A protruding nodule after filler injection

초록

A 49-year-old female patient presented with an 11-month history of edema and tenderness of the forehead. She had received an injection of a polymethylmethacrylate and crosslinked dextran filler (Licol-PⓇ, Chung Hwa MediPower Co. Ltd., Chunnam, Korea) to the forehead one year prior, and two additional injections were performed for correction of surface roughness. Physical examination revealed a 1.4 by 1.0 cm protruding skin-colored nodule on the forehead (Fig. 1A). A skin biopsy revealed filler material surrounded by multinucleated giant cells (Fig. 1B). This nodule was diagnosed as filler nodule. Filler nodules can form due to an inadequate injection technique and should not be confused with foreign body granulomas. Filler nodules typically appear as abrupt solitary lumps in the injected area that do not change in size over time. Often, they are well demarcated from surrounding tissue, not erythematous, and are harder than a foreign body granuloma. Intralesional steroid injections have a general tendency to be more difficult due to the nodule hardness1. They are frequently only marginally effective since the inflammatory reaction is not significant1. Filler nodules can be treated effectively with excision or wait for absorption1,2. Although multinucleated giant cells are not an emblematic indication of granulomas, they may nevertheless be created within the filler nodules in cases where the foreign material is too large to be enveloped and consumed by macrophages3. Unfortunately, the pathologic misdiagnosis of normal foreign body reactions is a significant factor leading to clinical confusion since the formation of foreign body granulomas triggered in response to fillers has not yet been well established. As a result, many dermatologists tend to misdiagnose a normal foreign body reaction to particulate material as a foreign body granuloma. To add to the confusion, particulate materials such as poly L-lactic acid, polymethylmethacrylate, and dextran filler are intentionally inserted to stimulate a foreign body reaction4,5. This case exhibits the typical clinical symptoms of a filler nodule. From a histological perspective, it was evident that the multinucleated giant cells had gathered in close proximity to the filler material. Due to this, we recommended excision of the nodule, however the patient refused treatment and preferred to wait for spontaneous absorption.

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