Complex Surgical Management of PDLLA-Induced Lower Eyelid Granulomas

BACKGROUND: Poly-D, L-lactic acid (PDLLA) is a biostimulatory injectable increasingly used for infraorbital rejuvenation. Although considered safe when properly handled and injected, evidence of severe complications in the thin, anatomically complex lower eyelid region remains limited. CASE: A 67-year-old woman underwent 3 periorbital PDLLA injection sessions performed with a sharp needle. ∼1 month after the final treatment, she developed delayed-onset, multiple bilateral granulomatous nodules in the subcutaneous plane, the orbicularis oculi muscle, and the sub-orbicularis oculi fat. The lesions progressively worsened, causing functional and aesthetic impairment. MANAGEMENT: Conservative therapy-including intralesional saline, monopolar radiofrequency, and 2 corticosteroid sessions-proved ineffective and resulted in steroid-induced dermal and subcutaneous atrophy. Due to progressive clinical deterioration, surgical treatment was required. Extensive debridement of granulomatous tissue was performed through a transcutaneous lower-blepharoplasty approach, followed by reconstruction with an orbicularis oculi myocutaneous flap anchored to the inferior orbital rim. Despite initial stabilization, the patient developed bilateral ectropion and new granulomas, requiring a second surgical procedure with further granuloma excision and lateral tarsal strip tightening. Histopathology confirmed foreign-body giant-cell granulomatosis associated with PDLLA. CONCLUSIONS: Poly-D, L-lactic acid (PDLLA) injections may lead to severe, persistent granulomatous reactions when improper technique or product misuse is involved. Conservative measures often fail, and corticosteroids may induce significant atrophy in the thin periorbital skin. In selected cases, timely surgical excision represents the most definitive management for optimal outcomes. Careful patient selection, appropriate injection technique, and comprehensive informed consent are essential when using PDLLA in the infraorbital area. This case highlights the need for caution when using PDLLA in high-risk anatomic regions.