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 Dr. Monheit |
AGE-OLD HAZARD Clearly, biofilms aren't new to medicine, and they can appear on everything from knee joint implants to heart valves, catheters and other solid implants. But only recently have they been identified as the possible culprits behind dermal filler complications such as granulomas and nodules, one practitoner who has researched the association tells Cosmetic Surgery Times .
"Biofilms have become well known in other disciplines, but we're only now being confronted with them as a problem in aesthetic medicine because of the fact that our fillers are longer lasting and are larger, and we're using greater amounts of them for volumizing," says Gary Monheit, M.D., associate clinical professor of the departments of dermatology and ophthalmology at the University of Alabama, Birmingham, Ala.
Specifically, a biofilm is a complex aggregation of microorganisms or a colony of bacteria that lives and functions around a solid material, attaching to the surface of the material and building up around it as a polymorphic protein.WAITING GAME What can make biofilms particularly dangerous is their maneuvering into dormancy, where they become protected from antibiotics. "The polymorphic protein develops a genetic diversity in which the bacteria goes into a dormancy phase, making it untouchable by antibiotics," Dr. Monheit explains.
In the dormant stage, the bacteria develop what are ominously known as persister cells, and when they awaken from dormancy, they have the ability to form granulomas, nodules, abscesses and smoldering infections.
"Biofilms have been implicated as causing capsular contraction in breast implants and granulomas from silicone implants, and they have now been identified in fillers ranging from Sculptra, Dermalive, Radiesse, Radience, Artecoll, Arteplast, and many of the longer-lasting, large-volume fillers," he says.
While biofilms haven't been reported in common hyaluronic acid fillers approved in the U.S., there have been reports in Europe of biofilms with granulomatous and infective complications in products that combine hyaluronic acids and permanent particles, such as such as Dermalive Revolution, Dr. Monheit relates.
The three-dimensional structures that biofilms form are particularly nasty, providing a source of infection and resistance to antibiotic therapy. One recent poster described the use of electron microscopy scanning to examine a periocular granuloma that formed following poly-L-lactic acid injection and confirmed that biofilm surrounded the granuloma.
The authors raised the concern that filler granulomas may be caused by bacterial contaminants producing biofilms and urged the use of a meticulous aseptic technique with filler injection.
POSSIBLE PROPHYLAXIS Dr. Monheit agrees, stressing that sterile surgical technique prior to and during injection is essential, and noting that prophylactic antibiotics may be called for in some situations involving permanent fillers.
"There remains the issue whether patients with permanent filler should be placed on prophylactic antibiotics prior to surgical procedures or dental cleaning, but there is currently no good evidence one way or the other."
And, as was concluded in the study, Dr. Monheit notes that the only true resolution for biofilms is excision of the host object or implant.
"The only way to really deal with biofilms at that point is through surgical removal of the object or material they've attached themselves to," he states.
HOLD THE STEROIDS When confronted with nodules or granulomas, doctors' first instinct may be to place the patient on corticosteroids. However, if a biofilm is in place, that therapy may only make things worse, Dr. Monheit cautions.
"Corticosteroids may only allow the bacteria go back into its platonic state. Instead, if there is a tender area over an implant, the first thing that should probably be done is to put the patient on antibiotics."
Prevention, meanwhile, may be elusive until more is known, he says.
"Until we really find out how to prevent biofilms and get rid of them during their sequestered stage and how to inhibit them, I think we can expect to continue to have this problem," Dr. Monheit notes.
"Our implants are only getting bigger, we're volumizing more, the fillers are lasting longer — many a year or more — and I think most fillers that last long enough are simply going to be susceptible to being encapsulated by biofilms."
DISCLOSURE
Dr. Monheit is a consultant and clinical investigator for Allergan, Genzyme, Colbar/J&J and Ipsen/Medicis, and he is a clinical investigator for Dermik.
REFERENCE
Lowe NJ, Maxwell A, Patnaik R, Shah A. Polymerized l-lactic acid for volume replacement: an extended case review of 221 patients [poster]. Presented at: American Society for Dermatologic Surgery Annual Meeting; November 6-9, 2008; Orlando, Florida. Poster 21.
