What do permanent and semi-permanent fillers mean?
Fillers are grouped according to how long the body takes to remove them. Hyaluronic acid fillers are broken down by the body over time and, if necessary, can be dissolved with the enzyme hyaluronidase. In this article, the expression permanent filler does not mean that a result will last for life; it is simply the name of a product group, indicating that the product contains a substance that does not dissolve in the body.
- Liquid silicone: an oily substance that does not dissolve in the body. It can spread through fat tissue and along blood vessels.
- Fillers with PMMA (polymethyl methacrylate) microspheres: contain tiny plastic beads; the beads remain in the body.
- Polyacrylamide gel: a gel with a high water content that does not dissolve in the body. It was widely used in some countries and later called into question because of its late complications.
- So-called semi-permanent fillers: this expression is also commonly used for fillers that stay longer than hyaluronic acid and are intended to stimulate collagen production, containing calcium hydroxylapatite or poly-L-lactic acid. These products are broken down by the body over time; however, they cannot be dissolved with the enzyme and can form nodules.
For general complications of hyaluronic acid fillers, see our articles “Filler Complications” and “Hyaluronic Acid Filler”. This article focuses on problems specific to fillers that do not dissolve or that stay for a long time.
Why does permanent filler cause problems years later?
The body perceives a substance that does not dissolve as a foreign body and wraps it in a kind of capsule. In most people this process remains silent. In some people, however, the immune system mounts an excessive inflammatory response to this substance. Because the product remains in the body, the risk also lasts for years: a problem can appear months or even years after the treatment.
As a result, people have often forgotten that they had filler, or may never have known the name of the product. When an unexplained swelling appears on the face, past treatments may not come to mind.
What is a granuloma? What are the signs?
A foreign body granuloma is a build-up of inflammatory tissue that the body forms in response to the filler substance. Scientific sources report that a granuloma usually appears after a silent period lasting months and often shows up at all the points where the filler was injected at the same time. In this respect it differs from firm areas caused by the product collecting, which are noticed in the first weeks after the treatment.
- Firm swellings that can be felt in the treated areas and may gradually grow
- Redness or a purplish discolouration in the area
- Tenderness to the touch, sometimes tightness and pain
- Sometimes a flare-up after an infection, a flu-like illness or dental treatment
With silicone, granulomas and other late problems can appear years after the treatment; experts note that these problems have little tendency to resolve on their own and may not go away completely despite treatment.
Why is it so important to know which type of filler you had before?
When a new swelling or firm area appears on the face, one of the physician’s first questions is which area was treated before, when and with which type of filler. This information helps to understand whether the problem is due to hyaluronic acid filler or to a product that does not dissolve, and it directly changes the treatment options. For example, dissolving with the enzyme is an option for hyaluronic acid filler, but not for silicone.
Many people do not know the product name of a treatment they had years ago; sometimes it may have been done in another country or outside a healthcare facility. There is no need to feel embarrassed or to hide it: even if you do not know the product name, telling the physician the date of the treatment, the area, how long the effect lasted and what you were told at the time is very valuable for a correct assessment. If needed, the physician can look for additional clues about the type of product with imaging such as ultrasound.
Can permanent filler move out of place?
Yes, this is a known problem. Liquid silicone in particular can spread easily between tissue layers and in fat tissue. The U.S. Food and Drug Administration (FDA) stresses that silicone can move around in the body, that this can make side effects worse and that it can make surgical removal difficult or impossible. This is why it is not surprising when filler in the lips, around the eyes or in the cheeks causes swelling in a neighbouring area years later.
Silicone injections into the buttocks or breasts for body contouring carry a much greater risk: silicone can pass into the blood vessels and block vessels in the lungs, heart or brain. The FDA has warned that such procedures can be fatal.
Infection and biofilm with permanent filler
A filler that does not dissolve provides a surface to which bacteria can attach. Bacteria can live there in a thin, protected layer called a biofilm. In a study of patients with late problems related to polyacrylamide gel, bacteria normally found on the skin were detected in the great majority of the samples taken; these bacteria were found even years after the treatment.
