Removal of granuloma - Courtesy of D. Cassuto, MD


Filler injections to fill volumetric deficits and eliminate wrinkles are one of the most used aesthetic procedures in the world. The increased demand and growth of different types of fillers means that the complication rate associated with these injections is constantly increasing. Non-resorbable fillers remain for years in the tissues and can potentially cause inflammation problems at all times. Inflammatory complications after injection of non-resorbable fillers are often called granulomas. This term refers to inflammatory lesions that appear as nodular formations characterized by an abundant proliferation of macrophages, multinucleated giant cells, proteins, fibroblasts and angiogenesis. This definition is on a histological basis, in the absence of a histological diagnosis we prefer to speak of inflammatory nodules. These lesions appear as nodules structured in an orderly and characteristic manner depending on the pathogen that triggered its formation. The intuition of a treatment that was effective and at the same time minimally invasive is attributed to the late dr. Ovidio Marangoni who performed the first cases in Italy in 2006. Afterwards a medical team together with Eufoton® studied for years the positive effect of the laser used to try to solve these complications. Let's see the process and the effects.
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    Correcting filler granulomas with ILT lasers

    ILT - Interstitial Laser Treatment - is the first technique to effectively and permanently eliminate granulomas caused by permanent fillers. These granulomas come from swelling and hardening that can occur around the area where fillers were injected due to a rejection of the substances used, which may not integrate perfectly with the tissue. To date, granulomas have always been treated with local injections of corticosteroids, antitumor drugs or with surgery. The results, however, are never satisfactory: in most cases, there is only a temporary improvement with the risk of obvious scaring, atrophy and tissue depressions. The laser, on the other hand, evacuates most of the filler and definitively stops the inflammatory process without leaving any obvious traces.

    How does the ILT laser work?

    The laser light transmitted through an optical microfiber into the granuloma works on three levels.
    Firstly, it warms the area, melting the filler. Being heat sensitive, all permanent fillers pass from the solid state to the liquid state due to this thermal effect. The melted substance comes out of the microscopic hole used to insert the optical fiber.
    Secondly, the increase in temperature caused by the laser necrotizes the inflammatory tissue that always generates around the granuloma. A sterile pus therefore forms, which also emerges from the small holes. In some cases a very small incision may need to be made, especially when the granuloma is large, after about a month in order to completely eliminate the material.
    It is also hypothesized that the laser acts on the so-called biofilm, a still unproven phenomenon, but which is increasingly accepted by industry experts. According to many experts, when a granuloma is formed, some bacteria colonize the contact surface between the injected substances and the tissue, causing a protective inflammatory reaction, where the inflammatory molecules destroy the bacteria.
    In reality, this is not what happens: the bacteria creates a membrane that envelops and protects them: the inflammation process therefore does not shut off and it becomes chronic. This would explain why drugs only have temporary success: after their effect, the reaction starts up again. The presence of bacteria would explain the very high percentage of recurrence after treatments with cortisone and other immunosuppressive agents. For ablative surgery, there is another explanation for the poor efficacy: the surgeon spreads the biofilm bacteria around the area with the scalpel. The bacteria reactivates after a short period of time, thus worsening the inflammatory phenomenon. The increase in temperature created by the laser, on the other hand, kills the bacteria and cures the inflammation.

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