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Before (a) and after (b) intralesional Nd: YAG laser therapy of PMMA-induced nodule on the mandibular margin
Source publication
BACKGROUND: Dermal fillers are widely used for facial and body contouring. Polymethylmethacrylate (PMMA) is a permanent biphasic filler for soft tissue augmentation. In case of unwanted side effects, drug therapy and surgical excision have been commonly used with mixed results.
AIM: We report on a series of patients with adverse events to PMMA and...
Contexts in source publication
Context 1
... there is no relationship between the amount of removed material using laser and the clinical improvement as well. Many patients with very small PMMA volume injections in the face had an impressive clinical and aesthetic improvement after laser therapy (Figures 4, 5 and 6). Histological studies were performed in all subjects, focusing on the effects of the laser. ...
Context 2
... there is no relationship between the amount of removed material using laser and the clinical improvement as well. Many patients with very small PMMA volume injections in the face had an impressive clinical and aesthetic improvement after laser therapy (Figures 4, 5 and 6). Histological studies were performed in all subjects, focusing on the effects of the laser. ...
Citations
... The use of laser in the treatment of PMMArelated complications was used in our case series study in only 2 patients. Factors such as still scarce and recent publications, lack of knowledge about laser technology and its application in medicine still limited to a few medical specialties, availability generally restricted to large urban centers, combined with the high cost of equipment, are possibly related to this small number of patients undergoing the laser treatment [13][14][15][16][17] . ...
Introduction
Polymethylmethacrylate is a permanent filler product. Injecting this material into the face can lead to complications. The objective of this study is to determine in a series of cases the median time for complications to occur, the most affected areas, the types of complications, and the treatments most performed.
Method
209 cases of patients with complications related to the use of polymethyl methacrylate on the face who sought treatment between the period of January 2000 and June 2021 were studied. The data analyzed were gender, age, number of injections, moment of application, interval time until the complication arises, type of complication, affected region, and treatment performed.
Results
The average age of patients was 45 years (23 to 79 years). Of these, 172 were women and 37 men. The number of applications ranged from 1 to 5. The median time for complications to appear was 71 months. The most affected regions were the malar, in 102 patients; mandibular, in 100; and zygomatic, in 91. Granuloma was observed in 135 patients; edema, in 120; and inflammation, in 78. The most common treatment was corticosteroid injection, in 111 patients, followed by surgical removal, in 40.
Conclusion
The results can serve as a knowledge base for a better understanding of complications with the use of polymethylmethacrylate in the face.
Keywords:
Polymethyl methacrylate; Foreign-body reaction; Long term adverse effects; Dermal fillers; Granuloma, foreign-body
... This can be done by using wide bore cannula and squeezing [15]. Recently, Laser assisted treatment for facial filler removal was reported [16]. They used Intralesional 1064-nm Neodymium YAG, while De-Santis et al., [17] used the 808-nm diode Laser, but in both reports the injected filler was Polymethylmethacrylate which was not the case in our study. ...
... The procedure was well tolerated and 86.4% of the patients were satisfied. 25 In our subset of patients, many ultimately required surgical removal of the granuloma, particularly if there was a single nodule. For those with multiple nodules, more aggressive treatments were pursued, including intralesional 5-FU. ...
Introduction Lip augmentation with dermal filler is rising in popularity. There are generally minimal side effects that are mild and transient. However, long-term complications may occur and include lumps, bumps, nodules, or granulomas. To better understand this uncommon but challenging outcome, we aim to perform a thorough systematic review of the published literature related to nodule or granuloma formation after cosmetic soft tissue augmentation of the lips.
Methods A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in April 2021 and included PubMed, ScienceDirect, Embase, Google Scholar, and Cochrane databases. The Medical Subject Headings (MeSH) terms used included the following terms: “lip filler,” “hyaluronic acid,” “lip injection,” “lip augmentation,” “silicone,” “poly-L-lactic acid,” “calcium hydroxyapatite,” “polymethylmethacrylate,” “complications,” “reaction,” “granuloma,” and “nodule.” All studies were reviewed by two independent reviewers. Any discrepancies were resolved by a third reviewer.
Results The initial search for filler-related nodules or granulomas yielded 2,954 articles and 28 were included in the final analysis containing 66 individual cases of lip nodules. All but one patient was female. The mean age was 50 years. Nodules presented on average 35.2 months or 2.9 years after initial treatment. Thirty-seven nodules underwent histological analysis, the majority of which identified the presence of a foreign-body granuloma. Silicone was the most reported filler used followed by hyaluronic acid. Most cases resolved following multiple treatments including oral antibiotics or steroids followed by surgical excision.
Conclusion Understanding the sequelae of lip augmentation with filler products allows clinicians to provide safe and effective treatment. Nodules that present months to years following dermal treatment may represent a foreign-body granuloma. A combination of oral antibiotics, intralesional or oral steroids, and surgical excision successfully treated the majority of cases in our study.
... We employed a subdermal, intralesional 1,064 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser in combination with suction using a blunt liposuction cannula of 2.0-2.5 mm of diameter. The present authors obtained good results with the intralesional Nd:YAG laser either as a single treatment or in combination with surgery(Goldman & Wollina, 2018).2 | CASE REPORTSCase #1: A 55-year-old female patient(Figure 1). ...
