Case Reports
Ophthalmic Plast Reconstr Surg, Vol. 35, No. 3, 2019
FIG. 2.  Hematoxylin and eosin stains at various magnifications: (A) 200×, (B) 40×, (C) 40×, (D) 100×. The mass shows mature
adipose tissue (*), with branching capillaries (◁) and thick-walled vessels (★). Fibrosis (◆) and thrombi (■) were evident (B and D), but
no necrosis.
REFERENCES
1. Carruth BP, Meyer DR. Angiolipoma of the orbit: a rare tumor in an
unusual location. Ophthalmic Plast Reconstr Surg 2015;31:e142–5.
2. Feinfield RE, Hesse RJ, Scharfenberg JC. Orbital angiolipoma.
Arch Ophthalmol 1988;106:1093–5.
3. Arenaz Búa J, Luáces R, Lorenzo Franco F, et al. Angiolipoma in
head and neck: report of two cases and review of the literature. Int
J Oral Maxillofac Surg 2010;39:610–5.
4. Tripathy D, Mittal R. Spindle cell lipoma of the orbit. Ophthalmic
Plast Reconstr Surg 2015;31:e53–5.
5. Sah K, Kadam A, Sunita J, et al. Non-infiltrating angiolipoma of the
upper lip: a rare entity. J Oral Maxillofac Pathol 2012;16:103–6.
6. Borrelli M, Buhlbuck D, Strehl A, et al. Leiomyolipoma of the or-
bit. Ophthalmic Plast Reconstr Surg 2012;28:e21–3.
Foreign-Body Granulomata
Caused by Injected Permanent
Filler Masquerading as Cutaneous
Sarcoidosis
Stacy M. Scofield-Kaplan, M.D.*, Sagar Y. Patel, M.D.*,
Andrew Mueller, M.D.*, W. Cameron Ford, B.S.*,
Bret M. Evers, M.D., Ph.D.†, R. Nick Hogan, M.D., Ph.D.*†,
and Ronald Mancini, M.D.*
Abstract: Foreign-body granuloma formation following filler
injections is most commonly seen with permanent fillers;
these reactions can occur years following the injections and
often require either an intralesional steroid injection or
surgical excision. The authors present a case of a 75-year-
*Department of Ophthalmology, UT Southwestern Medical Center; and
†Department of Pathology, UT Southwestern Medical Center, Dallas, Texas,
U.S.A.
Accepted for publication March 13, 2019.
The authors have no financial or conflicts of interest to disclose.
Address correspondence and reprint requests to Ronald Mancini, M.D.,
Department of Ophthalmology, University of Texas Southwestern Medical
Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9057. E-mail: Ronald.
Mancini@utsouthwestern.edu
DOI: 10.1097/IOP.0000000000001385
e82 © 2019 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2019 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
old woman with a history of systemic sarcoidosis previously
treated with numerous immunosuppressive medications
who was examined for bilateral infraorbital nodules and
swelling that were unresponsive to treatment. She underwent
a bilateral anterior orbitotomy through a transconjunctival
approach with mass excision. The histologic analysis was
consistent with foreign-body granulomata juxtaposed
to implantable material, specifically ArteFill, which
was injected many years prior. There were no separate
noncaseating granulomas to suggest sarcoidosis as the
underlying etiology. It is important to consider prior filler
injections in patients with sarcoidosis who present with
subcutaneous nodules as this changes management and may
prevent the need for more aggressive immunosuppressive
treatment.