A biofilm can cause recurrent swelling, redness and discharge; it can be difficult to detect with ordinary tests and may not respond to short courses of medication. For the general signs of infection, see our article “Infection after Aesthetic Treatments”.
Problems with fillers that do not dissolve in the body can appear even years later and are harder to treat. If you know what type of filler you have had before, be sure to tell your physician before any new procedure.
Dr. Hamza GemiciMedical Director, DoktorClub · Aesthetic Medicine Physician
Why does the filler-dissolving enzyme not dissolve permanent filler?
Hyaluronidase is an enzyme that breaks down only hyaluronic acid. Silicone, PMMA, polyacrylamide, calcium hydroxylapatite and poly-L-lactic acid have a different chemical structure; the enzyme has no effect on them. This is why the option of simply dissolving the filler does not exist with these products.
One exception is worth noting: sometimes different products may have been injected into the same area over the years. In such a mixed picture, the physician may consider dissolving the hyaluronic acid portion, if present; however, the part that does not dissolve remains in place.
What are the treatment options? What can your physician do?
Treatment is planned individually according to the type of problem, the kind of product, the area and how long the symptoms have lasted. The physician first takes a detailed history and examines you; imaging such as ultrasound, and sometimes a tissue sample (biopsy) or a culture, may be requested. They may then consider one or more of the following approaches:
- Monitoring: close follow-up for small, stable firm areas that do not cause discomfort.
- Injection of medicine into the area: medicines aimed at suppressing the inflammation in a granuloma; these treatments require dose adjustment and follow-up and can have side effects such as thinning of the skin.
- Oral medication: treatments chosen and monitored by the physician when an infection or biofilm is suspected.
- Drainage: for collections that contain fluid or are inflamed.
- Laser-assisted methods: used in some centres to remove part of the product from the area; the evidence is limited.
- Surgical removal: often considered as the last option, because a granuloma can extend like fingers into the surrounding tissue. Removal may not always be complete; it has its own risks, such as scarring, disfigurement and nerve damage.
Managing these problems requires experience and sometimes calls for specialists in dermatology, plastic surgery, ophthalmology or infectious diseases to work together. Be cautious about approaches that promise a quick and definitive solution.
Normal, see your physician, or an emergency?
| You can keep an eye on it | Consult your physician | Emergency |
|---|---|---|
| A small, stable firm area that is not painful that has not changed for years (still, have it examined once) | Firm areas that are new, growing or increasing in number | Problems with vision or speech, loss of strength: 112 (or your local emergency number) |
| Mild tightness that comes and goes in a known filler area | Recurrent swelling, redness, a purplish colour | Shortness of breath, chest pain (especially if silicone was injected into the body): 112 |
| If you have no symptoms, simply tell the physician about your old filler before any new procedure | Filler moving into a neighbouring area, a change in facial shape | High fever, rapidly spreading redness, severe pain: emergency department without delay |
Call 112 without delay
- Shortness of breath or chest pain
- Loss of vision, blurred or double vision
- Speech problems, facial drooping, weakness in an arm or leg
- Rapidly increasing swelling of the face, lips or tongue
Contact your physician immediately
- Increasing redness, warmth and pain in the filler area together with fever
- Discharge from the skin or the skin breaking open
- A firm swelling that grows noticeably within a short time
For a sudden change of colour and pain developing after a recent filler, the warnings in our article “After Fillers: When Is It an Emergency?” apply.
What can you do at home, and what should you avoid?
- Record the change with the date and a photo; note its size and any change in colour.
- Try to remember which area was treated in the past, on what date and with which product; if you have any documents, take them with you.
- Tell the physician about any fever, toothache or recent infection.
Do not do the following:
- Do not massage, squeeze or prick a firm area with a needle.
- Do not apply heat without consulting your physician.
- Do not use antibiotics, steroid medicines or creams on your own.
- Do not have new filler injected into the same area to cover up the problem.
- Do not buy so-called filler dissolvers or similar products online.
To reduce the risk
- Before the procedure, ask for the name and type of the product to be used and whether it dissolves in the body; ask for the information in writing.
- Mention all the fillers you have had before, even if you do not know the product name, before every new procedure.
- Do not accept liquid silicone or similar injections for body contouring, especially in the buttocks and breasts.
