Collagen-based injectables are widely used for soft tissue augmentation in aesthetic and reconstructive procedures, particularly for facial and hand rejuvenation. Artecoll (Rofil Medical International), a second-generation filler, consists of bovine collagen combined with polymethyl methacrylate (PMMA) microspheres. This formulation provides a long-lasting filling effect by stimulating fibroblast-mediated collagen production around the PMMA microspheres. However, complications associated with collagen fillers have been reported, including early reactions such as erythema and edema, as well as delayed reactions such as granuloma formation, foreign body reaction, and infection. Granulomas can significantly impair tissue integrity and hand function, necessitating prompt and effective management. Here, we present a case of bilateral hand complications following Artecoll injections, managed with surgical excision and reconstruction using MatriDerm (MedSkin Solutions Dr. Suwelack AG) dermal substitute grafts and split-thickness skin grafts, resulting in satisfactory long-term functional and cosmetic outcomes.

A 53-year-old female patient presented with complications 1 month after receiving Artecoll filler injections in both dorsal hands for rejuvenation purposes. The patient had been treated for early symptoms, including warmth and swelling, at another clinic for 1 month. Despite receiving antibiotics and anti-inflammatory analgesics during this period, she developed an ulcer and was subsequently referred to our clinic. No specific inciting events were identified before referral. The left dorsal hand exhibited redness, skin necrosis, and ulceration, while the right dorsal hand developed painful nodules (Fig. 1). The patient’s medical history included hypertension, diabetes mellitus, hyperlipidemia, and paroxysmal tachycardia.

Clinical examination revealed granuloma formation on both dorsal hands. The differential diagnosis included infection versus foreign body reaction. Given the severity of the tissue damage, surgical intervention was planned. Intraoperatively, the paratenon appeared fresh and clean, without signs of infection. The granulomas were excised, and reconstruction was performed using MatriDerm grafts of 90 cm² for the right hand and 50 cm² for the left hand, secured with surgical staplers. Split-thickness skin grafts (0.012-inch thickness, unmeshed) harvested from the right lateral thigh were applied to the right hand (100 cm²) and the left hand (60 cm²) and dressed with Bactigras (Smith & Nephew) (Fig. 2).

The skin graft was evaluated 1 week postoperatively and was well-taken, with no signs of graft loss, hematoma, or seroma. At a 3-month follow-up, hyperpigmentation was observed, but the range of motion (ROM) was not limited. To prevent hypertrophic scarring during the remodeling phase, the patient wore a pressure garment glove for 1 year. At the 3.5-year follow-up (Fig. 1), there was no evidence of scar contracture or hypertrophic scarring, and the patient maintained a full ROM without limitations. Functional outcomes were assessed by measuring the ROM and the Vancouver Scar Scale (VSS) score. ROM was determined by evaluating the patient’s ability to fully extend and flex the fingers without restriction. The VSS score was calculated as 3 points—1 point for mild pigmentation changes, 0 points for vascularity (normal appearance), 1 point for pliability (supple), and 1 point for height ( ≤2 mm thick scar tissue). Additionally, the patient expressed high satisfaction with both functional recovery and cosmetic appearance (Fig. 3).

Artecoll is a second-generation dermal filler composed of bovine collagen and PMMA microspheres. The PMMA microspheres serve as a permanent scaffold for fibroblast-mediated collagen production, resulting in long-lasting volume augmentation. However, complications associated with Artecoll primarily arise from foreign body reactions to the non-biodegradable PMMA microspheres, leading to chronic inflammation, granuloma formation, and, in some cases, late-onset infections due to biofilm formation. These complications are most commonly reported in facial applications, particularly in the lips, nasolabial folds, and periorbital regions. Nonetheless, complications following Artecoll injection in the dorsal hand are rarely reported in the literature, making this case both unique and clinically significant [1].

Complications after Artecoll injections can be classified as early or late, depending on the time of onset. This case emphasizes several key considerations in managing Artecoll-related complications. Proper differentiation between infection and foreign body reaction was critical for appropriate surgical management. The intraoperative finding of a clean paratenon without purulence strongly indicated that the ulcers resulted from granulomatous changes rather than infection. Meticulous surgical debridement and complete removal of the foreign body material resulted in the absence of postoperative foreign body reactions or recurrence [2-4].