T he use of injectable soft-tissue fillers has risen dramatically
over the last few years with 2.7 million injections performed
in 2017 based on data from the American Society of Plastic
Surgeons.1 Several types of dermal fillers are commercially
available ranging from nonpermanent hyaluronic acid gel to
permanent synthetic microspheres. Although injectable fillers
have an overall good safety profile, they can be associated with
a variety of adverse events and complications including swell-
ing, infection, pain, nodule formation, granuloma formation,
skin necrosis, and blindness.2,3 Foreign-body granuloma forma-
tion has been most commonly seen with permanent fillers; these
reactions can occur years after filler injection and may require
intralesional steroid injection or surgical excision.3–5 There have
been a few reports of patients with systemic sarcoidosis devel-
oping subcutaneous nodules/granulomas.3,5,6 The authors report
a case of a patient with systemic sarcoidosis and significant
facial nodules that did not respond to numerous immunosup-
pressive medications aimed at treating cutaneous sarcoidosis
nodules. She ultimately underwent a bilateral orbitotomy with
excisional biopsy, which revealed foreign-body granulomas
reactive to foreign-body material consistent with prior Artefill
(Suneva Medical, San Diego, CA, U.S.A.) filler injections.
This case was Health Insurance Portability and Accountability
Act compliant with protection of any identifiable information.
 Ophthalmic Plast Reconstr Surg, Vol. 35, No. 3, 2019 Case Reports

FIG. 1.   A 75-year-old woman with infraorbital areas of firm

mobile fullness.
Patient consent was obtained for use of identifiable clinical
photographs.
CASE PRESENTATION
A 75-year-old woman with history of systemic sarcoid-
osis sought treatment for 10 years of swelling and subcutaneous
nodules in the infraorbital area (Fig. 1). This swelling persisted
through multiple flare-ups of sarcoidosis and was unresponsive
to treatment with numerous immunosuppressive medications
despite resolution of her other clinical manifestations of sarcoid-
osis. A positron emission tomography scan of her face revealed
bilateral infraorbital tissue masses with 18F-fluorodeoxyglucose
avidity and dimensions of approximately 1.5 × 0.7 cm on the
right and 2.5 × 0.8 cm on the left.
On examination, her visual acuity, visual fields to con-
frontation, extraocular movements, and pupils were normal.
There were firm palpable masses in the medial aspect of the
cheek and lateral nose with extension up to the tear trough on
each side and small masses below the corner of the mouth on
each side. The slit-lamp examination and fundoscopic exami-
nation were otherwise unremarkable. She denied any history of
filler injections.
An MRI of the face revealed bilateral subcutaneous
infraorbital tissue masses with homogenous enhancement after
contrast of similar size and location as the prior positron emis-
sion tomography scan (Fig. 2). The patient underwent a bilateral
anterior orbitotomy through a transconjunctival approach with
excision of the subcutaneous nodules in an effort to relieve the
swelling and achieve a definitive diagnosis.
FIG. 2.   MRI demonstrating bilateral subcutaneous infraorbital
tissue masses (white arrows) with homogenous enhancement
after contrast. Coronal image (A) and Axial image (B) shown.
Gross examination of the excised masses revealed ho-
mogenous, firm, tan-white tissue masses. Histologic exami-
nation of the specimens revealed dense connective tissue with
multiple foreign-body granulomata (Fig. 3A). Within the granu-
lomata were numerous empty vacuoles (Fig. 3B), the most of
which were enveloped by foreign-body giant cells (Fig. 3C,D).
Notably, noncaseating granulomata of the type seen in sarcoid-
osis were not identified in these specimens; and all the granu-
lomata seen in this patient were associated with the empty
vacuoles consistent with foreign-body material. Once examined
forpathologic diagnoses, the patient recalled receiving ArteFill
injections many years prior and also noted having had chin and
breast implants removed due to the development of granulom-
atous reactions to the implants. The histologic evidence, along
with the resistance of the bilateral infraorbital masses to sar-
coidosis treatment, led to the diagnosis of foreign-body granu-
lomata rather than an exacerbation of sarcoidosis.
