Comments on an article by Ginat and Schatz.

We read with great interest the article by Ginat and Schatz entitled " Imaging Features of Midface Injectable Fillers and Associated Complications. " 1 The authors reviewed several midfacial foreign-body granulomas caused by injection with various medical fillers. They addressed an important area of investigation. Soft-tissue filler injections have become very popular. Foreign-body granuloma is one of the delayed complications of filler injection that is challenging to treat and consequently results in an embarrassing appearance. 2 Considering the popularity of noninvasive filling procedures, we totally agree with the Ginat and Schatz that radi-ologists should be familiar with the imaging features of commonly used medical injectables and avoid confounding these with true pathology. 1 Above all, accurate diagnosis based on clinical suspicion is most important for definite treatment. 3 In addition, due to cost-effectiveness, surgeons do not routinely perform imaging once a clinical diagnosis is obtained. Although an imaging study can help many clinicians to determine the injected materials, results of imaging do not affect the treatment approach whatever the materials are. We do not even perform pathologic studies in every case to identify the injected materials because they reveal only mild-to-moderate inflam-matory reactions without providing definite information regarding the materials, while incurring additional cost to the patients. 4 We would like to make several points: As a referral center for this entity in our country, we have treated Ͼ200 patients during 10 years (Fig 1). Although Ginat and Schatz showed several CT, MR imaging, and PET-CT examinations with patients injected with various fillers, we think radiologic findings can vary according to the patient's specific status—that is, radiologic findings according to various injected fillers that were presented by Ginat and Schatz cannot be applied in all cases. Thus, surgeons do not routinely perform radiologic examinations in all cases to determine the injected materials. Ginat and Schatz suggested scarring as one of the late complications after filler injections. Although scarring can be a complication of all surgical procedures, none of the authors of medical literature reported that scar formation can be one of the complications of filler injections. Rather, as we hypothesized in our previous study, filler injection causes soft-tissue expansion and " creeping effect, " leading to less scar formation. 2 Moreover, Ginat and Schatz argued that imaging can be helpful for delineating the extent of the excess material. However, plastic surgeons do not perform imaging studies to delineate the extent …