Polymethylmethacrylate Microsphere Injections in the Face

Abstract

Microspheres of polymethylmethacrylate (PMMA) have been injected beneath wrinkles and for facial volume augmentation since 1990 in more than 500,000 patients worldwide. They remain in the body permanently and are as safe as hyaluronic acid injections if injected strictly subdermally and epiperiosteally. Most serious complications occur after intra-arterial injections, and most nodules form after intramuscular injections. Foreign body granulomas are rare but can occur years after injection of PMMA subsequently to a systemic bacterial infection.

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Chapter Title Polymethylmethacrylate Microsphere Injections intheFace
Copyright Year 2019
Copyright Holder Springer Nature Switzerland AG
Corresponding Author Family Name Lemperle
Particle
Given Name Gottfried
Sufx
Division Division of Plastic Surgery
Organization/University University of California, San Diego
Address La Jolla, CA, USA
Abstract Microspheres of polymethylmethacrylate (PMMA) have been injected beneath
wrinkles and for facial volume augmentation since 1990in more than 500,000
patients worldwide. They remain in the body permanently and are as safe as
hyaluronic acid injections if injected strictly subdermally and epiperiosteally.
Most serious complications occur after intra-arterial injections, and most
nodules form after intramuscular injections. Foreign body granulomas are
rare but can occur years after injection of PMMA subsequently to a systemic
bacterial infection.
Keywords (separated
by “ - ”)
PMMA - Polymethylmethacrylate - Microspheres - Wrinkle ller - Dermal
ller

© Springer Nature Switzerland AG 2019
A. D. Costa (ed.), Minimally Invasive Aesthetic Procedures,
https://doi.org/10.1007/978-3-319-78265-2_81
81.1 Introduction
Polymethylmethacrylate (PMMA) microsphere injections
were developed in Frankfurt, Germany, in 1985 and have
been in the market in Europe since 1990 (Arteplast®,
Artecoll®), in Brazil since 1996 (Metacrill®, Bioplastia®,
Linnea safe®, Biosimetric®), in China since 2002 (Artecoll®),
and in the United States since 2006 (Artefill®, Bellafill®,
Permafill™) [1]. The risk of late-onset foreign body granulo-
mas inhibited their use during the first decades; however,
meticulous cleaning of the microspheres since 2006 and the
promotion of deep epiperiosteal injection of PMMA have
reduced this risk significantly [2]. As of today, approximately
500,000 patients have been injected with this permanent der-
mal filler worldwide [3–5].
Chapter 81
Polymethylmethacrylate
Microsphere Injections
intheFace
GottfriedLemperle
G. Lemperle (*)
Division of Plastic Surgery, University of California, San Diego,
La Jolla, CA, USA
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81.2 Materials
Artecoll, Bellall, and Permall
• PMMA microspheres, 40-μm in diameter (20% by vol-
ume), are suspended in a combination of bovine collagen
solution (3.5%) and lidocaine (0.3%).
• The key to Artecoll’s biocompatibility and safety is the
uniform, round, and smooth PMMA microsphere
(Fig.81.1a) and the reduction of all particles to less than
20μm in diameter.
• No allergy testing is required since Artecoll’s collagen
molecules are free of all telopeptide (atelocollagen)
allergens.
Carboxymethyl Cellulose
• It is the carrier for 2, 10, and 30% PMMA in Linnea Safe
and other Brazilian products. To date (2018), the micro-
spheres of other Brazilian PMMA fillers have not shown
to be cleaned from particles less than 20μm.
• Atelocollagen or cellulose carriers are absorbed within the
first weeks after injection to be replaced by the patient’s
own fibrovascular connective tissue within 3months.
• Thus, in contrast with all other dermal fillers, PMMA
becomes the patient’s own tissue and can be considered a
permanent “living implant,” that is, it will bleed when cut
(Fig.81.1b).
81.3 Techniques
Blunt 25G cannulas are preferred over pointed 26G needles
to avoid intravascular injection.