- Stay away from injections in places that are not healthcare facilities, such as homes, hotels or beauty salons; for details, see our article “Counterfeit Products and Unlicensed Treatments”.
- If you have old filler in your face and are considering a new procedure, your physician may want to assess the area first.
- If you experience a problem, stay calm and proceed step by step: our article “What Should You Do If a Complication Occurs after an Aesthetic Treatment?” will guide you.
Where is scientific knowledge limited?
How often late problems related to permanent fillers occur is not known for certain; the data are mostly based on case series and expert experience. There are few robust studies comparing treatment options with one another. For this reason, your physician’s recommendations will be individual and may change over time.
Questions to ask your physician
- What type of filler might I have had before, and how can we find out?
- Could this firm area be a granuloma, product build-up or an infection?
- Is an ultrasound or another test needed?
- Would hyaluronidase work in my case or not?
- Which treatments do you recommend, and what are the possible side effects of each?
- If surgical removal is needed, can all of the filler be removed, and will there be a scar?
- Can things like dental treatment, vaccination or an infection make my complaint flare up?
- Would it be appropriate for me to have a new procedure in this area in the future?
Frequently asked questions
How long after treatment can permanent filler cause problems?
Problems such as granulomas, infection or migration related to fillers that do not dissolve can appear months or even years later. As long as the product remains in the body, the risk does not disappear completely. If you notice a new swelling, also tell your physician about your old fillers.
Can silicone filler be dissolved?
No. The enzyme hyaluronidase used to dissolve filler only dissolves hyaluronic acid; it has no effect on silicone. For problems related to silicone, medication and sometimes surgery are considered, but complete removal of silicone is not always possible.
Is silicone injection into the face legal and safe?
In the USA, the FDA clearly states that injectable liquid silicone is not approved for any aesthetic use, including facial or body contouring. Silicone can move out of place and cause vascular occlusion and disfigurement that is difficult to reverse. For the regulations in Turkey, consult the physician who will perform the treatment and official sources.
Does a granuloma go away on its own?
Some mild reactions may decrease over time; however, most granulomas related to permanent fillers require treatment and have little tendency to resolve on their own. Early assessment can make treatment easier. Do not try to break it up with massage or heat.
Do semi-permanent fillers carry the same risks?
Fillers that stay longer, such as calcium hydroxylapatite or poly-L-lactic acid, are broken down by the body over time, which makes them different from fillers that do not dissolve. Even so, they can form nodules and cannot be dissolved with hyaluronidase. Their risks vary depending on the product and the injection technique; talk to your physician.
I do not know which filler I had; what should I do?
You can ask the centre or physician who performed the treatment for the records. If you cannot reach them, information such as the date of the treatment, the area and how long the effect lasted at the time will also guide the physician. If needed, imaging such as ultrasound can give clues about the type of product.
Can new filler be injected over old permanent filler?
This decision requires an examination. New procedures in an area where old product is present are thought to be able to trigger problems or complicate the picture. Your physician may want to assess the area first.
Sources
- Dermal Fillers (Soft Tissue Fillers) — U.S. Food and Drug Administration (FDA)
- FDA warns about illegal use of injectable silicone for body contouring and associated health risks (press announcement, 13 November 2017) — U.S. Food and Drug Administration (FDA), 2017
- Dermal Filler Do's and Don'ts for Wrinkles, Lips and More — U.S. Food and Drug Administration (FDA), 2023
- Foreign body granulomas after all injectable dermal fillers: part 2. Treatment options (Lemperle G, Gauthier-Hazan N). Plast Reconstr Surg 123(6):1864–1873 — Plastic and Reconstructive Surgery, 2009
- Management of complications of injectable silicone (Hexsel D, de Morais MR). Facial Plast Surg 30(6):623–627 — Facial Plastic Surgery, 2014
- Bacterial infection as a likely cause of adverse reactions to polyacrylamide hydrogel fillers in cosmetic surgery (Christensen L et al.). Clin Infect Dis 56(10):1438–1444 — Clinical Infectious Diseases, 2013
Medical Aesthetics Expert Board
This article has been reviewed by the DoktorClub Medical Aesthetics Expert Board.
