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Permanent Fillers

  • Márcio Soares SerraEmail author
  • Leonardo Zacharias Gonçalves
Living reference work entry

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Part of the Clinical Approaches and Procedures in Cosmetic Dermatology book series (CAPCD)

Abstract

Permanent fillers are mainly used in the correction of furrows and deep lines of the skin that are beyond the normal facial wrinkles that appear with aging. They can be an excellent option in facial rejuvenation, especially when there is need for facial and body volume restoration, such as in HIV lipodystrophy. Of the permanent fillers currently available, polymethyl methacrylate (PMMA) is the most commonly used, and has been shown to be safe, effective, and long lasting.

Keywords

Silicone Polyacrylamide Polyalkylimide Polymethyl methacrylate PMMA Fillers Lipoatrophy HIV Lipodystrophy 

Introduction

Despite the recent advances in industrial medical research, there is no ideal filler available. The ideal material for filling would need to meet certain criteria to be accepted by the medical community, such as being easy to apply, non-toxic, non-carcinogenic, non-immunogenic, and promoting a good cosmetic outcome. Currently, silicone-based products, polyalkylimide, polyacrylamide and polymethyl methacrylate (PMMA) are available on the world market. Of the permanent fillers available, only two are registered with ANVISA (Agência Nacional de Vigilância Sanitária, the Brazilian National Health Surveillance Agency) for use in Brazil: polyacrylamide and PMMA (Rorich et al. 2009; Casavantes 2004).

Types of Permanent Filler

Silicone

Liquid injectable silicone is a synthetic polymer composed of a common chain made of repetitive siloxane. Silicone has been used in the past as a filler because of its low cost and results; however, due to its capacity to migrate, its use as a filler has been banned in Brazil and several other countries. Recent research, mainly relating to the correction of facial lipoatrophy in patients with HIV, has demonstrated that if medical-grade silicone is used with the micro-droplet technique, silicone can be safe and have good filler aesthetics (Rorich et al. 2009; Jones et al. 2004).

Polyacrylamide and Polyalkylimide

Polyacrylamide (Aquamid®) and polyalkyimide (Bio-Alcamid®) are transparent biopolymers, hydrogels, biocompatible, non-toxic, physically and chemically stable, and non-reabsorb. They are indicated for the correction of cosmetic defects of the face caused by trauma or genetic damage, to increase soft tissue, to correct furrows, and to restore face contours as well as to increase the volume of the lips. According to their manufacturers, one of the advantages of these products is the ability to remove them; however, because of reports of infection of the hydrogel and other late complications they are no longer commonly used (Rorich et al. 2009; Casavantes 2004; Jones et al. 2007).

Polymethyl Methacrylate (PMMA)

Initially used as bone cement, PMMA is a vinyl polymer that is found in various products such as glasses, dental prostheses, and contact lenses. PMMA is the most commonly used permanent filler in Brazil, and five PMMA products have registration with ANVISA: one with import registration – Artecoll® – and four produced in Brazil – Metacrill®, LineaSafe®, Biossimetric®, and, more recently, Metaderm®. The main differentials among them is the vehicle, and the regularity and size of the particles. Artecoll® contains spherical PMMA particles with a smooth and polished surface, with 40 μ suspended in the ratio of 1:3 with 3.5% bovine collagen. Suitable for long-term correction of wrinkles and other skin defects, it is marketed in boxes with four syringes containing 0.5 ml of the product; according to the manufacturer, it should be implanted subdermally (Lemperle et al. 1998, 2000).

Although Artecoll® has recently been approved by the Food and Drug Administration (FDA) in the USA under the name of Artefill®, it has been widely used in Europe and Canada for some time. It has been used in more than 200,000 patients, and its worst complication, the formation of immune granuloma, has occurred in less than 0.01% of patients treated after more than 10 years of follow-up. It is not frequently used in Brazil, mainly because of its high cost and the need for testing prior to its use due to the possibility of bovine collagen allergic reaction (Rorich et al. 2009; Lemperle et al. 1998, 2000).

