Complications and Management of Polymethylmethacrylate (PMMA) Injections to the Midface

Extracorporeal Acoustic Shock Waves to Treat Complications of Polymethylmethacrylate

BACKGROUND

Polymethylmethacrylate (PMMA) fillers are permanent fillers known for their possible side effects. In case of complications, the only possible treatment is surgical removal, followed by procedures to minimize resulting deformity. The aims of this study were (1) to analyse the morphology of the PMMA material in the nodules, (2) to demonstrate that treatment by acoustic wave therapy (AWT) can help the removal of the nodules, and (3) to present an easy procedure to solve deformities.

METHODS

The data of 9 patients who underwent AWT, surgical PMMA removal, and deformity correction by enriched nanograft and dermagraft injections between April 2021 and May 2024 were presented. The leftover aspirated material was analysed by histology and scanning electron microscopy.

RESULTS

AWT resulted in no complications in all patients. After removal and correction surgeries, minor complications were observed in 5 cases. All the patients were delighted with the aesthetic outcome. In all patients, an important improvement of the deformities, with correction of the volume of the face, was observed. A substantial resolution of the initial clinical symptoms was documented. The ultrastructural analysis highlighted that PMMA appears in the form of laminar or prismatic formations with a paracrystalline structure.

CONCLUSIONS

AWT acted directly on PMMA to facilitate its removal and reduce fibrosis around the PMMA filler. The lack of volume correlated with PMMA removal was resolved with the enriched nanograft and dermagraft injections, which led to very satisfying aesthetic results.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Manufacturing Process of Hyaluronic Acid Dermal Fillers

Hyaluronic acid (HA) fillers are extensively utilized in aesthetic medicine due to their biocompatibility, reversibility, and effectiveness in enhancing skin hydration, volume, and overall appearance. These fillers are predominantly produced through microbial fermentation, followed by a critical cross-linking process that enhances their longevity by resisting enzymatic degradation. This review provides a thorough examination of the manufacturing processes that differentiate HA fillers, with particular attention to the distinctions between biphasic and monophasic variants. Unlike previous studies, this review emphasizes the specific cross-linking techniques and their substantial impact on the fillers' rheological properties, such as elasticity and cohesiveness, which are crucial to their clinical performance and patient outcomes. Additionally, the review offers a comprehensive comparison of HA fillers with non-HA alternatives, including calcium hydroxylapatite, poly-l-lactic acid, and polymethyl methacrylate, highlighting the unique advantages and potential complications associated with each type. By presenting novel insights into the latest advancements and challenges in filler technology, this review aims to provide clinicians with a deeper understanding of filler properties, thereby guiding them in making informed decisions to optimize patient safety and aesthetic results.

Sarcoidosis and Polymethyl Methacrylate (PMMA) Granulomas following COVID-19 Vaccination (ChAdOx1): Successful Treatment with Tofacitinib

Sarcoidosis and complications related to fillers have been reported following the COVID-19 vaccination. Additionally, cutaneous sarcoidosis has been observed around polymethyl methacrylate (PMMA) injection sites. Foreign-body reactions to PMMA can occur simultaneously with systemic sarcoidosis, suggesting a shared pathogenic mechanism between both conditions. To report a case of sarcoidosis and PMMA granulomas following COVID-19 vaccination (ChAdOx11), successfully treated with tofacitinib. We present a 59-year-old woman who developed systemic sarcoidosis and a granulomatous reaction to PMMA filler following the COVID-19 vaccination (ChAdOx11). Notably, both PMMA and the vaccine were potential triggers for sarcoidosis. Treatment with tofacitinib produced marked improvement in both the cutaneous and pulmonary involvement of sarcoidosis and the granulomatous reaction to PMMA. This successful outcome suggests tofacitinib, a pan-JAK inhibitor, an alternative treatment for cutaneous and systemic sarcoidosis, as well as a potential therapy for granulomatous complications of dermal fillers, such as PMMA.

