Ailesbury Clinic Cases
Removal of BioAlcamid Filler from lips
A 20yo Russian female patient was referred to Ailesbury with nodular swellings in her labial area for a period of over two years. She reported a history of their lips having being injected with the cosmetic filler BioAlcamid 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 BioAlcamid. She had previously been injected with another type of hyaluronic acid filler prior to the use of these semi-permanent type 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 3 cm × 2 cm along the lines of filler implantation in each patient (Fig 1-4). 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.
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 patients (1). 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, BioAlcamid 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 1-ml syringes for the lips (Bio-Alcamid LIPS) and one 3-ml 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).
Treatment options for filler complications include intralesional steroids, 5-fluorouracil (5-FU), anti-inflammatory and immunomodulatory drugs like minocycline, rifampicin or hydroxychloroquine.(14) Anecdotal reports also suggest some relief with the use of non-steroidal anti-inflammatory drugs (NSAIDs), antihistamines and tacrolimus (14) (15) . In case of widespread lesions or repeated failure of conservative therapies, surgical excision is the treatment of choice. (16) 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. (17).
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.