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restore facial volume and contours, but complications such Asia, the Middle East, and Latin America) and awaiting FDA
as granulomas and paraffinomas years after treatment have approval.
restricted their use for aesthetic treatment.
After injection, the implant is encapsulated and surrounded
Silicone by fibroblasts and microphages, theoretically preventing
No silicone product for soft tissue augmentation has been migration. Many studies have supported the usage of
approved by FDA. The major indication for FDA-approved Aquamid for the treatment of various rhytides, facial
products is retinal detachment with removal of the material contouring, and correction of HIV lipoatrophy. PAAG has
after reattachment. In soft tissue augmentation, removal been evaluated in clinical trials for facial contouring,
of silicone is not performed. The use of liquid silicon is off deep rhytides and folds, [90-92] and the correction of facial
label. For decades, horrendous complications have been lipoatrophy [93,94] with efficacy similar to nonanimal stabilized
[80]
reported from silicone injections into breasts, and its use has hyaluronic acid and duration of at least 1 year when used for
been banned by many authorities. Adverse effects have also the treatment of nasolabial folds. [95-98]
been noted after use for facial tissue augmentation. [81-83] After
illegal silicone injection, the silicone embolism syndrome For the past decade, Aquamid has gained popularity as
has been observed with potential fatal outcome in 24% of injectable filler. Similar to other facial fillers, there have
patients. Symptoms and signs of the “silicone syndrome” been reported cases of inflammation, nodule and granuloma
include dyspnea, fever, cough, hemoptysis, chest pain, formation, and delayed hypersensitivity reactions. Histologic
[84]
hypoxia, alveolar hemorrhage, and altered consciousness. analysis of Aquamid injected into the subcutaneous layer
They have almost been abandoned nowadays. revealed bioactive product that underwent cell infiltration
and integration into tissues between weeks 1 and 8. In
[99]
PMMA some instances, surgical extraction of the polyacrylamide
PMMA is rigid, transparent and colorless, thermoplastic product was necessary to correct the adverse event of
permanent skin filler with low cost, easy accessibility, and nodule formation. Careful attention to injection technique
potential to achieve lasting results. PMMA has been used and sterile precautions are necessary to minimize
as an injectable filler to treat hollows and reduce rhytids. unwanted reactions. In addition, there have been recent
PMMA injections have been associated with several side recommendations for the usage of prophylactic antibiotics
effects; especially they may lead to some undesirable effects to minimize complications from bacterial injections and
in the eyelids and periocular region. biofilm formation when injecting Aquamid. [100,101]

First-generation polymerized PMMA microspheres are Polyvinylpyrrolidone-silicone suspension
purified with diameter greater than 20 μm, which may This is a permanent filler comprised of particles of
produced foreign body granulomas; Lemperle et al. [85,86] polymerized silicone elastomer, 100-600 μm in size,
postulate that larger PMMA microspheres (30 to 50 μm) dispersed in a carrier of polyvinylpyrrolidone (Bioplastique;
[87]
may resist phagocytosis. However, Bachmann et al. Uroplasty BV, Geleen, The Netherlands). The suspension has
demonstrated that a giant cell reaction still occurs with larger been mostly used for lip augmentation and the correction
PMMA microspheres. Complications of PMMA injection were of facial rhytids. It should be injected in the subcutaneous
classified as nodular masses, inflammation, allergies and tissue. They usually remain at the injected site and could
skin hypopigmentation. The most affected sides were the avoid from being phagocytosed by macrophagesdue to the
lips (46%), followed by periocular, nasolabial folds, forehead, large size of the silicone particles. They would produce a
and cheeks. PMMA injection to the periocular region may local foreign body reaction and fibrosis, which contributes
be lead to erythema, hardening of the local tissues, edema, to the filling effect. [102] Local side effects include induration,
and formation of nodules and eyelid malposition, which are swelling, and granuloma formation. [103-105]
associated with fibrotic nodules, giant cell inflammation.
The best treatment for these PMMA injection complications Histopathologically, granulomas secondary to this filler
remains uncertain. Corticosteroid injection may have limited consist of irregularly shaped cystic spaces containing
efficacy while surgical debulking may achieve favorable translucent, jagged “popcorn” nonbirefringent particles of
results. varying size dispersed in a sclerotic stroma surrounded by
[88]
abundant multinucleated foreign body giant cells. [102-105]
Aquamid (polyacrylamide hydrogel)
Aquamid has been used extensively for soft tissue Polyalkylimide gel
[89]
augmentation and body contouring for 2 decades. Aquamid Polyalkylimide gel is a permanent hydrophilic translucent
is a biocompatible and nonabsorbable hydrogel consisting gel filler composed of a hydrophilic biopolymer with
of 97.5% water and 2.5% cross-linked polyacrylamide (PAAG). 96% sterile water and 45% polyalkylimide polymer (Bio-
The gel is manufactured through polymerization of the Alcamid; Polymekon, Brindisi, Italy), and different from
acrylamide monomers and N, N’-methylenbisacrylamide. polyacrylamide. It has been used to increase volume in
[89]
Aquamid is currently approved in several countries in the cheeks in HIV patients with facial lipoatrophy related
Europe, European Conformity marked in Europe in 2001 to antiretroviral therapy and for gluteal augmentation,
for facial augmentation and minor body contouring, PAAG correction of irregularities after liposculpture, scar
is available in more than 40 countries worldwide (Europe, depressions, and posttraumatic subcutaneous atrophy and
96 Plast Aesthet Res || Vol 3 || Mar 23, 2016