Management of a Visible Nodule Following Poly-L-Lactic Acid Injection in the Periorbital Area

Poly-L-lactic acid (PLLA) is a synthetic injectable medical agent used to treat patients with loss of volume in the face, chest, and hands. It consists of a biodegradable and bioresorbable powder, a synthetic nonpermanent polymer. PLLA was introduced in Europe in 1999 (NewFill; Ashford Aesthetics Inc., Brussels, Belgium) under the category of wrinkle filler [1]. The Food and Drug Administration (FDA) approved it for United States use in 2004 (Sculptra; Dermik Laboratories, Berwyn, PA, USA) for correction of facial fat loss secondary to lipoatrophy in human immunodeficiency virus (HIV) positive patients and in 2009 as a cosmetic volumizer for soft tissue enhancement in the non-HIV-positive population. PLLA is very effective at increasing tissue volume and it has been found to provide clinical benefits lasting up to 2 years [2]. Although it has been further suggested to have a low likelihood of adverse events [1], one of the most common side effects associated with PLLA is the occurrence of subcutaneous nodules [3]. Nodule formation may be cosmetically disfiguring and frequently leads to a therapeutic challenge. Here we present a case of a visible nodule on the infraorbital region resulting from foreign body granulomatous reaction to the injection of PLLA and its subsequent surgical management with a subciliary approach. We also discuss relevant injection techniques for minimizing the risk of subcutaneous nodule formation and treatment options for this complication.