Abstract
The use of injectable cosmetic fillers in orofacial tissues has increased in the past few years. Although a wide variety of agents are available on the market and satisfactory results have been achieved, adverse reactions can be observed. The authors report three new cases of oral reactions in three women who received injections of different cosmetic fillers in the perioral area. In two cases, the lesions presented as nodules on the lip mucosa, and in the last case, as an intraoral ulcer with submental swelling. Considering the concern of patients about malignancies in these lesions, clinicians and pathologists should be aware of these adverse reactions and a detailed history should be made to diagnose these conditions.
In recent years, concern about beauty standards has increased the demand for injections of cosmetic fillers into orofacial tissues. These injection techniques with filler agents are often used for wrinkle treatment and soft tissue augmentation.
Although a variety of agents is available, the ideal filler has not yet been discovered and adverse reactions, such as pain, oedema, ulceration, itching, scarring, and migration of the injected filler may occur in orofacial tissues. Long-term development of immunological and inflammatory reactions has been reported. The aim of this study was to report three new cases of reactions to cosmetic fillers affecting the oral mucosa.
Case 1
A 51-year-old Caucasian female was referred to the Piracicaba Dental School (Oral Diagnosis Service) for an evaluation of hardness in the lower lip mucosa. Oral examination revealed a nodular lesion measuring 2.0 cm × 1.0 cm, which was fibrous in consistency and slight painful ( Fig. 1 A and B) . On palpation, additional nodules, barely visible and non-tender, were found all over the lip mucosa, including the upper one. The patient reported an injection of cosmetic filler 6 months previously for nasolabial fold correction and she presumed that it was hyaluronic acid (HA). She denied any adverse reaction at that time. An excisional biopsy was performed with the provisional diagnosis of foreign body reaction. The histopathological examination showed a chronic inflammatory infiltrate in the connective tissue and the presence of numerous giant cells around translucent particles, showing fusiform or oval shapes, leading to the diagnosis of a foreign body reaction ( Fig. 2 A) .
To elucidate the nature of the material, polarised light microscopy, scanning electron microscopy (JEOL JSM-5600LV scanning electron microscope, Japan), and energy dispersive X-ray analysis were used. Birefringent fragments of different sizes, most of them showing a fusiform, oval, or spiky shape, similar to cholesterol clefts, were observed under polarised light microscopy ( Fig. 2 B). Scanning electron microscopy showed numerous scattered fragments of angular aspect with organic membranes remaining on the surface, embedded within the cellular elements and connective tissue ( Fig. 2 C). The energy dispersive X-ray analysis detected large amounts of carbon (C), silicon (Si), calcium (Ca), phosphorus (P), sulphur (S), sodium (Na), magnesium (Mg), aluminium (Al), and potassium (K). The identified material was compatible with poly- l -lactic acid (PLLA) (Sculptra ® ) and a letter from the dermatologist confirmed the injection of this material ( Fig. 2 D). After 1 year of follow-up, the surgical site had completely healed with no trace of the remaining nodules.
Case 2
A 30-year-old Caucasian female patient was referred for evaluation of a painless swelling on the upper lip, which had been developing over approximately 1 year ( Fig. 3 A and B) . Intraoral examination revealed a fibrous nodule on the left upper lip mucosa, which had quickly enlarged, then stabilised. The patient was concerned about the possibility that the lesion could be cancerous and brought with her an ultrasound scan previously requested by her doctor showing no important alterations. The patient was very cosmetically aware and reported the application of cosmetic filler 7 years ago for nasolabial fold reduction by her dermatologist, but she was not able to describe the material. Based on this information, the diagnosis was consistent with a reaction to a cosmetic filler and no surgical intervention was performed. The patient returned after 6 months with no complaints and is still being followed up.
Case 2
A 30-year-old Caucasian female patient was referred for evaluation of a painless swelling on the upper lip, which had been developing over approximately 1 year ( Fig. 3 A and B) . Intraoral examination revealed a fibrous nodule on the left upper lip mucosa, which had quickly enlarged, then stabilised. The patient was concerned about the possibility that the lesion could be cancerous and brought with her an ultrasound scan previously requested by her doctor showing no important alterations. The patient was very cosmetically aware and reported the application of cosmetic filler 7 years ago for nasolabial fold reduction by her dermatologist, but she was not able to describe the material. Based on this information, the diagnosis was consistent with a reaction to a cosmetic filler and no surgical intervention was performed. The patient returned after 6 months with no complaints and is still being followed up.
