Delayed Granulomas as a Complication Secondary to Lip Augmentation with Dermal Fillers: A Systematic Review

Abstract

Introduction Lip augmentation with dermal filler is rising in popularity. There are generally minimal side effects that are mild and transient. However, long-term complications may occur and include lumps, bumps, nodules, or granulomas. To better understand this uncommon but challenging outcome, we aim to perform a thorough systematic review of the published literature related to nodule or granuloma formation after cosmetic soft tissue augmentation of the lips. Methods A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in April 2021 and included PubMed, ScienceDirect, Embase, Google Scholar, and Cochrane databases. The Medical Subject Headings (MeSH) terms used included the following terms: "lip filler," "hyaluronic acid," "lip injection," "lip augmentation," "silicone," "poly-L-lactic acid," "calcium hydroxyapatite," "polymethylmethacrylate," "complications," "reaction," "granuloma," and "nodule." All studies were reviewed by two independent reviewers. Any discrepancies were resolved by a third reviewer. Results The initial search for filler-related nodules or granulomas yielded 2,954 articles and 28 were included in the final analysis containing 66 individual cases of lip nodules. All but one patient was female. The mean age was 50 years. Nodules presented on average 35.2 months or 2.9 years after initial treatment. Thirty-seven nodules underwent histological analysis, the majority of which identified the presence of a foreign-body granuloma. Silicone was the most reported filler used followed by hyaluronic acid. Most cases resolved following multiple treatments including oral antibiotics or steroids followed by surgical excision. Conclusion Understanding the sequelae of lip augmentation with filler products allows clinicians to provide safe and effective treatment. Nodules that present months to years following dermal treatment may represent a foreign-body granuloma. A combination of oral antibiotics, intralesional or oral steroids, and surgical excision successfully treated the majority of cases in our study.

Keywords: fillers; granulomas; lip augmentation; nodules; systematic review.

Fig. 1

PRISMA 2020 flow diagram of screening process.

Fig. 2

Country of study publication.

Fig. 3

Number of study publication by year.

Fig. 4

Initial site of injection for augmentation.

Fig. 5

Reported filler type used. CAHA, calcium hydroxy apatite; HA, hyaluronic acid; Mixed, combination of HA and hydroxy-ethyl-methacrylate (HEMA) and ethyl-methacrylate (EMA); PAAG, polyacrylamide gel; PAIG, polyalkylimide gel; PLLA, poly-L-lactic acid, PMMA, polymethyl-methacrylate microspheres.

Fig. 6

Treatment of cases. FU, fluorouracil.