Tunneled Paranasal Augmentation Using Diced Autologous Costal Cartilage in Asian Rhinoplasty: A Comparative Study

Due to the prevalence of anterior maxilla dysplasia in Asian population, paranasal concavity is a common accompaniment to low nose, but its impact on facial harmonization is often underestimated. A retrospective comparative study was conducted on patients diagnosed as low nose with paranasal concavity between June 2017 and June 2021, with a total of 56 patients followed up successfully. The control and observation groups were established according to whether the paranasal augmentation was performed. Demographic data were collected. Cosmetic enhancement was quantitatively evaluated by sagittal planimetry, establishing related anatomical landmarks and measuring columella base prominence (CBP) and alar base prominence (ABP). Subjective evaluation concluded the patient-reported satisfaction (FACE-Q-Rhinoplasty Module and Facial Appearance Module) and the third-party physician assessment (Global Aesthetic Improvement Scale, GAIS).Significant improvements in CBP and ABP were reported both in the control and the observation group (p < 0.01). In postoperative intergroup comparisons, the observation group was superior to the control group regarding ABP values (2.5 ± 0.75 degrees, p < 0.01), FACE-Q-Facial scores (7.49 ± 3.70, p < 0.05), and GAIS scores (p < 0.05). However, no statistical difference was found in CBP values and FACE-Q-Rhinoplasty scores. Paranasal augmentation-related complications included asymmetry of alar bases (6.9%) and facial or intraoral foreign body sensation (34.5%). This study affirmed that paranasal augmentation using diced costal cartilage in rhinoplasty is a safe procedure effective in remedying paranasal concavity and improving facial satisfaction. LEVEL OF EVIDENCE::  IV.

In vitro assessment of inflammatory skin potential of poly(methyl methacrylate) at non-cytotoxic concentrations

Poly(methyl methacrylate) (PMMA) is considered an attractive substrate material for fabricating wearable skin sensors such as fitness bands and microfluidic devices. Despite its widespread use, inflammatory and allergic responses have been attributed to the use of this material. Therefore, the main objective of this study was to obtain a comprehensive understanding of potential biological effects triggered by PMMA at non-cytotoxic concentrations using in vitro models of NIH3T3 fibroblasts and reconstructed human epidermis (RhE). It was hypothesized that concentrations that do not reduce cell viability are sufficient to activate pathways of inflammatory processes in the skin. The study included cytotoxicity, cell metabolism, cytokine quantification, histopathological, and gene expression analyses. The NIH3T3 cell line was used as a testbed for screening cell toxicity levels associated with the concentration of PMMA with different molecular weights (MWs) (i.e., MW ~5,000 and ~15,000 g/mol). The lower MW of PMMA had a half-maximal inhibitory concentration (IC50 ) value of 5.7 mg/cm2 , indicating greater detrimental effects than the higher MW (IC50  = 14.0 mg/cm2 ). Non-cytotoxic concentrations of 3.0 mg/cm2 for MW ~15,000 g/mol and 0.9 mg/cm2 for MW ~5,000 g/mol) induced negative metabolic changes in NIH3T3 cells. Cell viability was severely reduced to 7% after the exposure to degradation by-products generated after thermal and photodegradation degradation of PMMA. PMMA at non-cytotoxic concentrations still induced overexpression of pro-inflammatory cytokines, chemokines, and growth factors (IL1B, CXCL10, CCL5, IL1R1, IL7, IL17A, VEGFA, FGF2, IFNG, IL15) on the RhE model. The inflammatory response was also supported by histopathological and gene expression analyses of PMMA-treated RhE, indicating tissue damage and gene overexpression. Results suggested that non-cytotoxic concentrations of PMMA (3.0 to 5.6 mg/cm2 for MW ~15,000 g/mol and 0.9 to 2.1 mg/cm2 for MW ~5,000 g/mol) were sufficient to negatively alter NIH3T3 cells metabolism and activate inflammatory events in the RhE skin.

Adverse Reactions Associated with Dermal Fillers in the Oral and Maxillofacial Region: A Venezuelan Experience

BACKGROUND

Dermal facial fillers are increasingly popular. Published reports on the clinical and histopathologic characteristics related to adverse reactions to dermal fillers in the facial region have been relatively well documented. This study adds to the literature on adverse reactions to injected filler in the oral and maxillofacial region in a South American population.

METHODS

A retrospective, descriptive cross-sectional study (2019-2020) was performed. The study population was a dermatology service in Venezuela. Clinical and histopathologic features of patients with adverse effects were documented.

RESULTS

A total of 35 cases of adverse reactions associated with cosmetic filler procedures were diagnosed during the analyzed period; of these, six cases (17.1%) involved the oral and maxillofacial region. All cases occurred in women. The mean age at diagnosis was 59.3 years (58-73). In three cases, dermal fillers were used in different locations on the face, while three involved the lips. Five patients exhibited adverse reactions to lip filler. All six cases were histopathologically diagnosed as foreign body reactions to injected material. Four and two cases revealed microscopic features compatible with hyaluronic acid and polymethylmethacrylate, respectively.

