Nonthrombotic Pulmonary Embolism: A Potential Complication of Polyacrylamide Hydrogel Cosmetic Injection

Fatal pulmonary embolism following injectable gluteal filler usage: a case report

BACKGROUND

Despite the fact that injectable filler usage in the gluteal region has not been recommended in formal medical institutions, illegal procedures are performed in many clinics and beauty centers across Egypt. This case report illustrates the illegal practice culminating in a fatal complication.

CASE PRESENTATION

A 26-year-old female with no relevant medical history presented to the ER with acute onset shortness of breath. The complaint started 16 h before, with a rapidly progressive course, shortly after undergoing a gluteal filler injection at a center in Cairo. At ER, the patient was severely distressed, yet fully conscious and oriented. She was shocked (BP 70/40 mmHg), tachycardic (130 BPM), and tachypneic (30/min) with normal temperature. She had congested pulsating neck veins with positive Kussmaul sign. Chest auscultation revealed normal vesicular breathing with equal air entry and no adventitious sounds. Her O2 saturation was 60% on room air that improved to 85% on O2 mask. ECG showed sinus tachycardia. Echocardiography showed dilated right side, D-shaped septum with systolic flattening, dilated IVC, mild tricuspid regurgitation and estimated RV systolic pressure 53 mmHg. Her ABG showed compensated metabolic acidosis with elevated lactate level. At the ICU, CVP was 18 mmHg. Saline infusion was continued along with noradrenaline infusion initiation. A provisional diagnosis of high-risk pulmonary embolism was made, though CT pulmonary angiography was not available. Accordingly, thrombolytic therapy was initiated with alteplase (100 mg) over 2 h. Also, a dose of pulse steroids (methylprednisolone 200 mg) was given. Chest X-ray showed bilateral heterogenous opacity and ABG showed deteriorating hypoxia and combined metabolic and respiratory acidosis. The patient was intubated upon deterioration of conscious level and was put on mechanical ventilation. Her ET tube showed frequent blood-tinged secretions. Echocardiography showed more right-side dilatation that was consistent with deterioration of clinical status. Three hours after admission the patient developed cardiac arrest and died 2 h later.

CONCLUSIONS

This case report highlights the dangers associated with injectable filler usage in the gluteal region. Physicians and patients should be aware of the possible complications and how to avoid it.

Safety and Efficiency of Minimally Invasive Buttock Augmentation: A Review

BACKGROUND

Volume restoration and enhancement of the gluteal region appearance has become nowadays a popular concern in particular for many women. Several options are available, none however are without complications and side effects. Volume enhancement with soft tissue fillers of the gluteal region is emerging as a highly attractive minimally invasive modality. It has led unfortunately to more unlicensed, nonmedical practitioners administering illicitly injections for buttock augmentation at relatively low costs.

MATERIALS AND METHODS

To determine safety, efficacy, and cost effectiveness of mostly used soft-tissue fillers for buttock augmentation, a systematic literature search of PubMed, Medline, and Embase was conducted to identify the mostly used fillers for gluteal augmentation. It was complemented by searching for each of the identified filler material separately to retrieve any missed reports. References of clinical studies and trials, reviews, and consensus reports were reviewed as well for the same objective.

RESULTS

In the final analysis 12, mostly strongly biased clinical reports providing a low level of evidence, were identified for inclusion in the review. Two studies involved Polymethylmethacrylate (PMMA), 5 Poly-L-lactic acid, 1 Calcium hydroxyapatite and 4 hyaluronic acid filler injection. No studies were identified involving liquid silicone or Polyacrylamide hydrogel. The little available evidence provided by this review indicates that a specific brand of PMMA in Brazil has a demonstrable relatively good safety, efficiency, and cost-effectiveness record superior to surgical alloplastic gluteal augmentation or to lipofilling only when injected by experts.

CONCLUSION

Gluteal augmentation with soft tissue fillers is not as simple and innocuous as advertised. Serious complications may occur. Moreover, optimal buttock contouring entails not only volume augmentation but also volume removal; thus, volume augmentation with soft tissue fillers may not be ideal. Popularizing this modality must also be approached with great care. Serious complications do occur; they become inevitable when performed illegally by non-specialized, non-authorized, and unscrupulous practitioners in non-accredited facilities. Patients must be warned that adherence to regulations is critical and that only well-trained certified experts practicing legally in accredited facilities can address safely and efficiently their concerns.

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 .

[Injected non-absorbable fillers in large volumes]

AIM

To present treatment strategy for large volumes of injectable non-absorbable 'shell-less' soft tissue fillers (vaseline, synthol, silicone etc.).

MATERIAL AND METHODS

The authors present an experience of surgical treatment of 8 patients who underwent injections of medical vaseline (breast augmentation, n=5) and synthol (muscles enlargement, n=3) and review of the current literature devoted to this problem.

RESULTS

Injection of large amounts (over 50 ml) of non-absorbable fillers into soft tissues is unacceptable and leads to numerous complications. Oil-based 'shell-less' fillers cannot be removed by minimally invasive techniques (puncture, mini-incisions, etc.) due to multiple diffuse lesions in the form of oleogranulomas (cysts of different size) and surrounding widespread inflammation and fibrosis of tissues. Surgery is the only adequate method. However, this approach is followed by scars and often tissue contour deformation. Migration of these fillers to other anatomical areas (from the neck to the lower extremities) significantly complicates the situation, treatment and results. In case of categorical refusal of patients from surgical treatment and no complaints, they should be properly informed about possible consequences and complications and dynamic medical supervision is necessary. Intraoperative ultrasound examination is useful for the control of radical removal of pathological areas. Timely removal of non-absorbable fillers allows to avoid serious complications and to achieve good aesthetic results.