Restylane persistent for 23 months found during Mohs micrographic surgery: a source of confusion with hyaluronic acid surrounding basal cell carcinoma

Dermatol Surg. 2005 Oct;31(10):1366-9. doi: 10.1111/j.1524-4725.2005.31223.


Background: Restylane (Q-Med, Uppsala, Sweden), a hyaluronic acid (HA) that is microbiologically produced and then cross-linked, is becoming popular as a dermal filler for improvement of facial lines and wrinkles. However, it is currently believed that the clinical and histologic persistence of this filler is from 6 to 9 months. We recently encountered Restylane in tissue where it had been implanted 23 months prior to removal of a basal cell carcinoma (BCC) on the lip, and its presence caused some confusion with HA that surrounds BCC nests.

Objective: To show and to contrast the histologic dermal appearance of Restylane and its metachromatic staining characteristics with toluidine blue from those of HA that surrounds BCC nests.

Method: Toluidine blue staining at pH 7.07 was performed on excised tissue containing Restylane and BCC on the upper lip.

Results: Restylane appeared as reddish-purple amorphous masses, whereas the HA that frames BCC nests appeared redder and more well defined.

Conclusion: The amorphous metachromatic reddish-purple color staining of Restylane with toluidine blue is due to its HA content. This staining pattern should be differentiated from the well-defined red color of HA that normally borders BCC nests. Restylane may persist in the dermis as long as 23 months after implantation.

Publication types

  • Case Reports

MeSH terms

  • Adjuvants, Immunologic / analysis
  • Carcinoma, Basal Cell* / chemistry
  • Carcinoma, Basal Cell* / pathology
  • Carcinoma, Basal Cell* / surgery
  • Coloring Agents
  • Cosmetic Techniques
  • Female
  • Frozen Sections
  • Humans
  • Hyaluronic Acid / administration & dosage
  • Hyaluronic Acid / analogs & derivatives*
  • Hyaluronic Acid / analysis
  • Lip
  • Middle Aged
  • Mohs Surgery*
  • Skin Neoplasms* / chemistry
  • Skin Neoplasms* / pathology
  • Skin Neoplasms* / surgery
  • Staining and Labeling
  • Tolonium Chloride


  • Adjuvants, Immunologic
  • Coloring Agents
  • Tolonium Chloride
  • Hyaluronic Acid
  • Restylane