• The standard injection technique beneath a nasolabial fold
consists of subdermal tunneling and delivering a strand of
PMMA at the dermal-subdermal junction (Fig.81.2a, b) [2].
G. Lemperle
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a
b
F. . (a) Smooth PMMA microspheres of 40μm in diameter
are cleaned from all small particles <20μm. ( b) Three months after
injection, the microspheres are embedded and fixed in granulation
tissue
Chapter 81. Polymethylmethacrylate Microsphere…

• This strand beneath a fold acts as support structure that
protects against further folding and allows the diminished
thickness of the dermis to recover to its original thickness.
• Most fillers are injected too deeply—a waste of material.
The thickness of the facial dermis is 1.0mm, and the diam-
eter of a 25G cannula is 0.5 mm; therefore, the correct
plane for injection is only 2× the diameter of a cannula or
needle beneath the skin surface (Fig.81.3a).
• Push the cannula forward under pressure on the plunger,
so that the extruding filler may push small vessels aside
and thereby prevent hematomas.
• Filling the created channel as the cannula is being with-
drawn (Fig. 81.3b). Injection of any filler into facial mus-
cles may cause lumps and filler dislocation due to muscle
movement.
• Anchoring a “solid implant” either in the dermal-
subdermal plane (Fig.81.3b) or on the periosteum of the
underlying bone is therefore important.
• Palpating and gentle pressure to the injected volume
rather than excessive massaging of the injected site is
needed in order to prevent dissipation and bruising.
• Flattening irregularities from injection with a fingernail
during the first week after treatment, if necessary.
a
b
F. . (a) Beneath a wrinkle or fold, the correct injection
depth is the dermal-subdermal plane. (b) The channel is filled with
PMMA during withdrawal of the needle or cannula
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81.4 Indications
• Forehead and temples—Chinese women, for example, pre-
fer rounded foreheads and dislike temple depressions.
0.5–2 ml PMMA are injected epiperiosteally or epifas-
cially through cannulas in a fanlike manner.
• Horizontal frontal folds—Injection of forehead lines must
be deep enough that the gray of the cannula does not shine
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F. . (a) The filler has to be “anchored” in the network of
the dermal-subdermal plane. (b) At least two strands of PMMA will
level the fold. A third strand 4weeks later will improve the result
Chapter 81. Polymethylmethacrylate Microsphere…
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through the skin, since intradermal delivery of PMMA
microspheres may result in a chain of tiny white granules
(Fig.81.4).
• Glabellar frown lines—To avoid injections into the supra-
trochlear artery (risk of blindness), the PMMA should be
“anchored” in a strict superficial subdermal plane.
• Tear troughs—The thin skin in this area lacks subcutane-
ous fat and is fixed to the dark and thin orbicularis muscle
orbital rim (Fig.81.5a, b).
• After a strictly epiperiosteal injection [6], the tip of the
needle is scratched over the lower orbital rim, above the
infraorbital nerve, and beneath the orbicularis muscle.
a
b
F. . (a) Deep frontal folds need a very viscous filler like
PMMA to be leveled. (b) The result after 3months
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• This shall prevent the subdermal appearance of a chain of
small white nodules, compressed through muscle
movement.
• Nasal bridge—For correction of underdeveloped or
uneven nasal bone, a 1-inch cannula is inserted through a
nostril, parallel to the nasal bone; the space of the missing
bridge is filled during withdrawal (Fig.81.6a, b).
• The implant is then molded with slight pressure, and the
patient is advised to continue molding for another week, if
indicated.
a
b
F. . (a) Shadowed lower eyelids can be filled by a strand of
PMMA along the lower orbital rim. (b) The result 10years after the
injection of 2× 0.8 ml Artefill epiperiosteally, that is, beneath the
orbicularis muscle to avoid lumps
Chapter 81. Polymethylmethacrylate Microsphere…
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• For saddle noses, a “step-by-step” augmentation is recom-
mended to allow patients to get accustomed to their new
look.
