ORIGINAL ARTICLES Complications of Inject able Synthetic Polymers in Facial Augmentation COREY S. MAAS, MD IRA D. PAPEL, MD DAVID GREENE, MD DAVID A. STOKER, MD BACKGROUND. Injectabtc synthetic materials have been used for augmentation of soft tissue defects, correction of ivrinkles, and augmentation offacial features such as the nasal dorsum. Suc- cess has been limited by inflammatory reactions, material migration, and the difficulty of removal should complications oceiir. OBJECTIVE. To evahtate complications resulting from soft tissue augmentation with injectable alloplastic materials. METHODS. Retrospective review of seven cases. Clinical history, treatment, histopathotogic findings, and outcomes are assessed. RESULTS. Inflammatory reaction and tissue damage zvere refrac- tory to antibiotics and steroids, and surgery was required to remove the foreign material Histologic examination revealed giant cell foreign body reaction in ail cases. CONCLUSION. Injectable synthetic polymers can produce signif- icant complications including deformity and inflammatory tis- sue destruction, the control of which is complicated by the dif- ficulty of removing the materials. Removable tissue fillers, such as e-PTFE, or natural materials such as collagen, autologous, fat, or Alloderm, should be considered instead. © 1997 by the Amer- ican Society for Dermatotogic Surgery, Inc. Dermatol Surg 1997;23:871-'877. T he challenge of correcting subtle contour irregu- larities, fine rhytids, and augment focal anatomic areas of the face (eg, lips, nasolabial fold) has lead to trials, failures, and limited success with a num- ber of injectable naturally occurring and alloplastic ma- terials. Beginning at the turn of the century a number of reports have addressed this issue with mixed results. Gersuny suggested low-melting point paraffin in 1903, and later found extensive migration and inflam- matory reaction to the material.' Over the ensuing cen- tury a plethora of injectable materials including vege- table oils, mineral oil, lanolin, and beeswax were tried and met a common fate: chronic inflammation histolog- ically characterized by foreign body granulomas.~ Severe tissue reaction and unpredictability of long- term results with these materials lead investigators in the early 1960s to assess the new highly purified poly- From the Division of Facia] Plastic Surgery (CSM, DG, DAS), Depart- ment of Ototar\fngoiog\/-Hca(l and Neck Surgerif, University of California San Francisco, San Francisco, CaUfomia; and the Division of Facial Plastic and Reconslructizv Surgery (IDP), Department of' Ololaryngotogy-Head and Neck Surgery, The Johns Hopkins Medical Institution, Baltimore, Maryland. Presented at the annual Spring meeting of ihe American Academy of Facial Plastic and Reconstructive Surgery, Palm Beach, FL, May 13, 2994. Address correspondence and requests for reprints to: Corey Maas, MD, Division of Facial Plastic Surgery, 400 Parnassus, Suite A-717, San Fran- cisco, CA 94143-0342. mers for such apphcations. Injectable medical grade silicone was embraced as ideal among these synthetic polymers. Despite the caution suggested in a number of reports, silicone soon became wdely used for augmen- tation of many soft tissue defects by direct injection, in some cases using large volumes of the material.^*^ Se- vere complications of implanted large volume liquid silicone has been reported.''"^* However, some contro- versy still exists regarding the efficacy and safety of the so called "microdroplet injection technique" popular- ized by Orentreich and Webster.'"^'' In reports of sub- stantial numbers of patients with long-term follow-up, Webster suggested that, when used judiciously, this material was safe and effective." The interest in polymers for soft tissue augmentation was not limited to silicone, however. Polytetrafluoro- ethylene (Teflon) paste, still used for vocal cord reha- bilitation, was utilized for facial augmentation, but technical difficulties injecting the thick paste were en- countered, and an exaggerated inflammatory reaction seen with other nonautogeneic injectable materials oc- In sum, the use of many injectable synthetic poly- mers for injection augmentation of soft tissues is limited by tbe severe immunologic and inflammatory reactions they precipitate, as well as impredictable and occasion- ally short-lived augmentation results. These cases can © 3997 by the American Society for Dermatologic Surgery, Inc. • Published by Elsemer Science Inc. 1076-0512/97m7.00 • PU SW76-0512(97)00290-2