Journal of Cutaneous and Aesthetic Surgery
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CORRESPONDENCE  
Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 70-72
Plaque-type cutaneous sclerosis: A late complication of filler injection?


Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal

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Date of Web Publication17-Mar-2020
 

How to cite this article:
Neves JM, João A, Cabete J. Plaque-type cutaneous sclerosis: A late complication of filler injection?. J Cutan Aesthet Surg 2020;13:70-2

How to cite this URL:
Neves JM, João A, Cabete J. Plaque-type cutaneous sclerosis: A late complication of filler injection?. J Cutan Aesthet Surg [serial online] 2020 [cited 2020 Apr 4];13:70-2. Available from: http://www.jcasonline.com/text.asp?2020/13/1/70/280788




Dear Editor

Minimally invasive procedures are performed on a daily basis in cosmetic clinics worldwide. Filler injections are one of the most frequent interventions. Fillers can be divided into reversible—early/temporary and late/long—and irreversible.[1],[2],[3] Adverse events are common with any injectable dermal filler, and most of them are material independent and related to incorrect injection techniques or poor patient and localization selection.[2],[4],[5] The majority is classified as immediate reactions, which encompass mild bruising, redness, and edema. Necrosis, caused by intra-arterial injection, is the most serious early complication.[2],[3],[4],[5],[6],[7] Late complications are rarely reported and can develop weeks, months, or years after the filler injection, and they are often inflammatory and immune mediated. These mainly include foreign body granulomas, but also sarcoid-like reactions and panniculitis.[2] Herein we report the late development of skin sclerosis after a minimally invasive cosmetic procedure.

An 80-year-old woman presented with 1-year evolution ulcers of the right leg. On clinical examination, five small ulcers localized in the medial face of the right leg were observed. In addition, a brownish-orange, circumferential, sclerotic plaque covered both legs [Figure 1]. These cutaneous changes first appeared 5 years earlier as small plaques in both legs, with progressive extension and coalition, without any relevant symptoms. The patient had been submitted to a cosmetic procedure in 2009, consisting in the appliance of irreversible fillers, polymethyl methacrylate (PMMA) microspheres, Metacrill (Nutricel, RJ, Brazil), in both calves above the inner malleolus. This intervention was carried out for aesthetic purposes. Soft tissue and Doppler ultrasound of the lower limbs were performed, and skin biopsies were collected. The ultrasound examination revealed a bilateral, diffuse cutaneous and subcutaneous thickening, diffuse arterial atheromatosis, reflux of the greater saphenous vein on the right leg, and reflux of the lesser saphenous vein on the left leg. The histopathological examination [Figure 2] showed a dermal- and hypodermal-extended sclerosis, along with the focal deposition of small, irregular, non-birefringent spheres, and the presence of a perivascular and interstitial inflammatory infiltrate composed of lymphocytes, plasma cells, and multinucleated cells. Clinical–pathology correlation was not compatible with sclerosing panniculitis due to stasis. Laboratory screening for autoimmunity primary disease was negative. Negative wound pressure therapy was applied on the ulcers, which healed within 6 months. Considering the established and extensive fibrosis, the clinical stability of the sclerotic plaques, and the irreversibility of the used filler, the patient was instructed to daily use of emollient and compression stockings and to seek for early intervention in case of new ulcers.
Figure 1: (A) Asymmetrical sclerotic plaques on both legs. (B) Medial ulcers above the right inner malleolus on a sclerotic skin. (C) Left leg

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Figure 2: (A) Extensive dermal and hypodermal sclerosis (hematoxylin–eosin [H–E] ×40). (B) Deposition of irregular non-birefringent spheres (H–E ×200)