In Brazil, there are four formulations, produced here, based on PMMA registered with ANVISA: LeneaSafe®, which has hydroxyethyl cellulose as its carrier; and in Metacrill®, Biossimetric® and Metaderm®, the carrier of which is carboxymethyl cellulose, which makes it more fluid. These colloidal solutions include PMMA, with diameters between 30 and 80 μ, and are marketed at concentrations of 2%, 10% and 30% and sold in boxes containing 1 or 3 ml syringes. They are indicated for the definitive correction of wrinkles, depressions, and other skin defects such as scar depressions caused by acne sequelae and definition of facial (back of nose, chin, lips) or body (hands, legs, buttocks) contours. These products are biocompatible and have no animal component, and being a permanent filler produce immediate and prolonged results. The injection should be made in the deep dermis or subcutaneous level. Although intramuscular use is indicated, there are no recent publications on intramuscular use or regarding the use of large volumes (Carvalho Costa et al. 2009; Serra 2000; Pereira and Poralla 2001; Serra 2001, 2002a, b).

Procedure

Referring to PMMA performed using retrograde injections such as “parallel sticks,” “X crossed sticks,” “network crossed sticks,” or using the “fan” technique in the subcutaneous tissue (Fig. 1). When using needles, it is recommended that a luer-lock syringe be used and it should be aspirated before beginning the injection in order to prevent the material from being injected into the blood vessels. There are some important cautions to note prior to the procedure: suspend anticoagulants, when possible, 5 days prior; avoid analgesics and anti-inflammatories for 5 days before the procedure; and avoid natural substances such as Ginkgo biloba, which can also increase bleeding (Serra et al. 2004, 2013).
Fig. 1

(a) Paralell sticks technique on malar region and nasomental fold. (b) X crossed sticks technique on malar and mandibular regions and fan technique on temporal region. (c) Network crossed sticks on pre-auricular and mandibular regions

Prior to application, the implant site should be disinfected carefully with the help of a local antiseptic such as a chlorhexidine or alcohol 70% solution. Topical anesthesia, such as EMLA®, may be applied to the area to be treated. We currently prefer to use several small anesthetic buttons, using 0.05–0.1 ml of lidocaine with a vasoconstrictor, which makes the procedure less uncomfortable with reduced bleeding and less post-procedure edema (Figs. 2 and 3). Due to the high viscosity of PMMA, the area should be massaged after filling to ensure good molding of the product in the area.
Fig. 2

Anesthetic buttons marked in black and the area to be filled marked in blue using paralell sticks technique

Fig. 3

Anesthetic buttons marked in black and the area to be filled marked in blue using crossed sticks technique

Since PMMA is a permanent filler, care should be taken not to hypercorrect the area. If a complementary application is necessary, it should be performed after an interval of some weeks as otherwise initial tissue expansion and any excessive edema would make it difficult. In accordance with these consequences and the anatomy of the region, it is advised that any supplementary treatment be applied after a minimal interval of 30–45 days. During this period, the vehicle is absorbed and some histological changes can be observed. Cell migration and formation of collagen around the particles are reported. After the procedure, it is advisable to apply ice packs on the treated site for 15 min every 2 h or 10 min every hour on the day of filling. In case of persistent edema, we advise the use of cold compresses three times a day for another 3–5 days. Post-procedure, it is recommended that the following should be avoided for five days: heat, such as visiting a sauna or working close to an oven or stove; physical exercise; ingestion of alcohol; and excessive sun exposure for five days. There are no restrictions for the patient regarding sleeping position or eating before and after the facial filling procedure. Similar to other fillers, mild erythema and edema may occur. These reactions spontaneously improve (in more than 95% of cases) after 24–72 h (Serra et al. 2013).

Side Effects and Management

Every procedure that uses needles is capable of injuring small blood vessels, causing the appearance of ecchymosis, which may take 1–3 weeks to disappear. Other common symptoms after the procedure may be local pain, which usually resolves without medication, and edema in the treated area, which usually disappears after 3–7 days. In cases of more severe edema, anti-inflammatories or oral corticosteroids can be prescribed.

The injection may eventually cause the appearance of a discrete local erythema, which is a result of dilation of the blood vessel capillaries in the region, being part of the normal physiological response. These reactions are temporary and disappear spontaneously after 24–48 h.

