Periorbital Lipogranuloma after Autologous Fat Injection for Forehead Augmentation.

Dear Editor:

Autologous fat injection (AFI) for facial augmentation has become a popular cosmetic procedure at local plastic surgery clinics. It is considered safe, with no severe adverse reactions, compared with synthetic filler injection. However, we encountered a patient with a periorbital lipogranuloma, a rare side effect of AFI for forehead augmentation.

A 46-year-old woman presented with swelling on the left upper eyelid that was present for 3 weeks. She had received cosmetic AFI on her forehead at local plastic surgery clinics twice, 7 and 4 months previously. She stated that fat was harvested from her thighs during the first injection and stored frozen for the second injection. On physical examination, erythematous swelling with a palpable mass was noted on the left upper eyelid (Fig. 1A, B). Histopathologically, a foreign body reaction with lipid vacuoles, multinucleated giant cells, and fibrosis was observed in the subcutaneous layer (Fig. 1C). The patient was diagnosed with lipogranuloma following AFI for forehead augmentation and referred to the department of plastic surgery for surgical removal.

Fig. 1

(A, B) Erythematous swelling on the left upper eyelid. (C) Histopathologically, a foreign body reaction with lipid vacuoles, multinucleated giant cells, and fibrosis is observed at the subcutaneous layer (H&E, ×200).

Autologous fat is an easily accessible, renewable resource that can be harvested from multiple sites with little morbidity. When transferred to recipient site, autologous fat serves as a non-allergenic, well-tolerated, supple implant material1. Also, it does not have the potential risks of allogeneic fillers. Complications of AFI include visible lump, uneven contour, and hematoma. Rare, serious, and potentially fatal complications, such as skin necrosis, infection, central retinal artery occlusion, and cerebral infarction, have also been reported2. Granuloma formation is a well-known complication after synthetic filler injection, with 0.01%~0.1% incidence3. However, it occurs less frequently after AFI and is usually at the injection site. Lipogranuloma on the eyelid following AFI of the forehead has rarely been described.

AFI generally requires repeated injections because of the high rate of volume loss, which is up to 70% after fat transfer4. To avoid repeated harvesting, cryopreservation of harvested fat at -20℃ is widely performed3. During cryopreservation, ice crystals form inside the adipocytes, causing viability loss. Nonviable adipocytes may illicit a foreign body reaction and failure of engraftment23. In the case series of Sa et al.3, 7 of 9 patients developed lipogranuloma after the second injection using cryopreserved autologous fat.

The characteristic location of the lipogranulomas, the upper eyelid, is ascribed to the musculo-aponeurotic system. The galea is connected to the retro-orbicularis fascia to facilitate mobility of the frontalis muscle in the forehead. Therefore, fat injected into the forehead could move down to the upper eyelid along the galea. This could be exacerbated by gravity, massage, or facial muscle movement23.

Conservative treatments, such as cooling with ice, anti-inflammatory drugs, topical and intralesional steroids, diuretics, and antibiotics may have some therapeutic effects. However, in most cases, surgical excision is needed25.

To our knowledge, only 13 cases of periorbital lipogranuloma after AFI for forehead augmentation have been reported in ophthalmology and plastic surgery literature1235. None have been reported in the dermatologic literature. Dermatologists should know that, periorbital lipogranuloma can occur after AFI for forehead augmentation.