• The nasal tip can be elevated using bulk injections between
alar cartilages and skin—and below the columella above
the nasal spine (Fig.81.7a).
• Indented cheeks and facial dystrophy—Indented cheeks
are often caused by atrophy of Bichat’s fat pad. Facial dys-
trophy is a side effect of anti-HIV therapy.
• PMMA injections can either be “anchored” at the lower rim
of the malar bones or may be performed perpendicularly
through the cheek with a finger placed on the inner cheek
mucosa (“tower technique” of Bartus 2011, Fig.81.7b).
• Malar augmentation—After the patient points out her
need for augmentation in front of a mirror, one syringe
and a perpendicular directed needle are delivered with
one stroke onto the bone.
ab
F. . (a) A small curved nose in a relative large Brazilian
face should not be surgically reduced. (b) After PMMA injections
into the nasal bridge and elevation of the nasal tip (Fig.81.7a) it fits
the bigger nose to the face
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• The overlying muscles will smoothen and eventually flat-
ten the implant. A second injection may be required after
1–3months.
• Receding chin—The same technique of epiperiosteal bulk-
ing may be used in chin augmentation. Fanlike injections
and massage will flatten the implant and diminish
projection.
• One to two milliliters in one perpendicular epiperiosteal
injection can be delivered to the middle of the chin.
a
b
F. . (a) The elevation of the nasal tip needs two bulks of
fillers: one above the crura and one into the columellar base, that is,
on top of the nasal spine. (b) Augmentation of an indented cheek
with a permanent filler can best be done using the “tower tech-
nique” of Bartus (2011)
Chapter 81. Polymethylmethacrylate Microsphere…
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• Massaging is not recommended since the overlying mus-
cles contribute to a natural smoothening.
• Nasolabial folds—Deep nasolabial folds are best sup-
ported by two or three strands of high viscosity PMMA,
implanted through a cannula parallel and precisely medial
to the nasolabial fold (Fig.81.8a, b).
• To prevent intra-arterial injection, the facial artery should
be palpated beneath the nasolabial fold just above the
mucosa of the lips.
• In patients with thin skin, care must be taken that the
implant is deep enough or the implant site could appear
erythematous for several months.
• To prevent the implant from becoming visible in the form
of little granules, the dermis is scratched from beneath dur-
ing injection using a blunt 25G cannula.
• During the first 3days, PMMA has a pasty consistency and
may be shifted laterally through facial muscle movement.
ab
F. . (a) Deep nasolabial folds in a patient with thick seba-
ceous skin—an ideal indication for viscous PMMA. (b) Eight
months after two sessions with 2×1.7ml Artecoll
G. Lemperle
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• Therefore, the area should be kept quiet with a transparent
tape for 3days.
• If the subnasal triangle is indented, a fanlike strictly sub-
dermal injection is indicated to avoid any epiperiosteal
injection at this site since the underlying quadratus labii
superior muscle may move the implant upward.
• A second injection is often necessary, especially in the
lower nasolabial fold adjacent to the corners of the mouth.
• Lip Augmentation should be discussed very carefully
(Fig.81.9a).
• The accentuation of the upper and lower vermilion border
(“white roll”) is no problem and eliminates 5mm of the
radial lip lines (Fig.81.10a, b).
• The “empty space” between vermilion and muscle must be
targeted with the needle from the side—and the space is
filled with a strand of PMMA through pressure on the
plunger.
• Additional PMMA should never be injected into the
muscle but in form of microdroplets between the mucous
glands along the dry-wet border of the inner vermilion
(Fig.81.9b).
ab
F. . (a) The vermilion border can easily be augmented by
hitting the empty pocket beneath it. (b) PMMA must be injected
into the “white roll” and as microdroplets in the “dry-wet border”
intraorally
Chapter 81. Polymethylmethacrylate Microsphere…
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• Negative mouth corners—Horizontal augmentation of the
lower vermilion border 10mm from the corner everts the
lip and lifts the drooping corner.
