What Can I Do About Lumps from a PMMA Product Like Artefill or Artecoll?

Question

Hi
I have developed a granuloma under each eye in the tear trough area from a product called "Precise," which is a PMMA product I received in Mexico 2 years ago. This product is essentially the same as Artefill/Artecoll.
I have been to see several doctors and have done extensive research on the internet. It appears I have two real options, the first is to have the product removed doing micro-lipo suction with a fine needle to scrape out the particles, which should not cause scarring, and the other is to have it surgically removed. I tried steroid injections but the change was minimal and short lived.
Here are my questions:
Is it possible to remove PMMA with micro-lipo if the product is encapsulated or embedded?
Would surgically removing from the tear trough area cause serious scarring or can it be handled in a way to leave scars that are manageable?
I welcome and appreciate any answers or insight !!
Thanks.

Ryan Mitchell, DO, FAOCO · Answer

Hello,     Thank you for your excellent question regarding the treatment options for removal of a nodule in the tear trough of the lower eyelid caused by PMMA particles. You did not indicate the size of the nodules but in my opinion, the precise and complete surgical removal of the nodule in total, will be a better option then Micro-needle aspiration or curettage, both of which may very well not remove the entire nodule and more than likely, needle aspiration will cause more extensive bruising and swelling and more tissue damage that precise surgical excision.  I also believe that surgical excision will leave less scar tissue because this is a controlled and precise dissection of the nodule out of the tissues.  Using a needle will only break up the product to a degree and you will continue to have PMMA in the region.  This opinion is based on my previous experience regarding this issue and my opinion may change based on your physical exam. I make this opinion without seeing or feeling the nodules you are experiencing. I wish you the best of luck and I feel certain you will get this resolved.Best regards,Dr. Ryan Mitchell

Peter J. Malouf, DO · Answer

This is a very difficult problem and is probably due to the variability in particle size of precise.  Anything less than 80 microns can be gobbled up (phagocytized) by macrophages in your immune system.  So in this case, your body is attempting to attack and wall off the particles.  If it were my choice I would carefully use very dilute amounts of steroid injections over many months gradually with massage and hold off on procedures that can trade one problem for another.

	Dr. Malouf

Nissan Pilest, MD · Answer

First of all, to everyone reading this, don't have a permanent filler placed under the eyes. They have never been recommended for this area, for good reason!Unfortunately, most people do far less self-education on cosmetic treatments before they get them than after.
Second, stay at home for your cosmetic treatments and choose Board Certified Dermatologists or  Board Certified Plastic Surgeons for cosmetic treatments. The FDA assures that rigorous testing is done in clinical studies with dermal fillers before they are approved. This is not a certainty in other countries which have a different (or no) system of physician qualification, training or product safety rules and testing.
ArteFill is not the same as Precise (Percise) or Artecoll or other permanent fillers found outside the U.S. ArteFill was re-engineered from Artecoll (used in Europe) to lessen the problem potential of granulomas. ArteFill contains a low percentage of polymethylmethacrylate beads  -- 20% PMMA. The rest is collagen which breaks down and is removed by the body. ArteFill requires an allergy test (another safety factor).
I will not use ArteFill (Artefill is the only FDA approved noresorbable filler at this time) in any area other than that indicated in the FDA approval. Nor will I inject ArteFill before a patient has used a temporary filler first to gauge satisfaction with the correction they receive.
Any filler product can produce late stage reactions, but the chances are extremely low with temporary fillers like Juvederm, Restylane or a low concentration HA like Prevelle Silk. The more permanent the product, the more potential to small lumps or bumps.
Regarding the filler you received in Mexico:
There was no specific component information that I could find on Percise other than it is PMMA suspended in a saline hydrogel...and there was no information on percentages indicating the ratio of the PMMA to the carrier.
Now, to answer your question about removing a granuloma under your eye.
PMMA is a permanent particulate implant. It is meant for deeper injection in the nasolabial folds, not under the eyes, not in the lips and not in other areas of the face. Your problem will likely be most acceptably addressed with surgery - and I'd recommend you only go to a reconstructive plastic surgeon or an oculoplastic surgeon who will have the skills to minimize any scarring.

Steven Wallach, MD · Answer

PMMA is a permanent product that is extremely difficult to remove.  Liposuctioning will probably not be successful.  Yes, excision will leave scarring.  Tough decision to make.

Brian Windle, MD (retired) · Answer

I am very sorry to hear that you are having this problem.  The product you had is a PMMA based product
that is not available in the US for good reason.  The PMMA particles are uneven.  The earlier versions of Artefill (of
which Artecoll was one) had these
types of PMMA and they caused problems like lumps and bumps.  These complications were recognized by the
developers if Artefill and the PMMA particles, which act as bio stimulant were
all made smooth, round, uniform in size (slightly bigger than 40 microns) and
were negatively charged on the surface to further reduce any problems.  Artefill, as opposed to the other fillers,
has one of the best safety profiles of all the fillers as a result.  This includes the hyaluronic acids like
Juvederm and Restylane.

Unfortunately PMMA is non resorbable.  Therefore, at two years, the results you have
will not get any better.  There are two
potential solutions to your problem.  First, I have added more filler around the current filler
with great success.  If the intent was to
fill in an area and you have lumps from that treatment it may be that you just
need to get that area "tidied up". 
Airbrushing a filler like Artefill with a cannula, around the lumps can achieve
remarkable results.Second, surgical excision of lumps that are too big to fill
around can result in a nice result but is usually the second alternative I
would consider.I hope that helps.Best regards.

Nathan Mayl, MD (retired) · Answer

I am a trainer for Sculptra and consequently have been referred problem cases.

	Problems outside of the lids and lips are very rare.  

	These products should not be used in the lids because they are best under thicker skin and in a deeper level that does not exist in the eyes.

	However, i have removed the material from the lids by just making a tiny slit in a wrinkle and working the firm material out.  It DOES NOT RESPOND TO LIPOSUCTION because it is too dense.  Injections with cortisone are also difficult because the area moves away from the needle and you may place the cortisone just where you do not want it - about and not into the area of thickening.

	Dr. Mayl

	Fort Lauderdale

Richard P. Rand, MD, FACS (retired) · Answer

Permanent fillers are bad.  Period.  They cannot be removed and long term, they can develop granulomas and infections.  They also can emerge as you age like islands coming out of the ocean. I sincerely wish patients would get the message that these are bad products and ones to avoid.  Yes, it is painful and costly to have to reinject temporary fillers, but this is the only safe way to go.
That being said, other than direct excision, I don't think you can remove the product and remember that micro-liposuction IS surgery just as is open removal and micro-liposuction can also cause scarring.  This is a tough situation you have gotten into and there is no simple way out.  Sorry.

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