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DA-04
TREATMENT PROTOCOL FOR NONABSORBABLE FILLERS GRANULOMAS

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Introduction: PMMA-based inabsorbable fillers were widely used in Brazil in the early 2000s. The technique of injecting the substance using cannulae had won many surgeons and dermatologists. The low cost of the product compared to the value of hyaluronic acid, alternatively absorbable, also attracted large numbers of patients. There were several manufacturers using PMMA which was even available in handling pharmacies. After a few years of use, reports of series of complications began, including procedures performed by beauticians and other professionals without authorization in Brazil to perform the procedure. Complications include embolizations, sterile abscesses, and granulomas. The most frequent complication in our series was late granuloma, which should be differentiated from simple palpation of the product at the injection site. In the analysis of 568 patients submitted to this type of procedure by this author we detected and were asked to treat 36 patients. The complaint was the hardening and palpation of nodules, not always visible, in the injected areas. Based on the treatment carried out, we devised an algorithm for the approach of granulomas derived from PMMA.

Objective: To discuss the complications of inabsorbable fillers and to present a treatment algorithm for granulomas derived from PMMA.

Methods: We performed a retrospective study of the treatment performed on the 36 patients who presented reports of granulomas and palpable nodules after PMMA application. The selected patients were submitted to the application of the product in the concentration of 30% in the nasolabial sulcus and submalar region where the main complaints of granulomas were concentrated. We excluded mandibular, nose and body applications from the study. Multiple treatment combinations were performed or associated according to the case evolution: 4 weekly cycles intralesional injections of an engineered solution containing triamcinolone 4% (40mg / ml) and 2% Xylitol and 5-fluorouracil, diluted 1: 1 with 2% xylocaine with adrenaline, tripolar radiofrequency sessions, Allopurinol with successive doses up to 600mg / day and surgical excision.

Results: Patients presented mixed results with treatment. We started with the application of the solution containing triamcinolone, xylitol and 5 fluorouracil and enhances RF occurring not achieved reduction in size of the lesion, but not the total disappearance of granulomas. We noticed that the improvement was proportional to the time of application of PMMA, that is, the earlier the granuloma was treated, the better the results. Cases that did not improve with this protocol evolved to use allopurinol for a minimum period of 3 months. Cases with visible nodules and granulomas, with phlogistic signs, or discomfort of patients were somehow submitted to surgical resection. We noticed that granulomas were more frequent when the product was injected in a more superficial plane and at higher concentrations.

Conclusion: It is very important to choose carefully the products used for filling. Inabsorbable fillers can lead to late and difficult complications to solve. The authors' experience with PMMA complications motivated the elaboration of this treatment algorithm, which showed satisfactory results despite the fact that the complete elimination of the product can not be achieved with a conservative approach.

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