predictable in amount and volumizes the tissue to produce the
desired cosmetic result.
Lemperle et al25 have tabulated some well-defined clinical differences
between true inflammatory granulomatous reactions and
papules/nodules (Table 1).25 The most striking clinical difference
is that a true granulomatous reaction seems to be a systemic
response (ie, the reaction is seen in all treated areas at the same
time). In contrast to nodules, granulomas may become apparent
months or years post-injection9 (Table 1). They typically have
poorly defined borders and may persist and grow over time, although
they too are capable of spontaneous resolution.9
All injectable dermal fillers have the potential, in some patients,
to cause a foreign body–type reaction that may develop into a
granuloma.19,24,26 However, the incidence of visible, clinically significant
granulomas with injectables, including PLLA, in actual
clinical practice is very low (0.01%–0.1%),3,27,28 and their occurrence
is currently unpredictable.19 A recent review of the literature and
new case reports summarized the clinical features of 56 biomaterial-
induced granulomas involving oral and perioral tissues and is
shown in Table 2.28 In this review, there were 4 reports of granulomas
with PLLA use, less than the number reported with silicone,
collagen, HA, and acrylic hydrogel suspended in HA; however, this
may reflect which of these fillers is most commonly used.28
