Bacterial biofilm formation and treatment in soft tissue fillers

Abstract

Injection of soft tissue fillers plays an important role in facial reconstruction and esthetic treatments such as cosmetic surgery for lip augmentation and wrinkle smoothening. Adverse events are an increasing problem, and recently, it has been suggested that bacteria are the cause of a vast fraction these. We developed a novel mouse model and evaluated hyaluronic acid gel, calcium hydroxyl apatite microspheres, and polyacrylamide hydrogel for their potential for sustaining bacterial infections and their possible treatments. We were able to culture Pseudomonas aeruginosa, Staphylococcus epidermidis, and Probionibacterium acnes in all three gels. When contaminated gels were left for 7 days in a mouse model, we found sustainment of bacterial infection with the permanent gel, less with the semi-permanent gel, and no growth within the temporary gel. Evaluation of treatment strategies showed that once the bacteria had settled (into biofilms) within the gels, even successive treatments with high concentrations of relevant antibiotics were not effective. Our data substantiate bacteria as a cause of adverse reactions reported when using tissue fillers, and the sustainability of these infections appears to depend on longevity of the gel. Most importantly, the infections are resistant to antibiotics once established but can be prevented using prophylactic antibiotics.

Biofilm-based Healthcare-associated Infections

“…The viscous mucus is the perfect habitat for bacterial growth and biofilm development and facilitates persistent bacterial infection (Bjarnsholt et al 2009a;Johansen et al 2012). The presence of foreign bodies including artificial joints and indwelling catheters also support the advent of chronic biofilm infections , and we have found that the same is also true for injected tissue fillers (Alhede et al 2014;Bjarnsholt et al 2009b;Christensen et al 2013). Acquired chronic diseases such as diabetes mellitus, arteriosclerosis of leg arteries, and smoking-induced chronic obstructive pulmonary disease (COPD) also create perfect habitats for chronic bacterial infections as seen in COPD patients, who are prone to chronic lung infections or patients suffering from non-healing wounds, which are chronically infected with…”

“…It is still argued, however, that tissue fillers do not support bacterial growth (Alijotas-Reig et al 2010). To investigate this further researcher incubated different relevant bacteria (including S. epidermidis and P. acnes) with different tissue fillers in an in vitro setup (Alhede et al 2014). They found that non-degradable as well as slowly degradable and degradable fillers were able to nest bacterial biofilms (see Fig.…”

A Comprehensive Approach to Multimodal Facial Aesthetic Treatment

“…Recognition of the potential for adverse events contributes to the need for a judicious approach in applying optimal bolus volumes to achieve the desired effect. 34 The investigators emphasize the importance of not exceeding bolus volumes of 0.1-0.2 mL. Important factors, including slow and deliberate technique, smooth movement of the needle through the tissue, amount of filler injected, positions and plane of injection, and the overall experience and skill of the injecting physician, may impact safety and the incidence of complications that commonly occur with the use of all HA fillers.…”

Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers—Evidence- and Opinion-Based Review and Consensus Recommendations

“…15,16 These quiescent communities may become activated on repeated treatment. The surface area of product (large bolus), longevity of product, 16,17 and inadequate sterile technique are other factors hypothesized to play a role in biofilm development. In the panel’s opinion, hyaluronic acid fillers have a low incidence of biofilm formation, although the relative risk may vary by filler, and the risk may be increased if the product is placed in the presence of a previously injected permanent filler.…”