DISCUSSION
Complications from permanent filler injections have been
well documented in the literature.2,3 Delayed-onset complica-
tions are broad, but the more commonly encountered pathologic
findings include noninflammatory or low-grade inflammatory
nodules.3,4 Oftentimes, the diagnosis is obvious with few diag-
nostic alternatives, but a large delay in presentation following
filler injections may mask the underlying diagnosis especially
when the patient either denies or neglects to mention prior filler
injections. Furthermore, in patients with a known autoimmune

FIG. 3.   Hematoxylin and eosin (H&E)–stained sections of the infraorbital masses. These masses demonstrate dense connective tissue
(white asterisks in A) with multiple foreign-body granulomata (black asterisks in A). These granulomata contained numerous empty
vacuoles (B), the most of which were enveloped by foreign-body giant cells (white arrowheads in C;higher magnification in D). Scale
bars = 1.0 mm (A) and 100 μm (B–D).

© 2019 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. e83
Copyright © 2019 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 Case Reports Ophthalmic Plast Reconstr Surg, Vol. 35, No. 3, 2019
or inflammatory condition, these nodular reactions may go
misdiagnosed or may be attributed to part of a patient’s sys-
temic disease rather than a separate process. In fact, patients
with certain granulomatous diseases, such as sarcoidosis, may
have an increased propensity for these types of reactions.3 It has
been proposed previously that any foreign body inoculated from
minor trauma may serve as a nidus for granulomatous inflam-
mation in patients with sarcoidosis, although only one of these
cases involved a nodule on the face.6 In patients with sarcoid-
osis with implantable fillers, there can be mixed inflammatory
lesions, where sarcoidosis and foreign-body granulomas can be
found concurrently within the same region of inflammation.5
This case further supports the theory that patients with
sarcoidosis are more prone to developing foreign-body reac-
tions from implantable materials. Not only did she have foreign-
body granuloma formation following permanent dermal filler
but she also had a history of chin and breast implants requiring
removal and subsequent surgical excision of the foreign-body
granulomatous tissue. Our patient is unique in that her facial
granulomatous lesions were treated as a manifestation of sys-
temic sarcoidosis with years of numerous immunosuppressive
medications without any improvement. The underlying correct
diagnosis only became apparent following surgical excision and
the patient then recalling prior filler use.
Although the use of permanent implantable materials is
becoming more frequent, this case illustrates the growing neces-
sity of increased awareness of inflammatory responses to inject-
able materials and the importance of asking any potential filler
patient if they have a condition like sarcoidosis.1 Physicians and
all patients who are being evaluated for permanent implantable
e84 © 2019 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2019 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
fillers (especially those with sarcoidosis) should be educated on
the potential for scarring, tissue damage, and need for possible
surgical interventions due to the foreign-body granuloma for-
mation. Furthermore, it is imperative to consider foreign-body
granuloma in the differential diagnosis of tissue masses unre-
sponsive to initial immunosuppressive treatments, as this may
obviate the need for patients to be treated with immunosuppres-
sive medications that carry a vast array of side effects including
potentially life-threatening infections.
REFERENCES
1. American Society of Plastic Surgeons. 2017 Plastic surgery statis-
tics report. Available at: https://www.plasticsurgery.org/documents/
News/Statistics/2017/top-five-cosmetic-plastic-surgery-proce-
dures-2017.pdf. Accessed February 1, 2019.
2. Rayess HM, Svider PF, Hanba C, et al. A cross-sectional analysis
of adverse events and litigation for injectable fillers. JAMA Facial
Plast Surg 2018;20:207–214.
3. Daines SM, Williams EF. Complications associated with injectable
soft-tissue fillers: a 5-year retrospective review. JAMA Facial Plast
Surg 2013;15:226–231.
4. Kadouch JA, Kadouch DJ, Fortuin S, et al. Delayed-onset compli-
cations of facial soft tissue augmentation with permanent fillers in
85 patients. Dermatol Surg 2013;39:1474–1485.
5. Sidwell RU, McL Johnson N, Francis N, et al. Cutaneous sar-
coidal granulomas developing after Artecoll facial cosmetic filler
in a patient with newly diagnosed systemic sarcoidosis. Clin Exp
Dermatol 2006;31:208–211.
6. Marcoval J, Mañá J, Moreno A, et al. Foreign bodies in granulom-
atous cutaneous lesions of patients with systemic sarcoidosis. Arch
Dermatol 2001;137:427–430.