Case Scenario

"I've had these lumps for over a year now. Three rounds of steroid injections, two rounds of 5-FU — nothing worked. I just want my normal face back." When she sat down in the FILLER REVISION consultation room, the exhaustion in her voice told the whole story before the ultrasound did.

Patient Background: A middle-aged woman who received Ellansé (polycaprolactone) injections in the cheek area approximately two years prior to address cheek hollowing. Approximately 6 months post-injection, palpable lumps developed at the injection sites, gradually enlarging and becoming more visible over time. Treatment History:

Returned to the original clinic; told "this is normal collagen stimulation that will resolve on its own"

After 6 months of waiting with no resolution, sought additional medical attention

Received 3 sessions of local steroid injections — lumps slightly softened but did not noticeably reduce in size

Attempted 2 sessions of 5-FU injection with limited effect

Found information about ultrasound-guided micro-extraction through online research

Presentation at Consultation:

1-2 palpable lumps on each cheek

Slight skin elevation over the lumps, visible at certain angles

Firm to touch, non-tender

Approximately one year of conservative treatment with limited results

Deep Analysis

Root Cause Analysis

Aspect | Finding

-------- | ---------

Material characteristics | Ellansé consists of PCL microspheres suspended in CMC gel; PCL cannot be enzymatically dissolved Nodule etiology | Likely fibrous capsule reaction and excessive collagen stimulation around PCL microspheres Why conservative treatment failed | Steroids can soften fibrous tissue but cannot eliminate PCL microspheres; 5-FU has limited effect on PCL-induced collagen Ultrasound findings | Multiple medium-high echogenicity nodules in subcutaneous fat layer, irregular borders, surrounded by fibrotic bands Vascular assessment | Nodules located at safe distance from major vessels

Key Insight: Ellansé nodules are fundamentally different from hyaluronic acid nodules — they cannot be "dissolved." Conservative steroid or 5-FU treatment can only soften surrounding tissue but cannot eliminate the core PCL microspheres. When conservative treatment exceeds one year without significant improvement, physical extraction is a reasonable next step. At FILLER REVISION, ultrasound-guided micro-extraction is the standard protocol for persistent PCL nodules that have failed conservative management.

Related reading: Can Ellansé Be Removed?

Doctor's Perspective

Dr. Liu's analysis after evaluation:

"This patient's situation represents a typical case among Ellansé complications. Ultrasound clearly revealed multiple nodules, each approximately 8-15mm, wrapped in prominent fibrotic tissue. The positive finding was that the nodules were located in the subcutaneous fat layer at moderate depth, with no major vessels in close proximity — technically feasible for minimally invasive extraction.

Notably, because the nodules had been present for over a year and had undergone multiple steroid injections, the surrounding fibrosis was fairly dense. Greater care would be needed during extraction to separate the filler-tissue boundary. Our goal was to extract the PCL microspheres and their reactive tissue as completely as possible while preserving normal subcutaneous fat."

Treatment Plan and Process

Pre-Operative Planning

Planning Item | Content

-------------- | ---------

Ultrasound marking | Mark all nodule locations, sizes, and depths Vascular mapping | Confirm facial artery and vein pathways Entry point selection | Choose the nearest concealed micro-entry to each nodule Surgical sequence | Address shallower, easier nodules first, then deeper ones

Surgical Process

Local anesthesia: Precise local infiltration under ultrasound guidance

Micro-entry: 1-2mm pinhole as the operative entry

Ultrasound-guided targeting: Real-time imaging confirms instruments reach the target nodule

Dissection and extraction: Careful separation of nodule from surrounding fibrotic tissue, progressive removal

Real-time verification: Immediate ultrasound scan after each nodule extraction

Residual assessment: Comprehensive scan confirming no significant residual material

Extracted Material Observations

The extracted tissue consisted of firm white to grayish-white masses. Cross-section revealed PCL microsphere particles encased in fibrous tissue, consistent with pre-operative ultrasound findings.

FILLER REVISION Case Notes

Cases like this one illustrate why the FILLER REVISION protocol prioritizes ultrasound at every stage — before, during, and after extraction. The dense fibrosis from prolonged steroid treatment made this case more technically demanding than a typical Ellansé extraction. By maintaining real-time ultrasound visualization throughout the procedure, Dr. Liu was able to distinguish between fibrotic tissue and the PCL microsphere core, ensuring thorough removal while preserving healthy subcutaneous fat. This case reinforces a pattern we see frequently at FILLER REVISION: the longer patients wait after failed conservative treatment, the more complex the extraction becomes. Early referral for ultrasound-guided evaluation can significantly reduce procedural difficulty and improve outcomes.

Key Patient Notes

Post-Operative Recovery

Timeline | Expected Condition

---------- | --------------------

Immediately post-op | Mild swelling and bruising at surgical sites Days 1-3 | Peak swelling period, gradually begins to subside Week 1 | Most swelling resolved, bruising begins to fade Week 2 | Noticeable appearance improvement, lumps gone Month 1 | Tissue continues to soften and recover Month 3 | Final results gradually stabilize

Important Notes

Post-operative swelling is normal and does not indicate surgical failure

Bruising may persist 1-2 weeks and can be concealed with makeup

Temporary tactile changes at the surgical site typically resolve within weeks

Post-extraction depressions are usually assessed after swelling subsides to determine if further treatment is needed

Complete recovery requires 2-3 months

Key Insight: Ellansé nodule extraction differs from simple HA dissolution — it requires physical manipulation, so the recovery period is longer. However, compared to continuing to live with nodules or pursuing conservative treatments with limited effect, micro-extraction offers a more definitive resolution.

Clinical Takeaways from This Case

Ellansé nodules require timely and accurate assessment — prolonged conservative treatment may worsen fibrosis

Ultrasound is essential for evaluation and extraction — palpation cannot accurately determine nodule count, size, or depth

Micro-extraction is a viable option — large open excisions are not necessary

Patient expectation management is critical — recovery takes time, and final results are not immediate

If you are dealing with Ellansé nodules or other non-dissolvable filler complications, the FILLER REVISION team specializes in ultrasound-guided micro-extraction for cases that have not responded to conservative treatment. Every case begins with a thorough ultrasound evaluation to map the full extent of the problem before any intervention is planned.

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Related reading: Filler Lump Extraction Technique