Foreign Body Granulomas Caused by Polymethylmethacrylate Microspheres

A 61-year-old woman was referred to our clinic with livid, red, firm nodules, tender to pressure, along the horizontal and vertical wrinkles of her forehead (Figure 1A). The patient reported significant swelling and redness of her entire forehead and eyelids that had occurred “overnight” about 6 weeks previously and disappeared spontaneously within 2 days. After regression of the swelling, persistent confluent nodules became apparent. The patient had discontinued a yearlong regimen of -blockers without effect because her family physician suspected a drug-induced angioedema. A thorough examination of the patient’s history revealed injections of a polymethylmethacrylate (PMMA) and collagen mixture (hereinafter, Artecoll; Rofil Medical International, Breda, the Netherlands) into the forehead area 6 years prior for the correction of wrinkles, initially with 0.5 mL followed by 2.0 mL 4 weeks later. During the first 5 years after injection, the patient showed no symptoms (eg, hardening and pain) and no infections or autoimmune diseases. A biopsy was performed for histopathologic and electron microscopic examination. Since the differential diagnosis included sarcoid granulomas, radiography of the chest, ultrasound examination of the lymph nodes, and measurement of the angiotensin-converting enzyme level in the serum were performed without any abnormal findings. In addition, the results of patch tests with acrylates were negative, excluding delayed-type allergy to PMMA, which is a component of Artecoll in the form of microspheres.