Cosmetic Procedures and Lymphedema
Cosmetic surgeries and procedures to make us look younger are a multi-billion dollar industry that seems to b growing exponentially as we strive to hide our age and look more beautiful. We of the Western world seems to be driven in a frenzy to deny and hide our age, as if growing older is some type of horrible taboo to be avoided at all costs.
But, a what is the actual cost in terms of potential complications and pitfalls? I have long wonder about the long term effects of these injectable wrinkle removers. I have wonder about the possibility of damaging the lymphatics as these materials work their way through our lymph system.
Is there a possibility of these materials causing lymphedema.
Now, there is a newly release study that seems to indicate just that. Admittedly, reports thus far are rare, but if this initial report is any indication, the rate of secondary lymphedema may be just starting.
This is another important item we will be following and updating as new information becomes available.
June 2, 2008
Plast Reconstr Surg. 2008 May
Salles AG, Lotierzo PH, Gemperli R, Besteiro JM, Ishida LC, Gimenez RP, Menezes J, Ferreira MC. Division of Plastic Surgery, Faculty of Medicine, University of São Paulo, Brazil. firstname.lastname@example.org
BACKGROUND: During the past 15 years, polymethylmethacrylate has been used as a synthetic permanent filler for soft-tissue augmentation.
METHODS: This article reports 32 cases of complications seen at Hospital das Clínicas, Faculty of Medicine, University of São Paulo, for procedures performed elsewhere.
RESULTS: The average age of the patients was 43.6 years (range, 22 to 70 years). Twenty-five patients were women. Sixteen injection procedures were performed by certified plastic surgeons, nine by dermatologists, two by urologists, and one by a nonphysician. Complications were classified into five groups according to main presentation as follows: tissue necrosis (five cases), an acute complication that can be related to technical mistakes but that can also be dependent on patient factors or caused by local infection; granuloma (10 cases), which usually presents as a subacute complication 6 to 12 months after the procedure; chronic inflammatory reactions (10 cases), which usually occur years later and can be related to a triggering event, such as another operation or infection in the area that was injected (these reactions are immunogenic in origin and may have cyclic periods of activation and remission); chronic inflammatory reaction in the lips (six cases), which may be present with severe symptoms, especially with lymphedema, because of mobility of the lip; and infections (one case), which are rare but possible complications after filling procedures.
CONCLUSIONS: Polymethylmethacrylate filler complications, despite being rare, are often permanent and difficult or even impossible to treat. Safety guidelines should be observed when considering use of polymethylmethacrylate for augmentation.
Dermatol Surg. 2008 Mar
Zielke H, Wölber L, Wiest L, Rzany B. Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany.
BACKGROUND: Injectable fillers are widely used in aesthetic medicine. Although most materials are considered to be safe, adverse events occur. Our knowledge on frequency and potential risk factors is limited.
OBJECTIVE: The aim of this study was to describe adverse reactions to injectable fillers based on a partly population-based case series.
METHODS: Dermatologists, plastic surgeons, and maxillofacial surgeons in Berlin were asked to report patients with adverse reactions. Additional patients were obtained from a private practice. A standardized questionnaire was used to assess all data. All data were analyzed by descriptive measures.
RESULTS: Fifty-six patients (age, 48+/-11.2 (SD) years) who had been treated with nine different fillers were assessed. In 48 patients treated with only one filler, 167 areas had been treated. In 129 (77.3%) areas adverse reactions occurred 12.2+/-15.6 (SD) months after injection. Adverse reactions to biodegradable fillers occurred after 4.9+/-5.8 (SD) months, and reactions to nonbiodegradable fillers after 18.3+/-19.0 (SD) months (p=.005). As adverse events, continuing pain, swelling, nodules, pigmentation, abscess formation, and erythema were found.
CONCLUSION: Adverse reactions can be documented for all injectable fillers. Time until reaction as well as type of reaction, however, vary between different fillers. Further research is necessary to evaluate potential risk factors.
Dermatol Surg. 2007 Dec
Christensen L. Department of Pathology, Bispebjerg University Hospital, Copenhagen, Denmark. LC24@bbh.regionh.dk
BACKGROUND: All gels act as foreign bodies. Host response ranges from a few macrophages to an intense foreign-body reaction with fibrosis, depending on gel type. For polymer gels the filling effect stems from their volume. For combination gels it stems from the intended host foreign-body reaction to the microparticles. OBJECTIVE: This review explains how host tissue reacts with different gel types and how adverse reactions differ depending on gel type.
METHODS AND MATERIALS: This study is based on observations during the past 6 1/2 years from experimental/clinical studies and biopsies from adverse reactions.
