Update on Midface Fillers
A nodule is a firm, sometimes mobile, mass under your skin. In the context of Voluma®, it is believed that the Vycross technology creates a hyperdense concentration of injected hyaluronic gel, resulting in a variably sized lump, or nodule. Size can vary from a pine nut to a golf ball depending on the exposure. Treatment can involve direct injection of reversal agents, steroid therapy, and sometimes, if warranted, surgical removal. Why do they matter? Functionally, the honest truth is that they don’t. If the nodule does not interfere with facial function, they are easily tolerated in permanence. Problems are very common in lower eyelids, nose, and lips, but less common in the cheek or jaw due to the greater amount of soft tissue coverage. Patients tend to dislike these, especially in the context of higher Voluma® pricing.
As I mentioned above, the thinner the soft tissue coverage, the more problematic these nodules are. To illustrate this, just pinch your lower eyelid, and then pinch your cheek. Notice the difference in both the thickness of the fat pad, and the thickness of the skin? This basic anatomic difference is why the effect of nodularity is variable. If you have a chick pea sized area of hardness in your cheek, you may hate it, but it won’t change who you are. If you have that same chick pea in your lower eyelid, it can be debilitating and life altering.
Nodules and granulomas are related entities, but they are still different. The term “nodule” refers to the foreign substance itself bound to itself. It is basically an inert foreign body made up of injected filler. A granuloma, on the other hand, is the body’s response to a foreign body. Not all foreign bodies cause granulomas, but some fillers have a greater propensity for granuloma formation than others. The most common granuloma producing dermal filler was Artecoll®. Artecoll was then altered chemically, and re-named Artefill®, and is now named Bellafill®. Artefill and Bellafill® are the same product, with different branding. These poly methylmethacrylate-based fillers appear to cause granuloma formation more than their counterpart fillers.
In summary, nodule formation refers to an adverse event following filler injections. It is most common with methylmethacrylate based fillers, but Juvederm Voluma® appears to be causing later nodule formation in the marketplace. Nothing has been published yet in peer review on this topic, but we anticipate something will be coming soon. Meanwhile, your best bet against nodules and granulomas include:
1) Using a non-nodule formation filler such as Radiesse Plus®, Restylane Lyft®, Renuva®, or Fat
2) Receiving injections from board certified plastic surgeons, or their partners rather than less comprehensively trained practicioners.
3) Informed Consent- Ask questions, always.
4) Avoid injections in high risk areas from non-Plastic Surgeon injectors. These include the lips, lower eyelids, nose, and jawline.
5) Live your best life, and make aesthetic decisions based on result quality and safety rather than price alone.
Hope to see you soon!!
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