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Complications from fillers: granulomas

When "lasting a long time" is often not synonymous with "I want a safe product"

Granulomas are one of the most frequent complications due to the inoculation of dermal fillers. Fortunately very rarely, it happens to come across subjects who complain the formation of lumps, nodules or cysts caused by the filler implant.


In recent years these occurrences have been greatly reduced, thanks to the use of modern products that are made of very pure cross-linking agents and present in minimal percentages, compared to the past. Surely also thanks to the evolution of inoculation techniques: from the needle we have largely passed to the use of the cannula, thus avoiding the formation of accumulations.


I believe that one of the main risk factors is the demand "I want a filler that lasts a long time". This pushes the doctor to use semi-permanent fillers (in the past silicone, now fortunately banned), or high molecular weight and long-lasting hyaluronics. The patient is not aware of the fact that a foreign body, such as a filler molecule, inserted in human tissue, is not inert, but undergoes a series of biological processes, which have the purpose of isolating it from the rest of the body.


A modern BBDE filler, with medium / high G ', and with excellent rheological characteristics, has an estimated duration of 6 months, during which it is metabolized (= dissolved) by on site hyaluronidases. This should not be seen as a limitation, but as a safety: after 6 months there will be no trace of the inoculated substance, whether the procedure was appreciated, but more importantly, in case there were any unwanted effects.


On the other hand, long-lasting fillers with a hard consistency and cross-linking agents resistant to hyaluronidases can lead to serious problems over time. These products produce the formation of a collagen capsule that isolates the filler from the surrounding environment. The same happens with the periprosthetic capsule of a breast implant. This is because the filler is recognized as foreign substance, and our body's response is to isolate it. Fibrotic collagen is then produced and a hard lump results, which can be more or less palpable and annoying depending on the location.


Recently I had two cases of patients who came to me with granulomas. Both are extremely difficult to cure due to their localization and the presence of abundant fibrous tissue.


The first case

granuloma complications from fillers

The first case is a patient (F), with zygomatic granulomas dating back to 2 years, caused by inoculation of body volumizing fillers and calcium hydroxyapatite. The reaction due to the mixture of these two was severe with liponecrosis and formations of cysts, which periodically underwent inflammation. In the surrounding context, liponecrosis caused the formation of extensive fibrosis, with skeletonization of the cheeks.

At first, the biggest problem was the fibrosis due to the destruction of the fat pads of the cheeks, with scar retraction of the skin. Granulomas were not visible except during inflammation.

My first choice was to treat the patient with a course of PRF to reduce the scar adherence and dissolve any residual calcium hydroxyapatite.

After 5 sessions, one every of 30-40 days, the situation was considerably improved with reduction of adherence. The elimination of the fibrosis also allowed the granulomas to rise to the surface and it was possible to evacuate them (after two years the filler was still perfectly intact and present in considerable quantities!) and to treat the small residues with hyaluronidase.

To restore the volumes, I resorted to lipofilling, also to further improve the scar component and skin quality.





The second case

The second case is a patient (M) who had undergone penis enlargement treatment with hyaluronic acid fillers. He performed two sessions: after the first one he did not report side effects, but with the second he began to show hard bumps that caused pain and pseudophimosis. He reports that the product used in the second session was much harder than the first one and that these lumps developed immediately.

About 4 months after this episode he came to my practice as the center where the treatment was performed was no longer available. We started with hyaluronidase cycles once a week for 8 times, performed with a cannula with curettage of the fibrotic component. The dissolution of the product was very mild, as granulomas of fair size and abundant fibrous component had already formed, even tough only 4 months have passed.

Two further sessions of triamcinolone were necessary to eliminate two hard granulomas (very abundant collagen component) formed on the foreskin. The patient is now happy with the resolution (after 6 months of treatment) and will undergo a cautious penis enlargement session with me.



granuloma filler penis penis enlargement
In the circle the largest granuloma

From these personal experiences, and, above all, to provide maximum safety and quality to my patients, I have chosen not to use permanent products or products containing calcium hydroxyapatite or acrylics. The fillers that I use are produced exclusively by Bioformula, a leading Italian company in the world of aesthetic medicine. This way I can provide products of the highest quality, and it also enhances the "made in Italy", allowing me to bring to light an all-Italian excellence, of which I know the products and I know how they are processed. I often go to the company to be personally present even during the processing of materials. Quality standards and patient safety are always in first place in the Bioformula world, in fact from our collaboration a "Charter of Values" will be born in which the values of transparency, completeness and correctness of communication between doctor and patient will be reported.

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