were able to provide some information.

The histopathological findings in most cases of foreign body granuloma formation due to dermal fillers show a dense lymphocytic infiltration with eosinophils and granulomatous infiltrates with multinucleated giant cells often containing basophilic amorphous material multiple vacuolated cystic like structure and Swiss cheese appearence are also possible.

Typical presentations include Erythematous painful nodules but subcutaneous painless nodules have also been reported.

The strategies for treatment involves hyaluronidase injection alone or in combination with intralesional or oral steroid injections. Empirical antibodies is also an option to treat granulomas in response to fillers. In resistance and a long standing cases or in case of failure to medical treatment surgical excision of nodules and granulomas is considered. (7,8,9,10)

Hyaluronic acid is produced by biotechnology it is obtained by fermentation of bacteria a process using lactic acid bacteria then it is collected stabilised, sterilised, purified, cross linked and dehydrated to form a powder when added to water it forms a more or less tested gel cross linked HA is more durable it involves a process that allows linear hyaluronic acid molecules to be linked together to form a HA filament with higher molecular weight. (2)

the exact pathogenesis of late onset granulomas is still in debate but several hypothesis have been suggested. These involved derivation of impurities during bio fermentation hypersensitivity responses in patients who undergo repeated filler injections antibody formation could be possibility or disintegration of cross linking may be responsible for an inflammatory reaction. (3-6)

Conclusion

Long term complications due to dermal fillers can happen after months and years patients undergoing cosmetic procedures may be fully informed regarding the late possible adverse effects that can happen. The diagnosis and treatment of this complication is a challenging for physicians proper history, examination radiological and histopathological examination play a main role in making diagnosis of foreign body granulomas and its management.