Complications after polymethylmethacrylate (PMMA) injections in the face: a literature review

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications

INTRODUCTION

The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment.

METHODS

A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes.

RESULTS

The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant.

CONCLUSION

The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers.

LEVEL OF EVIDENCE III

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 .

Polymethylmethacrylate Microspheres are Immunologically Inert in Mouse Tissues

Nowadays, aesthetic concerns have gained attention, especially by patients looking for a less invasive alternative to minor facial corrections. Polymethylmethacrylate (PMMA) is widely used as a soft tissue filler; the demand for this polymer has increased, and along with it, there are some reports of adverse reactions. Such adverse reactions stem from consequences of immune and inflammatory reactions to PMMA. Some animal models have been used to unravel the causes of these reactions, among other factors involving the management of PMMA. The aim of this study was to determine the immunogenic profile of PMMA implantation in different anatomical planes of mice, over up to 360 experimental days. In this study, BALB/c mice were divided into 30 groups for immune evaluation of the interaction between the organism and the polymer; 2% PMMA was implanted subcutaneously, 10% intramuscularly and 30% in periosteal juxtaposition and followed during five experimental days (7, 30, 90, 180 and 360 days after implantation-DAI). Pro- and anti-inflammatory cytokines (IL-2, IL-4, IL-6, IFN-gamma, TNF, IL-17A, IL-10 and TGF-beta) were quantified in all experimental days. There was no statistical difference between the groups analyzed considering the evaluated parameters. Therefore, at all implanted depths, PMMA behaved inertly in a murine model.No Level Assigned 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 .

Surgical Treatment for Cutaneous Mycobacterium abscessus Infection Caused by Injections of Hyaluronic Acid

Background

Facial injection has become popular in aesthetic dermatology. Although injections of these tissue fillers are considered a low-risk procedure, they are not without potentially significant drawbacks.

Case Presentation

We would like to report a case about cutaneous Mycobacterium abscessus infection after facial injection of hyaluronic acid in China, which obtained satisfactory clinical efficacy by drainage and surgical excision.

Conclusion

Biological techniques are useful in the diagnosis of cutaneous M. abscessus infection. Surgical excision of skin lesion is effective for cutaneous M. abscessus infection.

Application of Nonsurgical Modalities in Improving Facial Aging

Objective. This review aims to summarize different kinds of applications of minimally invasive surgery in improving facial aging to provide a comprehensive and accurate introduction on the issue of esthetic treatment of facial skin. Overview. In the twentieth century, facial rejuvenation has become a new beauty trend. Facial cosmetology has entered a period of antiaging and rejuvenation therapies and microplastic surgery. The pursuit of beauty has promoted the development of minimally invasive plastic surgery. This review introduces the possible causes of facial aging and its related topics with a focus on facial injectable drugs, such as botulinum toxin, main filler materials (hyaluronic acid, calcium hydroxyapatite, poly L-lactic acid, collagen, autologous fat, and polymethyl methacrylate), and some current antiwrinkle technologies, such as thread lift and radiofrequency rhytidectomy. Conclusions. Despite the difference in mechanisms of action, each technique can address facial aging involving the loss of collagen, displacement and enlargement of fat, and muscle relaxation. Combinations of these treatments can provide patients with reasonable, comprehensive, and personalized treatment plans.

Bioactive injectable polymethylmethacrylate/silicate bioceramic hybrid cements for percutaneous vertebroplasty and kyphoplasty

Polymethylmethacrylate (PMMA) cement has been widely used to fill and stabilize hard tissue defects in clinical surgery, especially in percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP). However, the dense body of pure PMMA in defects has no ability to promote bone regeneration. We herein aim to fabricate novel PMMA/silicate bioceramic hybrid cements by adding bioactive calcium silicate (CS) particles into PMMA to endow PMMA/CS hybrid cements with bioactivity and biodegradability without losing the excellent mechanical strength and injectability. Following comprehensive characterization of the physicochemical properties and in vitro bioactivity study, our results showed compared with PMMA cement, the constructed PMMA/CS hybrid cements possessed significantly lower curing temperatures and simultaneously retained the acceptable mechanical strength and injectability. Moreover, obvious bioactive ion release and hydroxyapatite formation could be detected and observed after the PMMA/CS hybrid cements were soaked in simulated body fluid, indicating their pronounced bioactivity. A further in vivo study of the PMMA/CS hybrid cements on goat vertebral body defect models reflected that the PMMA/CS hybrid cements could be biodegraded well and could significantly promote new bone formation in defects 6 months of post-injection. Our results suggest that PMMA/CS hybrid cements may be promising candidates for PVP and PKP in clinic.

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.

Penile Girth Enhancement With Polymethylmethacrylate-Based Soft Tissue Fillers

INTRODUCTION

An unknown percentage of men will take every risk to develop a larger penis. Thus far, most injectables have caused serious problems. Polymethylmethacrylate (PMMA) microspheres have been injected as a wrinkle filler and volumizer with increasing safety since 1989.

