Avoiding granulomas, lumps with facial fillers. Sculptra - polylactic acid.

Facial fillers have become quite popular in the cosmetic market.  The objective of facial filler use is to restore volume to the face in an anatomically and physiologically correct manner to improve aesthetic outcome.  The risks to fillers are twofold:

• Distortion of anatomic subunits
• Granulomas or lumps under the skin

Avoiding complications is relatively easy with facial fillers.  Recommendations are to avoid undergoing procedures with inexperienced physicians or practitioners; being conservative with volume and intervals of treatment, and finally, maintaining harmony and normal aesthetic proportions.  Practically speaking, the risks of Sculptra injections can be minimized by:

• Avoiding areas of thin skin such as the eyelids and lips
• Conservative treatment
• Requesting a lower dilution of injectate

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Previous authors have adequately explained the common approaches in avoiding surface irregularities that may result from injecting Sculptra (or other materials) too superficially in the periocular regions. I would like to add several solutions and “pearls” by discussing surgical alternatives (usually as a last result) that may be beneficial in treating chronic or long-lasting irregularities.

To review:

• Sculptra, or Poly-L-lactic acid, has traditionally been reserved for the deeper lines, grooves, or trough facial regions. Its FDA approval stipulated use in the nasolabial folds that often result from lipoatrophy that is witnessed in immunocompromised patients.

• Most physicians approach the periocular region more carefully than any other facial region because of its thin skin. The focus in this region has been away longer acting fillers. I personally will not inject the infraorbital hollowing or tear trough areas beneath the areas, because I believe there are better and safer options in my hands. Excellent correction has been seen with Restylane, Juvederm, etc., and patients are willing to tolerate two injections per year.

• If Sculptra is injected under the eyes, using a higher volume dilution (roughly 8-10 cc’s per vial), allowing the product to sit for at least 24 hours after mixing the constituent to allow for little residual precipitation or powder, using a small gauge catheter to assure small participate size placement, and placement in a deep level.

• If superficial placement by the injector is suspected (at the time of injection), I believe immediate subsequent injection with normal saline in the region to further dilute the composition, followed by massaging can alleviate the complication. It’s a smarter decision to “void” out the treatment than risk a long-term complication.

HOWEVER, what treatments can be offered if persistent surface irregularities, bumps, or granulomas persist?

In addition to Sculptra, I have personally seen these same complications in patients who were injected with Artefill, silicone, and other materials that are often injected abroad.

• If the patient can tolerate them without significant complaint, don’t offer surgical alternatives.

• I have found that massaging for chronic granulomas usually doesn’t improve the appearance.

• Surgical Approach: In patients who can benefit from additional periocular rejuvenation procedures, i.e. blepharoplasty, then alternatives such as crushed fascial grafts or thin strips of alloderm can be superficially placed at the same time as the cosmetic procedure. Routinely, I’ll make two small stab incisions (along the medial punctum and next to the lateral canthus, take a small tendon passer and pass a thin 25 x 5mm strip of alloderm superficially under the skin to mask the bumps associated with silicone injections.

• Attempting to surgical excise these granulomas is tedious and problematic at best, and significantly high for injury. Conservatively “masking” the bumps is a better and safer option.

I hope these are beneficial to patients and physicians alike.