The lips are essential part of the beauty and attractiveness of the human face. Lip augmentation has become an increasingly used method to improve appearance. Soft tissue fillers are the most commonly used tools. Permanent fillers, however, have been associated with unwanted side effects after lip augmentation. In the present paper we will focus on permanent fillers based on polymethylmethacrylate (PMMA). We provide a short review on PMMA fillers and known associated adverse events. We provide a critical review of treatment options. Illustrated by clinical cases we report our preferred treatment of PMMA nodules on lips by intralesional neodymium:YAG laser and blunt suction cannula with or without minor surgery.
This article is protected by copyright. All rights reserved.
... The emitted laser energy can cause fragmentation of PMMA by (1) charge-directed fragmentations, (2) charge-remote rearrangements, and (3) charge-remote fragmentations via radical intermediates. 44,45 An example of treatment is shown in Figure 2. ...
Dermal fillers are among the most versatile tools in esthetic medicine. A broad range of temporary, semipermanent, and permanent filler products is on the market. We performed a narrative review on spontaneous and induced degradation of dermal fillers in vitro and in vivo. Hyaluronic acid-based fillers are the most frequently used temporary fillers. The products differ in their hyaluronic acid content, cross-linking, and rheological parameters. Endogenous hyaluronidase and reactive oxygen species are responsible for the spontaneous degradation of these fillers. Hyaluronidase digests the filler material by cleavage of the β-1,4 glycosidic linkage between N-acetyl-glucosamine and d-glucuronic acid. The enzyme can be used for treatment of medical and cosmetic adverse events due to hyaluronic acid-based filler. Higher hyaluronidase content and higher degree of cross-linking are major factors contributing to filler persistence over time. Semipermanent fillers are poly-(d),l-lactic acid and calcium hydroxylapatite. These filler types are decomposed by hydrolysis and osteoclastic enzymes. They usually persist up to 2 years, in single patients even more than 5 years. Sodium thiosulfate can stimulate degradation of calcium hydroxylapatite, but it is slow acting and not effective in case of emergency. Permanent fillers may show some kind of modification in situ, but spontaneous or induced degradation has not been documented. Once implanted the permanent fillers remain lifelong. Intralesional laser treatment supports the removal of permanent filler material as an alternative to surgery. Besides biocompatibility and toxicity, filler materials should also be assessed for degradation to improve patient safety.
Although permanent fillers have been introduced in order to get long lasting results, many studies have shown numerous severe and disfiguring complications. Non-surgical procedures may mitigate those adverse events but the only way to remove the filler previously injected is represented by surgical excision. We present a pathway of facial surgical accesses to be performed achieving two goals: permanent filler removal and restore facial aesthetic balance. The proposed surgical accesses are already standardized in aesthetic surgical practice in order to avoid direct excision and unpleasant facial scar. 231 patients underwent surgery for permanent filler removal and aesthetic restoration of the involved facial area, represented by forehead, glabella, nose, cheeks, eyelids, chin, jawline and lips. Magnetic resonance evaluation was performed with the exception of lip patients evaluated with ultrasound. Postoperative follow-up was 12months to 6years. Subjective and objective methods were used to outcome evaluation according to FACE-Q questionnaire. Functional and aesthetic correction was scored using the patient-graded Global Aesthetic Improvement Scale(GAIS), overall patient satisfaction was assessed by a five-point scale questionnaire. Functional and aesthetic restoration was globally recognized as improved according to the Global Aesthetic Improvement Scale. Patients reported high levels of satisfaction assessed by a five-point scale questionnaire. A very good satisfaction level was registered in both subjective and objective judgment scores. To the best of our knowledge, we present the largest case series regarding surgical removal of permeant facial fillers. A proper pre-operative evaluation, filler removal followed by restorative facial aesthetic surgery technique is paramount to approach challenging cases.
Background:
As nonsurgical rejuvenation with fillers continues to grow in popularity, patients are increasingly interested in more durable results. Polymethylmethacrylate (PMMA)-collagen gel is unique among fillers in that the PMMA microspheres are not completely absorbed and phagocytosed by the body. This durability coupled with the biophysical properties of PMMA makes it a poor choice for periorbital rejuvenation, an unforgiving and highly complex anatomic area.
Methods:
Between 2011 and 2018, 14 patients with PMMA granulomas in various facial areas self-referred to the senior author's practice. Of these patients, 11 were managed nonsurgically; however, all 3 patients who presented with granulomas in the infraorbital area required surgery to remove the filler and restore a natural aesthetic.
Results:
The 3 patients with significant swelling and PMMA filler nodules in the infraorbital area with unacceptable cosmetic appearance were females between the ages of 50 and 55 years. Nonsurgical protocols were unsuccessful, and surgical removal was required. All subjects have been followed for a minimum of 2 years with no immediate- or long-term postoperative complications secondary to PMMA removal. Patients remain satisfied with the outcome of the surgery.
Conclusions:
Despite the evidence that the periorbital area is prone to adverse events when injected with particulate fillers, misguided enthusiasm for PMMA-collagen gel as a durable treatment continues to lead to unnecessary and severe complications in patients. The case studies presented here highlight that this product should not be introduced into the periorbital area. We also describe a surgical treatment approach for its removal if complications arise.
