A 20-year-old woman presented with nodular swellings in her lips that had been present for over two years after injection with the filler Bio-Alcamid. Previous treatments with steroids provided no relief from the worsening swellings. Surgical excision of the nodules was performed, and biopsies showed no foreign body giant cells or crystalline structures. Various treatments are discussed for filler complications including steroids, 5-FU, anti-inflammatories, and surgical excision when conservative therapies fail. Bio-Alcamid has been removed from the market in many countries due to significant reported adverse reactions.

1. 61
CASE FILES
Aesthetic Medicine • June 2014
S K I N / D E R M AT O L O G Y
www.aestheticmed.co.uk
Dr Patrick Treacy shares some of his most challenging cases.
This month, the he talks about the removal of Bio-Alcamid
filler from a lip…
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish
Association of Cosmetic
Doctors and Irish regional
representative of the British
College of Aesthetic Medicine
(BCAM). He is European medical
advisor to Network Lipolysis
and Consulting Rooms and
holds higher qualifications in
dermatology, laser technology
and skin resurfacing. In 2012
and 2013 he won awards for
‘Best Innovative Techniques’
for his contributions to
facial aesthetics and hair
transplants. Dr Treacy also
sits on the editorial boards
of three international
journals and features regularly
on international television and
radio programmes. He was
a faculty member at IMCAS
Paris 2013, AMWC Monaco
2013, EAMWC Moscow 2013
and a keynote speaker for the
American Academy of Anti-
Ageing Medicine in Mexico City
this year.
>>
SPONSORED BY
A
20-year-old Russian female patient was referred to the Ailesbury Clinic
with nodular swellings in her labial area, which had been present for a
period of over two years. She reported a history of her lips having being
injected with the cosmetic filler Bio-Alcamid, 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 Bio-Alcamid.
She had previously been injected with a
hyaluronic acid filler prior to the use
of this semi-permanent 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 3cm ×
2cm along the lines of filler implantation in
each patient (Fig 1-4).
“The labial
swellings were
worsening in appearance
as time passed and the patient
was emotionally distressed.
Thereferringdoctorhadtreated
thepatientwithaninjectionof
Triamcinolone(40mg/ml)at
intervals,withnoresolution
oftheswelling.”
Fig 1.
Fig 3. Fig 4.
Fig 2.

2. 62 Aesthetic Medicine • June 2014
S K I N / D E R M AT O L O G Y
CASE FILES SPONSORED BY
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
outbydirectuseofasize11scalpel
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.
DISCUSSION
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
patients1
. 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)isanon-reabsorbable
polymeric material composed of 96% of apyrogenic water
and 4% of an alkylimide-amide group. Unlike other materials,
Bio-Alcamid 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 1ml syringes for
the lips (Bio-Alcamid LIPS) and one 3ml 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
havebeenreportedincludingsignificantinfectionsandmigration
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
CONCLUSION
Treatment options for filler complications include
intralesional steroids, 5-fluorouracil (5-FU), anti-
inflammatory and immunomodulatory drugs like minocycline,
rifampicin or hydroxychloroquine. Anecdotal reports
also suggest some relief with the use of non-steroidal
anti-inflammatory drugs (NSAIDs), antihistamines and
tacrolimus. In case of widespread lesions or repeated failure
of conservative therapies, surgical excision is the treatment
of choice. 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. AM
REFERENCES
1. GlavasI.P.:Fillingagents.OphthalmolClin.NorthAm.8:249-
257,2005.
2. NarinsR.S.andBeerK.:Liquidinjectablesilicone:Areviewofits
history,immunology,technicalconsiderations,complications,
andpotential.Plast.Reconstr.Surg.,118(3S):77S-84S,2006
3. Hönig,J.(2008).“CheekAugmentationwithBioAlcamidin
FacialLipoatrophyinHIVSeropositivePatients”.Journalof
CraniofacialSurgery19(4):1085–1088.
4. EvaluationoftheSafetyandEfficacyofBio-AlcamidforFacial
SoftTissueAugmentation.MohammedAbdElMageed.Egypt,J.
Plast.Reconstr.Surg.,Vol.31,No.2,July:129-137,2007
5. TreacyP.;GoldbergD.,UseofaBioPolymerFillerforFacial
LipodystrophyinHIV-Positivepatientsundergoingtreatment
withAntiRetroViralDrugs.JournalofDermatologicalSurgery
Volume32,Number6,June2006,pp.804-808(5)June6,2006
6. GoldanO,GeorgiouI,Grabov-NardiniG,etal. Earlyandlate
complicationsafteranonabsorbablehydrogelpolymerinjection:
aseriesof14patientsandnovelmanagement.DermatolSurg
2007;33(Suppl2):S199-206.
7. RossAH,MalhotraR. Long-termorbitofacialcomplicationsof
polyalkylimide4%(Bio-Alcamid).OphthalPlastReconstrSurg
2009;25(5):394-7.
8. DeBoulleK.Managementofcomplicationsafterimplantationof
fillers.JCosmetDermatol.2004;3:2–15.
www.aestheticmed.co.uk
“Anecdotal
reports also suggest
some relief with the
use of non-steroidal
anti-inflammatory
drugs (NSAIDs),
antihistamines and
tacrolimus.”