Early complications of Artecoll fillers include erythema, edema, pain or tenderness at the injection site, bruising, discoloration, and, in rare instances, infection or skin necrosis. These reactions are typically non-immunological and resolve with conservative management, such as cold compresses, analgesics, or antibiotics if an infection is suspected. Skin necrosis is a severe but uncommon complication that occurs when inadvertent vascular occlusion leads to tissue ischemia and damage.

Later complications of Artecoll injections often result from immunological or foreign body responses to PMMA microspheres. The most frequently reported late complication is granuloma formation, estimated to occur in approximately 0.01% of cases. These granulomas present as persistent nodules caused by a chronic inflammatory response to the non-biodegradable microspheres. Foreign body reactions can also lead to tissue ulceration when the immune response remains unresolved. Additionally, delayed infections, although rare, can arise due to biofilm formation around the filler material, making these infections challenging to treat. Skin discoloration, including prolonged hyperpigmentation, is another potential complication at injection sites [2-4].

Reconstruction of hand defects requires a strategic approach tailored to the size and location of the defect. Small defects can often be managed with primary closure or skin grafting, while medium defects may necessitate local flaps. For large defects involving multiple metacarpal surfaces, free flaps such as the anterolateral thigh or radial forearm flaps provide ample tissue coverage with minimal donor site morbidity. When tendons are exposed, skin grafting alone can lead to adhesions that impair tendon gliding, thereby necessitating flap surgery. For dorsal hand defects, maintaining mobility and function is critical. Thin and pliable flaps are preferred to allow free movement of the underlying tendons and joints without causing adhesions or restricting motion. The flap choice should also consider aesthetic outcomes, as the hands are highly visible. The use of perforator-based flaps, such as the dorsal metacarpal artery perforator flap or posterior interosseous artery flap, offers a good balance between function and appearance [5,6].

In this case, the patient had only a small defect of the paratenon, which allowed for successful reconstruction using dermal substitutes and skin grafts without the need for flap surgery. Since the filler injection was administered just beneath the dermis, it was anticipated that the paratenon would remain unaffected. Intraoperatively, after complete debridement of necrotic tissue, this assumption was confirmed by the intact and clean paratenon with no signs of infection. Given the absence of purulent discharge or active infection, a one-stage reconstruction was deemed appropriate. A MatriDerm-reinforced split-thickness skin graft was selected to provide adequate coverage while preserving tendon mobility and minimizing the risk of adhesions [4].

The reconstruction method using MatriDerm proved highly effective. The MatriDerm grafts provided several advantages by creating an optimal foundation for split-thickness skin graft take through improved wound bed quality, contributing to better cosmetic outcomes by ensuring adequate thickness and promoting neovascularization, and, most importantly, allowing unrestricted tendon gliding, which resulted in complete preservation of hand function. The use of dermal substitutes is indicated in cases where flap failure is anticipated or has occurred. However, their application should be carefully considered in patients requiring additional corrective surgeries, as areas treated with dermal substitutes may be at risk of necrosis following subsequent interventions. Therefore, careful planning is necessary to ensure that the reconstructed area does not require further revisions that could compromise the grafted tissue’s integrity [7,8].

MatriDerm offers the advantage of a one-step procedure, enabling immediate split-thickness skin grafting at the time of application. By facilitating faster restoration of the dermal layer, Matri-Derm contributes to a more efficient healing process while maintaining satisfactory functional and cosmetic outcomes [7,9].

The patient’s achievement of a full ROM without scar-related limitations demonstrates the success of this surgical approach. Follow-up at 3 months and at 3.5 years revealed excellent cosmetic and functional outcomes with no recurrence of granulomas, validating the long-term success of this management strategy.

As this is a single case report, its limitations must be acknowledged, particularly regarding its applicability only to cases where the paratenon remains intact and no signs of infection are present. The findings should be interpreted with caution, and further studies with larger patient cohorts are needed to validate the effectiveness of MatriDerm in similar cases. The frequency of Artecoll-related complications specifically occurring on the dorsal hand has not been well documented in the literature.

In conclusion, this case underscores the importance of comprehensive excision and the appropriate choice of grafting materials, which together contribute to excellent long-term cosmetic and functional outcomes.