AIM

To report on a safe and permanently effective method to enhance penile girth and length with an approved dermal filler (ie, PMMA).

METHODS

Since 2007, the senior author has performed penile augmentation in 752 men mainly with Metacrill, a suspension of PMMA microspheres in carboxymethyl-cellulose.

MAIN OUTCOME MEASURES

The data of 729 patients and 203 completed questionnaires were evaluated statistically.

RESULTS

The overall satisfaction rate was 8.7 on a scale of 1 to 10. After one to three injection sessions, average girth increased by 3.5 cm, or 134% (10.2 to 13.7 cm = 134.31%). Penile length also increased by weight and stretching force of the implant from an average of 9.8 to 10.5 cm. Approximately half the patients perceived some irregularities of the implant, which caused no problems. Complications occurred in 0.4%, when PMMA nodules had to be surgically removed in three of the 24% of patients who had a non-circumcised penis.

CONCLUSION

After 5 years of development, penile augmentation with PMMA microspheres appears to be a natural, safe, and permanently effective method. The only complication of nodule formation and other irregularities can be overcome by an improved injection technique and better postimplantation care.

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

BACKGROUND

Polymethylmethacrylate (PMMA) has been used as an injectable filler to treat hollows and reduce rhytids. PMMA injections have been associated with several side effects, however, the literature is scarce on periorbital complications and their treatments.

OBJECTIVES

The purpose of this study is to report a series of complications after periorbital PMMA injections to the midface and to describe their management.

METHODS

Retrospective chart review, including photography and histopathology when available.

RESULTS

The authors identified 11 cases of complications of PMMA injections to the midface. Patient ages ranged from 36 to 62 years (mean, 47 years; median, 44 years). Two (18%) were males and 9 (82%) were females. Adverse effects began between 2 to 24 months after injection (mean, 7.2 months; median, 6 months). All patients had edema, erythema, and contour irregularity. Seven (64%) patients had nodules, 4 (36%) had yellow, xanthomatous skin changes, and 2 (18%) had eyelid malposition. Histopathology demonstrated a giant cell inflammation in 5 of 6 cases. Corticosteroid injection was tried in 6 cases but was associated with minimal clinical improvement. Surgical debulking of the implanted material was performed in 9 (82%) cases and was effective in improving edema, erythema, and nodularity.

CONCLUSIONS

PMMA injection to the midface may be associated with chronic inflammation, fibrotic nodules, yellowing of the skin, and eyelid malposition. Intralesional corticosteroid injections yielded minimal or no improvement; surgical debulking achieved favorable results. LEVEL OF EVIDENCE 4: Therapeutic.

Location of injected polymethylmethacrylate microspheres influences the onset of late adverse effects: an experimental and histopathologic study

Polymethylmethacrylate (PMMA) has been widely used in the correction of wrinkles because of its long-lasting cosmetic improvements. However, side effects and complications may occur, and its clinical appearance on the oral mucosa can be similar to that of inflammatory or neoplastic disease. The aim of this research was to compare the clinical and histopathologic responses to PMMA injected by two different methods. Twenty-two rats received an injection of PMMA using the tunneling technique (gold standard), with subcutaneous deposition of the filler in the face, or a variation of the technique with transcutaneous submucosal deposition of the filler in the cheek. The tissue reaction was analyzed clinically every 24 hours during the first week, then once a week for the following 3 months. Histologic evaluation was based on the local inflammatory response to the filler. No clinical changes were observed during the initial evaluation period (0-14 days). After 14 days, only the submucosal group showed extra-oral enlargement (n=4, 18.2%). Histopathologic analysis revealed nodule formation in four animals (18.2%) in the submucosal group, with no nodules observed in the subcutaneous group. The data obtained in this study demonstrate that the technique used to deliver the filler may influence the risk of adverse reactions.

Polymethylmethacrylate dermal fillers: evaluation of the systemic toxicity in rats

This study evaluated local and systemic reactions after an intravascular injection of polymethylmethacrylate (PMMA) at two concentrations in a murine model. Thirty rats were divided equally into three groups: 2% PMMA, 30% PMMA, and a control group (normal saline only injection). The filler was injected into the ranine vein. The rats were sedated at 7 and 90 days and a clinical evaluation performed. After euthanasia, the right lung, liver, and right kidney were removed, weighed, and microscopically analyzed. The submandibular lymph nodes and tongue were removed and examined microscopically. Serum was subjected to liver and kidney function tests. No groups showed clinical alterations. Microspheres were not observed at any distant organ. Two samples from the 2% PMMA group showed a local inflammatory response at day 7 and another two samples from the 30% PMMA group at day 90. The group injected with 30% PMMA presented higher levels of alanine aminotransferase (P = 0.047) after 90 days when compared with the other groups. The data obtained in this study demonstrate that intravascular injections of PMMA fillers show potential health risks such as chronic inflammation at the implantation site.