“Are you a doctor?”
“No, I run a medical aesthetics company.”
“Like Botox and fillers?”
“Yep.”
The next hour of the flight the woman next to me poured out her harrowing experience. Fourteen years ago she got filler for under-eye hollows. It was perfect until recently.
Gradually her under eyes became increasingly puffy and firm to the touch. She dismissed it as allergies until she was embarrassed to go in public. That’s when she contacted the original injector.
That was three months ago. Since then she had two rounds of corrective injections. First round was hyaluronidase. No response. Second, triamcinolone, worked for two weeks, then her whole face swelled so much it hurt and she could hardly see.
“You look great now. I guess it resolved?”
“Only because I’m on a lot of steroids. The minute I stop, I puff up like an angry balloon.”
She reported it to the manufacturer.
They told her they’d never heard of it happening.
0
Times the word “granuloma” appears on Juvéderm’s warning label.
If it’s not on the label, is it a disclosed risk?
(AbbVie’s own PMA data: 11% nodule rate in Juvéderm Ultra subjects, 19-22% in Ultra Plus. Label lists “nodule” inside a 30-item box. Glossary defines twenty terms and skips this one.)
The industry’s first-order victory was the massive success and scale from marketing HA as temporary, a natural, reversible sugar gel. The second-order chaos is our current clinical reality: millions of syringes in the wild, and immune systems that haven’t forgotten.
Reactions aren’t always immediate. As Almadan’s group documented, an HA injection can sit quietly for 10 years before the immune system decides it’s time to attack. Through imaging, surgery, and pathology they confirmed: foreign body granuloma, multinucleated giant cells around cystic spaces filled with frothy HA residue.
Safran’s 2025 study dissolved a range of fillers with hyaluronidase and found enormous variance. Restylane Lyft surrendered first, dissolving in forty minutes. Resilient, highly cross-linked HAs like Volux and RHA4 required 300 units and 90 minutes to break down.
More crosslinking, more hyaluronidase, more time to fix.
Peros and Haneke documented 23 women with delayed, rubbery ridges pulling their mouths into a “joker smile.” Hyaluronidase did nothing. Why? The HA triggered a fibrotic reaction. The bulge was collagen, not filler. Intralesional triamcinolone cleared it in six weeks.
Just because HA was injected doesn’t mean hyaluronidase will fix it.
When complications arise, we’re often flying blind. Modarressi’s retrospective found 65% of the time patients didn’t know what was injected, injectors didn’t record it, leaving clinicians to biopsy faces to find out what’s in them.
Funt’s algorithm is a frequently cited protocol for treating delayed-onset nodules. Although he wasn’t paid for the study, he’s a fixture on the bankroll of Galderma, Merz, Revance, and Allergan. There’s nothing wrong with that, but it does provide context. His sub-1% rate for Vycross delayed nodules is tidy, reassuring, and built on what got reported.
We covered that reporting collapse in Issue 5, The Industry’s <0.1% Problem: fewer than one in a thousand BoNT-A complications were reported to the FDA while a meta-analysis tallies the real complication rate at 16%. Filler complications are reported through the same voluntary system. With a lackluster reporting system, no one can say how rare DONs are, only that they’re rarely reported.
The Garcia v. AbbVie lawsuit alleges the manufacturer intentionally kept the word “granuloma” off the patient label.
Is this the beginning of our reckoning?
Sources: Granulomas and Nongranulomatous Nodules After Filler Injection: Different Complications Require Different Treatments (Modarressi A, Nizet C, Lombardi T, J Plast Reconstr Aesthet Surg. 2020 Nov); Comparison of the Degradability of Hyaluronic Acid by Ovine and Recombinant Human Hyaluronidase (Safran et al., Aesthet Surg J. 2025 Sep); Fibrotic Reaction to Hyaluronic Acid Fillers in the Face (Peros I, Haneke E, J Cosmet Dermatol. 2024); Exuberant Delayed Granulomatous Reaction to Hyaluronic Acid Filler Material (Almadan et al., J Surg Case Rep. 2025 Jun); Treatment of Delayed-Onset Inflammatory Reactions to Hyaluronic Acid Filler: An Algorithmic Approach (Funt DK, Plast Reconstr Surg Glob Open. 2022 Jun); Garcia v. AbbVie complaint (N.D. Ill. Case 1:26-cv-07542, June 2026).
“An unreported complication is still a complication.”
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