However, as occurs with other fillers, PMMA may trigger additional local reactions such as visible and palpable nodules (Fig. 4a, b) and necrosis (Fig. 5). These nodules are mistakenly referred as “granulomas” but they are actually a consequence of incorrect technique, when the filler is injected very superficially in the skin. Necrosis occurs when the filler is injected inside the vessels, forming obstruction as “pistons.” The glabella area is a risk zone due to the presence of superficial and large-caliber veins in the region; if the material is applied inside these veins, it may lead to emboli in the intraorbital veins, compromising the retina and, consequently, the patient’s vision. It is recommended that this product should not be applied in glabellar wrinkles or the nasal area to avoid local necrosis and unaesthetic results (Fisher et al. 2007; Serra et al. 2008; Lemperle et al. 2009).
Fig. 4

(a, b) Visible and palpable nodules

Fig. 5

Side effect: necrosis

Some late side effects include modifications in the volume and hardening of the treated area during an episode of systemic or localized infection close to the area previously filled (Fig. 6a–c). Rhinitis, sinusitis, and infections of the oropharynx have been reported as triggers. The edema and hardening usually disappear after treating the infection. These signs may also occur during the use of interferon for hepatitis C treatment. Patients should be warned of the risk of these late side effects.
Fig. 6

(a) Pre procedure (malar region filling with PMMA). (b) Edema of the malar regions and lips in the presence of dental infection. (c) Complete recovery after treating the dental infection

In Brazil, a colloidal solution with PMMA microspheres has been widely used for the correction of facial lipoatrophy with good results in patients with HIV/AIDS (Fig. 7) and is currently offered to patients in government referral centers for treatment of facial lipodystrophy. A case series report of 504 patients with 5 years of follow-up demonstrated that PMMA was safe and effective and there were no occurrences of long-term side effects such as infection or formation of immune granulomas.
Fig. 7

(a, b) Before and after with PMMA for facial lypoatrophy in HIV patient

Theoretically, any region of the body can be treated with this filler, as long as the tissue is distensible, and the treatment technique is basically retrograde injections into the subcutaneous tissue. The amount to be injected per area, the number of injections, and the interval between each session vary according to the patient, and the area to be corrected and the indication to correct or not must be determined by the physician (Carvalho Costa et al. 2009; Serra 2000, 2001, 2002a, b; Pereira and Poralla 2001; Serra et al. 2004, 2013; Soares and Costa 2011; Orsi et al. 2011). At the moment, there are no studies that have determined the maximum amount of PMMA that can be used in each session, the number of sessions, or the maximum quantity that can be used by one person. Extensive experience is fundamental to gaining the best results.

In addition to the face, other areas of the body such as the back of the hands, buttocks, and chest have been treated with PMMA. Although some professionals apply PMMA intramuscularly to add volume to the calves and buttocks, there are no studies regarding this technique. We consider that the best use of PMMA for large areas such as buttocks is to improve the shape and contour rather than to give volume. Generally, we use 40–60 ml per session, but a maximum amount of 120 ml has been used. Subcutaneous retro-injections, using the “in network” technique, should be performed in all areas, with a 3-month interval between sessions (Serra et al. 2015).

A study on the use of PMMA in 616 HIV (Serra et al. 2008) patients over 10 years has been reported. The amount of PMMA used per patient for treatment ranged from 6 to 38 ml. For the buttocks, the amount used ranged from 40 to 250 ml per patient. For both regions, most patients required two to three sessions to achieve good results. This is in contrast with our experience, in which the largest amount we used to treat buttock lipoatrophy in a HIV-patient was 938 ml in total, divided into 11 sessions (Fig. 8) (Serra et al. 2015).
Fig. 8

(a, b) Before and after with PMMA for buttock lypoatrophy in HIV patient

Conclusions

Permanent fillers are used to correct furrows and deep depressions in the skin and for volume replacement. Of all of the permanent fillers available on the market, PMMA is the only one that is regularly used. PMMA has been demonstrated to be safe, effective, and long lasting, with few adverse reactions when utilized correctly correctly.

Take Home Messages

  • Permanent fillers are used for deep depression corrections and volume replacement.

  • Silicone, polyacrylamide, polyalkylimide, and PMMA are the most common permanent fillers on the market.

  • PMMA is the main permanent filler used currently.

  • In Brazil, PMMA is widely used for correction of HIV lipoatrophy.

  • PMMA can also be used for body volume restoration.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Márcio Soares Serra
    • 1
    • 2
    • 3
    • 4
    Email author
  • Leonardo Zacharias Gonçalves
    • 3
  1. 1.DermatologyFederal University of The State of Rio de JaneiroRio de JaneiroBrazil
  2. 2.Cosmiatric Dermatology, Gaffrèe and Guinle University HospitalRio de JaneiroBrazil
  3. 3.Brazilian Society of DermatologyRio de JaneiroBrazil
  4. 4.American Academy DermatologyScaumburgUSA

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