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PMMA is a permanent filler material currently used for soft tissue augmentation. It is composed by PMMA microspheres suspended within a solution. The specific features of the composition of the solution, the diameter of the microspheres, and the vehicle used for dilution are variable according to each type. Metacrill, in particular, consists of PMMA microspheres (30%), ranging from 40 to 60 μm in diameter (although it has been shown that dimensions actually range from 1 to 80 μm), suspended in a chemical nonabsorbable colloid composed of carboxymethylcellulose.[8] The number of serious complications reported with the use of PMMA is extremely low.[2],[4],[5],[9] Other from immediate reactions, most of them related to the injection technique, late complications include nodule formation, potential allergic reaction, and granulomas.[4] Chronic inflammatory reactions are normally reported years after the injection and can be interpreted as foreign body reactions to the PMMA molecule,[5] presumably due to the production of antibodies against PMMA-binding proteins, which being the inflammatory reaction onset triggered by systemic infection or surgical trauma.[5],[7] No standardized treatments for these complications are available, although removal surgery, intralesional injection of corticosteroids, or intralesional laser have been used in nodules or granulomas.[2] Metacrill is considered nowadays as a product with very low quality[5] due to the physical characteristics of its particles,[10] but it was commonly used between 2006 and 2012.[5] To the best of our knowledge, no reports are available in literature of a plaque-type cutaneous sclerosis reaction secondary to PMMA implantation. Nevertheless, given the anatomical and temporal evolution between the filler application and the emergence of the lesions, we assume the existence of an etiological connection. The clinical findings of uniform, symmetric, sclerotic plaques in association with extensive sclerosis in areas of microsphere deposition on histopathology strengthen this connection. We hypothesize that an inflammatory reaction targeting the PMMA particles can be the underlying mechanism of the cutaneous trophic changes observed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ledon JA, Savas JA, Yang S, Franca K, Camacho I, Nouri K. Inflammatory nodules following soft tissue filler use: a review of causative agents, pathology and treatment options. Am J Clin Dermatol 2013;14:401-11.  Back to cited text no. 1
    
2.
Haneke E. Adverse effects of fillers and their histopathology. Facial Plast Surg 2014;30:599-614.  Back to cited text no. 2
    
3.
Gold MH, Sadick NS. Optimizing outcomes with polymethylmethacrylate fillers. J Cosmet Dermatol 2018;17:298-304.  Back to cited text no. 3
    
4.
Park TH, Seo SW, Kim JK, Chang CH. Clinical experience with polymethylmethacrylate microsphere filler complications. Aesthetic Plast Surg 2012;36:421-6.  Back to cited text no. 4
    
5.
Blanco Souza TA, Colomé LM, Bender EA, Lemperle G. Brazilian consensus recommendation on the use of polymethylmethacrylate filler in facial and corporal aesthetics. Aesthetic Plast Surg 2018;42:1244-51.  Back to cited text no. 5
    
6.
Parada MB, Michalany NS, Hassun KM, Bagatin E, Talarico S. A histologic study of adverse effects of different cosmetic skin fillers. Skinmed 2005;4:345-9.  Back to cited text no. 6
    
7.
Vent J. Prevention and treatment of complications after polymethylmethacrylate-microspheres injections. 2014;1:628-35.  Back to cited text no. 7
    
8.
Salles AG, Lotierzo PH, Gemperli R, Besteiro JM, Ishida LC, Gimenez RP, et al. Complications after polymethylmethacrylate injections: report of 32 cases. Plast Reconstr Surg 2008;121:1811-20.  Back to cited text no. 8
    
9.
Lotierzo PH, Ferreira MC. Complications after polymethylmethacrylate injections: report of 32 cases. Plast Reconstr Surg. 2008;121:1811-20.  Back to cited text no. 9
    
10.
Piacquadio D, Smith S, Anderson R. A comparison of commercially available polymethylmethacrylate-based soft tissue fillers. Dermatol Surg 2008;34:S48-52.  Back to cited text no. 10
    

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Correspondence Address:
Jose M Neves
Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Alameda de Santo António dos Capuchos, 1169-050 Lisboa.
Portugal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCAS.JCAS_114_19

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