CONCLUSION

Reflecting the dramatic increase in cosmetic procedures with soft tissue fillers, this study contributed by reporting six cases of foreign body reaction involving the oral and maxillofacial region, confirmed with biopsy and histopathology.

Surgical Management of Polymethylmethacrylate-Collagen Gel Complications in the Lower Eyelid: A Case Series

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.

Clinical commentary about foreign body complications over 20 years after polymethyl-methacrylate face implants and control of late sequelae with Polynucleotides Highly Purified Technology (PN-HPT® )

INTRODUCTION

Mainly in the past, foreign body complications, including granuloma, were pretty frequent after semi-permanent polymethyl-methacrylate (PMMA) implants.

RESULTS

The authors describe a twenty-year history of recurring post-PMMA complications interspersed by long uneventful years, with acute edematous side effects evolving into unpleasant skin dystrophia with persistent cutis laxa. The case report also discusses a simple clinical algorithm to discriminate among foreign body complications with particular attention to granulomas.

CONCLUSIONS

The authors conclude by discussing the benefits of the anti-dystrophic treatment with natural-origin remodeling PN-HPT^® (Polynucleotides Highly Purified Technology).

Case Report of Idiopathic Masseteric Hypoplasia Treated With Polymethyl Methacrylate-Collagen Gel

Congenital hypoplasia of the masseter muscle is a rare condition most commonly associated with craniofacial or poly-malformation syndromes, with a small number of reported idiopathic cases. The condition is most commonly managed by orthodonture and later surgical intervention; however, surgery is not an option for all patients. Nonsurgical approaches to correcting asymmetry may be considered for patients for whom the functional impact of hypoplasia has been largely managed and the patient's concern is primarily aesthetic. In this case study, the patient presented for a consultation seeking a nonsurgical solution for marked facial asymmetry. The patient underwent physical examination and magnetic resonance imaging to confirm diagnosis of congenital masseter muscle hypoplasia. To treat the asymmetry, a total of 9.6 cc of polymethyl methacrylate (PMMA)-collagen gel (Bellafill; Suneva Medical, Inc., San Diego, CA) was injected along the border of the mandible from the gonial angle out to the area of the mental foramen and slightly above over the course of 6 months (2 visits spaced 3 months apart) to provide long-term, nonsurgical correction. The patient was very satisfied with the results, highlighting the potential for PMMA-collagen gel to be used in clinical situations in which durable, nonsurgical correction of lower-face asymmetry is needed.

LEVEL OF EVIDENCE 5

Efficacy and Safety of Lyophilized Articular Cartilage Matrix as an Injectable Facial Filler

OBJECTIVE

To evaluate the efficacy and safety of an injectable lyophilized articular cartilage matrix (LACM) which is in the form of cartilage powder that may increase the convenience of use and become unaffected by donor site morbidity as a potential filler.

METHODS

The safety test was conducted using 20 rabbits with an intravascular embolization model. Commonly used commercial hyaluronic acid (HA), acellular dermal matrix (ADM), polymethyl methacrylate (PMMA), and polylactic acid (PLA) products were selected for comparison of efficacy and adverse effect of LACM. The efficacy test was performed using 30 mice subcutaneous buttock-injection model. Gross assessments of the changes in size of injected materials and histological examinations were conducted.

RESULTS

Regarding the safety test, in one rabbit in the HA group, complete blurring occurred in the left eye, and necrosis of the posterior auricular artery was observed in one rabbit in the ADM group. In the ADM, severe ecchymosis around the injection sites was observed, and the bruises lasted longer than in the other groups. The LACM exhibited faster bruise resolution. Comparing the changes in size between weeks 4 and 12 in the mouse model, no significant changes in size were observed in the LACM (p = 0.359), HA (p = 0.421), and ADM (p = 0.097), but a significant change was observed in the PMMA (p = 0.001). In the histological examination, LACM exhibited well-demarcated margins with good biocompatibility.

CONCLUSION

The LACM shows potential as a facial filler according to the in vivo safety and efficacy tests LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Restoring Facial Contour and Harmony Using Biphasic Calcium Phosphate Bioceramics

Background:

The restoration of facial contour is one of the pillars for the treatment of facial disharmonies and deformities. Fat transplantation and fillers have been widely used to improve the positioning of soft tissues, which are, however, directly related to the conditions and positioning of the underlying bone tissue. Recontouring of the latter has been performed using osteotomies and several types of bone grafts or biomaterials, as inlay or onlay grafts/implants. Here, biphasic calcium phosphate bioceramics were applied in a series of cases, their long-term results are shown, and their advantages, discussed.

