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Aesthetic Medicine • June 2014

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Dr Patrick Treacy shares some of his most challenging cases. This month, the he talks about the removal of Bio-Alcamid filler from a lip…

Dr Treacy’sCASEBOOK

DR PATRICK TREACYis chairman of the Irish Association of Cosmetic Doctors and Irish regional representative of the British College of Aesthetic Medicine (BCAM). He is European medical advisor to Network Lipolysis and Consulting Rooms and holds higher qualifications in dermatology, laser technology and skin resurfacing. In 2012 and 2013 he won awards for ‘Best Innovative Techniques’ for his contributions to facial aesthetics and hair transplants. Dr Treacy also sits on the editorial boards of three international journals and features regularly on international television and radio programmes. He was a faculty member at IMCAS Paris 2013, AMWC Monaco 2013, EAMWC Moscow 2013 and a keynote speaker for the American Academy of Anti-Ageing Medicine in Mexico City this year.

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A20-year-old Russian female patient was referred to the Ailesbury Clinic with nodular swellings in her labial area, which had been present for a period of over two years. She reported a history of her lips having being injected with the cosmetic filler Bio-Alcamid, at the site of the swelling, to correct and project her labial profile. Her referral letter stated a 23G

needle had been used to inject the compound and entrance was made 0.5cm medial to the oral commissure with infiltration done along the vermilion border. Each hemilip was injected with a maximum of 0.6ml of Bio-Alcamid. She had previously been injected with a hyaluronic acid filler prior to the use of this semi-permanent filler. The labial swellings were worsening in appearance as time passed and the patient was emotionally distressed. The referring doctor had treated the patient with an injection of Triamcinolone (40 mg/ml) at intervals, with no resolution of the swelling. There was no relevant medical history and the patient did not have any clinical evidence of autoimmune or allergic diseases. On palpation, the patient presented with firm longitudinal swellings measuring 3cm × 2cm along the lines of filler implantation in each patient (Fig 1-4).

“The labial swellings were

worsening in appearance as time passed and the patient

was emotionally distressed. The referring doctor had treated the patient with an injection of Triamcinolone (40 mg/ml) at intervals, with no resolution

of the swelling.”

Fig 1.

Fig 3. Fig 4.

Fig 2.

62 Aesthetic Medicine • June 2014

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The nodules were prominent anteriorly and projected from inside the oral cavity. The patient was willing to accept surgical correction and histopathological evaluation of her underlying problem. Surgical excisions were carried out by direct use of a size 11 scalpel blade, without the use of local anaesthesia, by allowing the nodules to point under digital manipulation. The wound was thoroughly cleaned and the vermillion tissues were approximated in some cases with 5-0 Vicryl Rapide sutures (Ethicon, Inc) to achieve haemostatis. (Fig 5-6) The operation sites healed well and most had healed within a few days. The excision biopsies showed no evidence of foreign body giant cells or irregular crystalline structures.

DISCUSSION The search for the ideal filling material has been ongoing for centuries. The ease of use, effectiveness and low morbidity of hyaluronic acid types have made them popular among patients1. Various other materials, including collagens, autologous fat, hyaluronic acids and injectable liquid injectable silicone have also been used for this indication.2 Bio-Alcamid (Polymekon, Brindisi, Italy) is a non-reabsorbable polymeric material composed of 96% of apyrogenic water and 4% of an alkylimide-amide group. Unlike other materials, Bio-Alcamid can sometimes be removed even after long time after implantation.3 The gel is colorless and trans-parent. It is supplied in packs containing two sterile 1ml syringes for the lips (Bio-Alcamid LIPS) and one 3ml syringe for the face (Bio-Alcamid FACE).4 Some studies consider Bio-Alcamid to be almost an ideal injectable substance for the treatment of facial aesthetic defects.5 It also used medically to treat soft tissue deficits such as pectus excavatum, gluteal atrophy, acne scars as well as HIV facial lipoatrophy and Poland syndrome.6

Since its initial use, numerous reports of adverse reactions have been reported including significant infections and migration resulting in significant facial deformity.7 Because of this, Bio-Alcamid has been taken off the market in many countries and the original manufacture has since stopped production.8

CONCLUSION Treatment options for filler complications include intralesional steroids, 5-fluorouracil (5-FU), anti-inflammatory and immunomodulatory drugs like minocycline, rifampicin or hydroxychloroquine. Anecdotal reports also sug gest some relief with the use of non-steroidal anti-inflammatory drugs (NSAIDs), antihistamines and tacrolimus. In case of widespread lesions or repeated failure of conservative therapies, surgical excision is the treatment of choice. Surgical extirpation can also allow a dermatologist to prevent the cutaneous side effects of intradermal steroid or 5-FU injection and a histopathological confirmation can be done to rule out the possibility of a granuloma. AM

REFERENCES 1. Glavas I.P.: Filling agents. Ophthalmol Clin. North Am. 8: 249-

257, 2005.

2. Narins R.S. and Beer K.: Liquid injectable silicone: A review of its history, immunology, technical considerations, complications, and potential. Plast. Reconstr. Surg., 118 (3S): 77S-84S, 2006

3. Hönig, J. (2008). “Cheek Augmentation with BioAlcamid in Facial Lipoatrophy in HIV Seropositive Patients”. Journal of Craniofacial Surgery 19 (4): 1085–1088.

4. Evaluation of the Safety and Efficacy of Bio-Alcamid for Facial Soft Tissue Augmentation. Mohammed Abd El Mageed. Egypt, J. Plast. Reconstr. Surg., Vol. 31, No. 2, July: 129-137, 2007

5. Treacy P.; Goldberg D., Use of a BioPolymer Filler for Facial Lipodystrophy in HIV-Positive patients undergoing treatment with Anti Retro Viral Drugs. Journal of Dermatological Surgery Volume 32, Number 6, June 2006, pp. 804-808(5) June 6, 2006

6. Goldan O, Georgiou I, Grabov-Nardini G, et al. Early and late complications after a nonabsorbable hydrogel polymer injection: a series of 14 patients and novel management. Dermatol Surg 2007;33 (Suppl 2):S199-206.

7. Ross AH, Malhotra R. Long-term orbitofacial complications of polyalkylimide 4% (Bio-Alcamid).Ophthal Plast Reconstr Surg 2009;25(5):394-7.

8. De Boulle K. Management of complications after implantation of fillers. J Cosmet Dermatol.2004;3:2–15.

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“Anecdotal reports also suggest some relief with the use of non-steroidal anti-inflammatory drugs (NSAIDs),

antihistamines and tacrolimus.”