Delayed-Onset Nodules Secondary to a Smooth Cohesive 20 mg/mL Hyaluronic Acid Filler

The shift from 2- to 3-dimensional soft tissue augmentation has allowed the development of hyaluronic acid (HA) fillers, which are long lasting and also reversible. Delayed-onset inflammatory nodules have recently been reported with the use of HA fillers.The authors document their experience with delayed-onset nodules after 3-dimensional facial injection of Juvéderm Voluma (HA-V) over 68 months.The authors conducted a retrospective chart review of patients who were treated with HA-V between February 1, 2009, and September 30, 2014, to evaluate for delayed-onset nodules.Over 68 months, 4,702 treatments were performed using 11,460 mL of HA-V. Twenty-three patients (0.5%) experienced delayed-onset nodules. The median time from injection to reaction was 4 months, and median time to resolution was 6 weeks. Nine of the 23 (39%) had an identifiable immunologic trigger such as flu-like illness before the nodule onset. In the authors' experience, prednisone, intralesional corticosteroids, and hyaluronidase were effective treatments.Although delayed nodules are uncommon from HA-V (0.5%), it is important to be aware of this adverse effect and have a management protocol in place. It is the authors' opinion from the patients' responses and from the literature that these nodules are immune mediated in nature.