Methods:

A retrospective analysis of 20 patients, who were subjected to facial recontour with onlay implants of biphasic calcium phosphate bioceramics, is reported. Patients were seeking to improve facial harmony due to congenital deformities, trauma, tumor resection or signs of aging, and were followed for up to 16 years. Clinical data, radiographic images, and information regarding pain and other findings were retrieved from medical records.

Results:

Six patients were men and 14 were women. Their ages ranged from 19 to 64 years. Bioceramics were implanted under the periosteum through external or intraoral incisions. Some patients underwent combined procedures, such as rhinoplasties or facial lifting. None of the patients presented exacerbated inflammation or pain. One of them had infection in the intraoral incision, which was resolved with medication.

Conclusion:

All patients had improved facial contours following the use of bio-ceramics to augment bone tissue and presented stable results at long-term evaluation.

The use of periocular fillers in aesthetic medicine

The periocular area is the first to display signs of ageing. Dermal fillers are an increasingly popular, minimally invasive method for facial rejuvenation. The eye is anatomically delicate and complex. Therefore, special consideration must be taken if dermal fillers are employed. This article examines the literature to assess the efficacy and safety of dermal fillers around the eye as well as the management of complications secondary to dermal filler use, such as oedema, granuloma formation, filler migration, xanthelasma, skin necrosis and visual loss. Hyaluronic acid (HA) is the most popular and commonly employed dermal filler for periocular use. It is effective, with good observer improvement and patient satisfaction (p<0.0001). Ninety percent of adverse events are mild in nature and self-resolve within 1 month. Malar oedema is a delayed complication unique to the periocular area, occurring in 11% of patients. This can be managed with use of hyaluronidase if a HA filler has been employed. Other complications, such as granuloma formation, filler migration and xanthelasma, have also been reported with variable management outcomes. Vascular adverse events include skin necrosis and visual loss. No Level 1 evidence exists for the management of visual loss. Two cases of visual restoration have been identified in the literature; however, this is rare.

PMMA Safety for Facial Filling: Review of Rates of Granuloma Occurrence and Treatment Methods

PMMA is composed of microspheres suspended in bovine collagen. Once injected in a dermal area, the carrier is absorbed, giving place to collagen that gives volume and maintains the spheres in the place. This process may give origin to exacerbate foreign body reaction and granuloma. The frequency of such complication is not clear. The primary objective was to review and compare the frequencies of granuloma between the published studies. The secondary aim was to compare the therapies and efficacies. The series of cases in which PMMA was used as facial filler were reviewed, and the rate of granulomas was compared; the case report studies describing those complications were also reviewed, and the therapies and outcomes were quantified. The data showed general frequency of PMMA-related complications of 4.9% and granulomas 1.9%; the incidence of granuloma was 1/2075 patients-year, and the time to development ranged from 6 to 180 months. The most used therapies were steroid, surgery or both, with satisfactory results. In conclusion, considering the actual risks and benefits of PMMA, we may affirm that it is a safe filler; doctors and patients must be conscious of potential risks when deciding for its use. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Another face of dermal fillers

Potential complications related to dermal fillers depend on the type of the fillers and the site of their application. The classification of dermal filler complications can be divided into early and late, and into minor and major events. According to their mechanism, they can be divided into non-ischaemic and ischaemic complications. The aim of this study is to present possible complications related to dermal fillers, to explain their aetiology and to propose preventive management and treatment. Non-ischaemic complications can be technique-dependent and include the reactions at the site of the injection, contour irregularities, and inflammatory and infectious reactions. They are usually resolved as a matter of course after 2-7 days. Arterial or venous occlusion leads to ischemia, with subsequent necrosis of the skin and/or vision loss.

Intralesional Neodymium YAG laser to Treat Complications of Polymethylmethacrylate

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 an innovative minor invasive procedure to reduce disfigurement by nodules and lumps.

METHODS

We employed a subdermal, intralesional 1,064 nm neodymium-doped yttrium aluminium garnet (Nd: YAG) laser in combination with suction using a blunt liposuction cannula of 2.0-2.5 mm of diameter.

RESULTS

For 12 years, a total of 81 consecutive subjects (79 females and 2 males) were treated. The average age of the patients was 43.7 years (range 26 to 76 years). Granulomas and lumps could be removed in a minor invasive procedure with tumescent anaesthesia. In a minority of cases, the procedure had to be repeated. The results were impressive and not adverse events related to intralesional laser therapy were observed, 86.4% of patients were satisfied.

CONCLUSION

The procedure should be used before or in combination with classical surgery to remove PMMA in case of adverse tissue reactions to PMMA.