Periorbital lipogranuloma related to filler migration: A rare complication of facial fillers

Abstract

Facial fi llers, injectable therapeutic materials for soft tissue augmentation, are ideal for restoring facial volume and contour. With recognition of its value, as well as the ease of offi ce procedures, fi ller injection has become one of the most commonly performed cosmetic procedures. Yet, fi llers are implants and essentially foreign bodies that can trigger an infl ammatory response in individuals. In addition, fi ller injection is a blind procedure in which the physician is unable to see exactly where the material is placed. With these characteristics, injectable fi llers have the potential for a myriad of complications. Moreover, in East Asian countries, injection of illegal materials by unlicensed practitioners are widespread with an increased risk of fi ller complications. We herein present a case of fi ller migration to the eyelid, a rare complication following illegal fi ller injection. To our knowledge, this complication has not been reported previously in the dermatologic literature. A 74-year-old female presented to the dermatologic outpatient clinic with a history of gradually enlarging swelling on the left upper eyelid. Clinical examination disclosed a yellowish, fi rm and nontender mass on the left upper eyelid (Figure 1A and B). The mass was not associated with decreased visual acuity, ocular motility limitation, or proptosis. The patient stated that she received fi ller injection on the forehead by an illegal practitioner 3 years ago and the lesion was said to develop a month afterwards. Although our patient recalled the injected material as a liquid agent, she was not able to identify the exact nature of the substance. She denied of being injected in the periorbital region and also of a trauma history. A skin biopsy was performed from the eyelid mass. Histopathologically, there was diffuse granulomatous infl ammation throughout the dermis. Under high magnifi cation, numerous lipid vacuoles were seen surrounded by epithelioid histiocytes and multi-nucleated giant cells. The overlying epidermis was intact and unremarkable (Figure 2A and B). Although we were not able to identify the exact fi ller substance, the clinical and histological fi ndings were in keeping with the diagnosis of a lipogranuloma from fi ller migration. The patient was asked to undergo treatment, but is currently lost for follow-up. Clinically detectable granuloma formation following facial fi ller injections is a well-known complication, where complication rates vary from 0.01% to 0.1% (1). This is not surprising, as all skin-implanted exogenous substances can trigger an infl ammatory response in individuals. Notably, oily substances such as silicone and paraffi n have commonly been reported to produce a foreign body granulomatous reaction known as “ sclerosing lipogranuloma ” (2). The pathogenesis of eyelid mass formation after fi ller injection to the forehead can be explained by the consideration of the galea as the superfi cial musculo-aponeurotic system (1). The layers of the forehead consist of the skin, subcutaneous tissue, frontalis muscle, galea aponeurotica, loose areaolar tissue, and periosteum. The subcutaneous fat layer in the forehead is connected with the brow fat pad, while the galea is connected with the posterior orbicularis fascia. The galea is a broad sheet, and the tissue plane formed by the galea and the posterior orbicularis fascia can function as a migration pathway of the injected material from the forehead to the upper eyelid. Injected fi ller substances may migrate through the galea aponeurosis and the retroorbicularis fascia by gravity, facial muscle movement and postoperative massage of the injection sites for better distribution of the injected material. Moreover,