• Marionette lines—The vertical elongation of a negative
mouth corner should be filled with cross-hatching horizon-
tal and vertical PMMA strands.
• Since there is little fat between skin and orbicularis oris
muscle, the cannula must be guided very superficially
(Fig.81.2a, b) above the muscle to avoid lumping.
• Acne scars: Flat scars can be approached with the needle
tip from 1cm distance [7].
• “Boxcar scars” should be filled perpendicularly— best by
using 1:1 diluted PMMA injected with the help of a
Dermojet®.
81.5 Clinical Follow-Up
• PMMA is a permanent filler with long-lasting aesthetic
effects, especially when injected in motionless areas, such
as the temples, cheeks, nose, or chin.
ab
F. . (a) Radial lip lines are rather difficult to inject. (b)
The lower half disappears after the accentuation of the vermilion
border (Fig.81.9a)
G. Lemperle
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• High viscosity fillers like Artecoll are ideal for soft tissue
and bone augmentation [2], whereas low viscosity fillers,
like hyaluronic acids, are superior for the augmentation of
fine wrinkles and lips.
• Earlier studies have shown that a small percentage of
patients were dissatisfied with “non-visible effects.”
• Since PMMA is not absorbed, a “non-visible effect” may
be caused by an inadequate amount of volume injected or
by PMMA injected too deeply into the subdermal fatty
tissue [8].
• Since strict epiperiosteal use has been recommended, no
foreign body granulomas have been reported so far in
China [4].
81.6 Side Effects andComplications
Nodules
• The most commonly reported side effects are nodules
(Fig.81.11a, b) and unevenness due to inadequate techni-
cal skills of the injectors.
ab
F. . (a) Two intradermal ridges after too superficial injec-
tion of hyaluronic acid. (b) Two Artecoll nodules in the lip caused by
smoking just after the injection
Chapter 81. Polymethylmethacrylate Microsphere…
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• Nodules may occur when PMMA is implanted too deeply
and close to a facial muscle, causing small palpable or vis-
ible lumps to form [1].
• If PMMA was implanted beneath a muscle (as in submus-
cular tear trough or chin augmentation), the constant
muscle movement leveled the implant within the first
3weeks.
Foreign Body Granulomas
• Foreign body granulomas may occur from 6 months to
years after intradermal injection of PMMA (Fig.81.12a, b)
a
b
F. . (a) Foreign body granulomas developing 1year after
Arteplast injections. (b) Total regression 4weeks after intralesional
injections of 2×40mg triamcinolone
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at a rate of roughly 1:1000 patients, similar to most other
dermal fillers [9].
• The treatment of choice is the immediate intralesional
injection of high doses of triamcinolone (40 mg/ml) or
betamethasone (5mg/ml) [10].
• If the effect is not obvious after 4 weeks, steroid doses
must be doubled.
• There is no risk of over-treatment: A a Chinese woman
received 4× 240 mg triamcinolone without signs of skin
atrophy after facial injections of 67ml Artecoll.
Tip Box
• PMMA injections are safe and permanent if applied
epiperiosteally in the face or “anchored” subder-
mally in nasolabial and glabellar folds.
• The meticulous knowledge of the anatomy of the
face and a three-dimensional imagination of its
muscles and vessels are prerequisite for effectiveness
and satisfaction.
• To avoid intra-arterial injection and possible skin
necrosis or even blindness, a blunt cannula is recom-
mended—or to move the pointed needle back and
forth during injection!
• To date, granulomas have occurred only in patients
following intradermal injections—the dermis is the
organ with the most severe immunological reactions.
References
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Zimmermann U, Duffy D. Foreign body granulomas after all
injectable dermal fillers: part 1. Possible causes. Plast Reconstr
Surg. 2009;23:1842–63.
2. Lemperle G, Knapp TR, Sadick NS, Lemperle SM. ArteFill®
permanent injectable for soft tissue augmentation: 1. Mechanism
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Author Query
Chapter No.: 81 00 04175047
Queries Details Required Author’s Response
AU1 Please provide in-text citation for
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