We read with interest the article,“Poly-methylmethacrylate Collagen Gel-Injectable Dermal Filler for Full Face Atrophic Acne Scar Correction” from December 2019. 1 The authors demonstrated the efficacy and safety of the most recent and third generation of polymethylmethacrylate filler, Bellafill (PMMA-B), in the treatment of atrophic acne scars. 1 Bellafill was originally FDA approved under the name Artefill and later renamed Bellafill in 2015. Currently, acne scarring and nasolabial folds encompass the 2 FDA-approved indications. Although Joseph and colleagues report only bruising and ecchymosis in the treatment of atrophic acne scars, granulomatous reactions to PMMA-B have been reported in the 5-year FDA-approved study for treatment of nasolabial folds with an incidence of 1.7%. 1, 2 Consequently, we feel it is imperative to exercise caution with off-label use of polymethylmethacrylate filler for facial contouring. In our practice, we have seen a number of patients develop disfiguring granulomatous reactions after off-label use of PMMA-B outside of our clinic. Herein, we describe 3 cases of off-label use of PMMA-B that resulted in inflammatory nodule formation, the treatment approach used, and the clinical course that followed.