Fillers and granuloma: anatomopathological and clinical analysis and treatments

The increasing use of dermal filler substances in the treatment of wrinkles, as well as the immense variety of new products and introduction of new names without proper disclosure of their chemical contents – at least in some countries – makes any overview difficult.1 Unfortunately, the general lack of reliable scientific evidence ('a hydrogel') and trustworthy data ('patient satisfaction'), and the general habit of the manufacturers to provide the most positive data ('duration 2-7 years'), meet with a general lack of scientific interest and criticism on the side of the injecting physician. No wonder then, that the sudden occurrence of a complication leads to astonishment, negligence, blame directed at the product, and wrongful treatment of these often troublesome complications. Only proper education of physicians and patients will draw a realistic picture of this new field of injectables, currently filled with enthusiasm and negligence, warnings and hypotheses, and widespread happiness, but some disasters too. In general, all injectable substances exerting a positiveeffect may be expected to also cause side-effects. All current dermal fillers, resorbable and non-resorbable, are associated with adverse effects.2 Biological substances such as collagen or hyaluronic acid may cause allergies, lumps, long-lasting redness, sterile abscesses, and eventually early foreign body granulomas (FBGs) (Figure 37.1); longer-lasting artificial substances such as the many polymers used in medicine may cause lumps, long-lasting redness, and late FBGs (Figure 37.2). The following opinion on successful treatment oflate adverse events is based on a joint experience with various injectable filler substances and their complications, as well as a thorough review of the existing literature. The problem of all here enclosed statistics is obvious: late adverse events after fillers have to be reported neither to the manufacturer nor to the health authorities in most countries, and when they have to be reported they seldom are. This accounts for the lowrates that the manufacturers produce. Until official statistics are available, we have to rely on those of single physicians! In order to get reliable and trustworthy numbers, calculations were limited here to reports on case-numbers above 500 patients. It is estimated that the calculated range of occurring genuine FBGs varies between 1 in 100 (1%) and 1 in 5000 (0.02%) patients, depending on the injectable used.