RESULTS: Hydrophilic polymer gels constantly exchange water with their host tissue with minimal fibrosis. Degradable gels are encircled and degraded by macrophages; polyacrylamide gel is traversed by macrophages, replaced by fibrous, vessel-bearing strands. All other gels provoke a foreign-body reaction with ensuing fibrosis. Adverse reactions include bacterial infection for the hydrophilic gels and a fibrous granuloma for all other gel types. It is hypothesized that bacteria are maintained within a biofilm (a film comprising bacteria, their nutrients, and their waste products) giving rise to a low-grade infection.
CONCLUSIONS: Infectious nodules must be treated with antibiotics. Granulomas must be treated with a combination of both steroids and antibiotics or excision.
Wolfram D, Tzankov A, Piza-Katzer H. Department of Plastic and Reconstructive Surgery, Medical University of Innsbruck, Innsbruck, Austria.
Key Words: Facial fillers; Foreign body granuloma; Surgical intervention
BACKGROUND: An increasing number of soft tissue fillers have been introduced to the beauty market and these filler substances are widely used as non-toxic, non-immunogenic and relatively harmless injectable alternatives to surgical rejuvenation. Generally, facial fillers are injectable - or surgically insertable - products that are used to fill up the volume loss in the aging face. Depending on bioavailability, chemical composition and degradation, fillers can be classified as temporary or permanent, organic or inorganic and autologous or heterologous.
OBJECTIVE: A plethora of new products has swamped the beauty market since face rejuvenation has become socially acceptable as well as affordable to a wider population, but adverse reactions cannot be excluded. We present 4 patients with complications after injection of facial fillers [including Artecoll(polymethylmethacrylate microspheres), Restylane (hyaluronic acid), DermaLive (hyaluronic acid plus acrylic hydrogel particles) and Newfill (polylactic acid)] and surgical correction.
RESULTS: Surgical intervention led to good aesthetic and functional results after multiple unsuccessful conservative therapies.
CONCLUSION: We recommend that only physicians familiar with the injection techniques and the biological and chemical characteristics of the various injectable products should perform such interventions. Especially permanent fillers should be used with utmost reticence in cosmetic surgery and we would recommend their application only in reconstructive procedures. Additionally, documentation and reporting of all adverse effects must be mandatory.
Aesthetic Plast Surg. 2005
Christensen L, Breiting V, Janssen M, Vuust J, Hogdall E. Department of Pathology, Rigshospitalet Fred., Copenhagen, Denmark. email@example.com
Keywords: Adverse reactions - Facial augmentation - Literature review - Permanent effect - Synthetic injectable fillers
BACKGROUND: Synthetic injectable facial fillers with a permanent effect are widely atoxic and nonimmunogenic, but they differ with respect to composition and in chemical and biologic characteristics. Yet, they all act as foreign bodies in the tissues eliciting a host response that try to remove the gel. Inflammatory nodules may develop at the sites of injection-for some fillers, many years later, for others, not. Why is that?
METHODS: Biopsies were contributed by various plastic surgeons from Europe and Australia after requests were made at international congresses and workshops. The study was based on (a) 5 biopsies from unreactive tissue obtained at different times after injection of polyacrylamide hydrogel (Aquamid); (b) 28 biopsies from intermediate or late inflammatory nodules after injection of polyacrylamide hydrogel (Aquamid) (20 cases), a hyaluronic acid-polyhydroxyethylmethacrylate/ethylmethacrylate gel (Dermalive) (2 cases), and a gel consisting of polylactic acid in mannitol/carbomethoxycellulose (New-Fill) (6 cases); and © a review of the literature on adverse reactions after injection with permanent fillers.
RESULTS: Clinically unreactive tissues after injection with Aquamid showed modest or no host reaction. Inflammatory nodules showed an increased foreign body reaction and a bacterial infection after injection with Aquamid, and a combination of moderate foreign body reaction, fibrosis, and in some cases also bacterial infection after injection with Dermalive and New-Fill. According to the literature, inflammatory nodules occur no later than 1 year after injection with polyacrylamide hydrogel, but up to 6 years after injection of combination gels (Artecol), and up to 28 years after injection of silicone gel.
CONCLUSIONS: Inflammatory nodules are likely to be caused by a low-grade infection maintained within a biogfilm surrounding the hydrophobic silicone gel and the combination gels. Aquamid gel may prevent formation of a biofilm through its high water-binding capacity, explaining why late inflammatory nodules are not seen after injection of this polyacrylamide hydrogel product.