Nodules after male enhancement are small, firm lumps under the skin. They can be as small as a seed or as large as a marble. Nodules can occur after both HA and PMMA fillers, but they are more common with PMMA. It’s important to understand the different types of nodules, the various causes, and how nodules can be treated.
Noninflammatory nodules generally happen immediately after the procedure. In most cases, they last a few days to several weeks. At GMG we tell you that you will be a little lumpy or bumpy right after the procedure until the filler material has fully integrated with your tissue. Gentle massage and using the compression dressing provided will speed the resolution of the bumps. However, even without any intervention, they will generally resolve on their own.
Occasionally, these bumps or nodules can last longer than a few weeks. This happens when the body does not completely integrate the filler. This is more common with high G prime fillers, like Volux. In the case of HA fillers, like Voluma and Volux, they can be treated with hyaluronidase. This is an enzyme that can dissolve filler but, in very small quantities, can be used to treat a bump or nodule. With PMMA fillers, like Bellafill, early intervention is more complex.
Inflammatory nodules generally occur after the first few weeks or months following treatment and can even occur years later. There are different types of inflammatory nodules, each with its own cause and best treatment. However, the cause of these nodules is most often your own immune system and its reaction to the filler.
The most common type of inflammatory nodules are granuloma-type nodules. During an enhancement procedure, you are having a foreign substance placed in your body. In the case of PMMA fillers, this substance causes the production of collagen as a reaction to the filler. Here, the reaction is desired. But occasionally, 5–10% of the time, the reaction can be too active, and a granuloma is formed. Granulomas are an attempt by the immune system to wall off the foreign material. This can happen with any substance the body is unable to degrade or eliminate quickly.
This type of nodule is a result of a late immune response. It may be triggered by anything that “activates” the immune system. For example, an infection or a vaccine may trigger it. Delayed inflammatory nodules are characterized by tissue hardening, swelling, and painful lumps. These reactions can arise unexpectedly, days to months after the filler procedure. The increased incidence of such reactions during the COVID-19 pandemic (caused by both the vaccine and the infection) suggests that the immune system’s heightened response to a virus or infection may also be impacting areas treated with fillers.
Filler factors like particle size and shape play a role in determining the likelihood of an immune response. Fillers like HA are generally designed to be absorbed and metabolized by the body over time. This reduces the risk of a severe foreign-body reaction. HA is naturally found in the human body and is generally considered non-immunogenic. However, the manufacturing process and chemical cross-linking to increase its longevity and stability can alter its immunogenic potential. Variations in cross-linking techniques, HA chain lengths, and particle sizes influence the filler’s properties, like hydrophilicity (water absorption) and resistance to enzymatic degradation (how long it lasts), thereby affecting its interaction with the host’s immune system. Non-biodegradable fillers like PMMA, due to their very nature, can lead to more persistent and pronounced immune responses.
There is also likely a role of bacterial biofilms in the development of chronic nodules and granulomatous inflammation. Filler materials can serve as a nidus for bacterial colonization, leading to the formation of biofilms. These complex bacterial communities are enveloped in a protective matrix, rendering them highly resistant to antibiotics and immune clearance, making some nodules even more difficult to treat.
The treatment of filler-induced nodules depends on the underlying cause. Just as not all nodules are the same, the treatments are different too. For early nodules, often the best strategy is time. If waiting does not resolve the nodule, hyaluronidase injections to dissolve HA fillers and intralesional corticosteroids to target other nodules usually fix the problem.
For delayed nodules, it is very important that the physician knows what type of nodule is present. Granulomatous nodules are best treated with intralesional steroids, with possibly the addition of an anti-metabolic. Sometimes, mechanically breaking up the nodule can be highly effective. But when all else fails, surgical removal may be required. For delayed inflammatory nodules, initial treatment may include antibiotics or oral steroids to reduce inflammation. Recently, certain blood pressure medications have proven useful in treating this type of nodule.
