What happens if a patient with rheumatism immunity gets a lipolysis injection?

About the complications of liposuction needles

At present, the only approved lipolysis needle is Kybella under Allergan, which is certified by the US FDA and Taiwan Food and Drug Administration.

Kybella lipolysis needle works by inducing the lysis of fat cells

However, can Kybella be used for those seeking beauty who are undergoing immunomodulatory therapy?

Here, the case we are going to talk about today is a case of a patient with rheumatoid arthritis who suffered secondary mumps after injection of Kybella fat-dissolving needles on both sides of the maxillofacial region

Complication details

This is a 70-year-old Caucasian woman who sought mandibular fat at the private clinic of an ophthalmologist in Vancouver

Her past medical history was rheumatic polymyalgia, taking diclofenac and azathioprine

At that time, the doctor gave 400 mg of ibuprofen and 1g of acetaminophen before the injection for pain relief

The dose injected by the doctor is: 2ml of Kybella+1ml of triamcinolone acetonide and then injected into the subdermal fat on each side

On the second day after surgery, the patient developed pain and numbness on the right side of the face

Figure 1B

One month after the treatment, a CT scan of the facial bones was performed.

figure 2

The doctor instructed the patient to use ciprofloxacin 500 mg twice a day for 1 week, and the patient's symptoms began to improve objectively

Figure 3: Still the elegant old lady

Possible mechanism

1

Kybella physically destroys cell membranes as a surfactant, and fat is more sensitive to the lysis of these cells than other tissues

2

Common side effects include discomfort, pain, swelling, and ecchymosis at the local injection site, while less common and serious complications include mandibular nerve margin damage, difficulty swallowing, or skin ulcers

Picture: Common complications of lipolysis needles

3

Doctors believe that this unique manifestation may be multifactorial, but part of the reason may be due to the patient's pre-existing rheumatoid arthritis

4

Finally, the inflammation of rheumatoid arthritis also has end-of-organ effects, such as exocrine glands, including parotid glands (secondary Sjogren’s syndrome)

5

On the other hand, because this mumps is unilateral and is not completely suppressed by prednisone

I hope that this complication case will attract everyone's attention, because Kybella has been on the market abroad not long ago, so I think it is the right way to pay more attention to the complication
.

About the complications of liposuction needles

At present, the only approved lipolysis needle is Kybella under Allergan, which is certified by the US FDA and Taiwan Food and Drug Administration.
Its approved indication is for submental fat accumulation, which is the position of the double jaw.
It is not approved for use in other parts of the body.
All clinical trials are only used to eliminate the accumulation of submental fat, and cannot guarantee the safety of use in other locations (this sentence must be focused, and it is related to our popular science today)
.

Kybella lipolysis needle works by inducing the lysis of fat cells
.
Commonly reported side effects of subcutaneous injection include pain, erythema, local hematoma or edema, and heat or burning sensation during injection
.
Although Kybella has a local pro-inflammatory effect, it is very rare to have a local or systemic inflammatory response to this drug
.

However, can Kybella be used for those seeking beauty who are undergoing immunomodulatory therapy?

Here, the case we are going to talk about today is a case of a patient with rheumatoid arthritis who suffered secondary mumps after injection of Kybella fat-dissolving needles on both sides of the maxillofacial region
.

Complication details

This is a 70-year-old Caucasian woman who sought mandibular fat at the private clinic of an ophthalmologist in Vancouver
.
She has received facial and neck medical beauty treatments (such as botulinum toxin, IPL, Thermage) without any complications
.

Her past medical history was rheumatic polymyalgia, taking diclofenac and azathioprine
.
She has no previous medical history of facial inflammation, surgery, trauma or infection
.

At that time, the doctor gave 400 mg of ibuprofen and 1g of acetaminophen before the injection for pain relief
.
According to the anatomical changes of the mandibular line, the fat in the mandible and submental area was measured (Figure 1A is what she looked like before the operation, this is an elegant old lady)
.

Figure 1A (before surgery)

The dose injected by the doctor is: 2ml of Kybella+1ml of triamcinolone acetonide and then injected into the subdermal fat on each side
.
Pay special attention to separating the skin from the bone during injection to avoid injury to the mandibular nerve
.
Administer 2.
0 mL per side
.
Before and after treatment, apply ice for about 10 to 15 minutes
.

On the second day after surgery, the patient developed pain and numbness on the right side of the face
.
The examination showed mild erythema and swelling in the right mandible, without induration, discharge or ecchymosis (see Figure 1B)
.
There is a slight lip asymmetry because the swelling on the right side is greater than that on the left side, and she has difficulty opening her mouth
.
Take prednisone 25 mg/d orally for 10 consecutive days and increase to 50 mg/d after 5 days
.
After the prescribed duration, steroids were stopped due to lack of improvement in clinical symptoms
.

Figure 1B

One month after the treatment, a CT scan of the facial bones was performed.
The imaging results showed that the right parotid gland was enlarged, and the diffuse changes were consistent with the continuous inflammation process (see Figure 2)
.
No masses, swollen lymph nodes, parotid duct stones or facial bone abnormalities were found
.

figure 2

The doctor instructed the patient to use ciprofloxacin 500 mg twice a day for 1 week, and the patient's symptoms began to improve objectively
.
During the 6-month follow-up, she reported that she was still recovering, but the examination showed that the right parotid gland was enlarged and the posterior asymmetry was significantly improved (see Figure 3)
.

Figure 3: Still the elegant old lady

Possible mechanism

1

Kybella physically destroys cell membranes as a surfactant, and fat is more sensitive to the lysis of these cells than other tissues
.
The destruction of the cell wall of adipocytes leads to a local inflammatory response, which first absorbs neutrophils and macrophages to clear the released lipids, and then promotes the subsequent formation of new connective tissue fibroblasts
.

2

Common side effects include discomfort, pain, swelling, and ecchymosis at the local injection site, while less common and serious complications include mandibular nerve margin damage, difficulty swallowing, or skin ulcers
.
In the MEDLINE and EMBASE databases, we could not find any previously recorded cases of mumps complications
.

Picture: Common complications of lipolysis needles

3

Doctors believe that this unique manifestation may be multifactorial, but part of the reason may be due to the patient's pre-existing rheumatoid arthritis
.
It is well known that such patients' circulatory inflammatory pathways are upregulated-including cytokines, acute phase reactants, immune complexes and lipid changes
.
Among these pro-inflammatory cytokines, tumor necrosis factor alpha and interleukin 6 (IL-6) are key molecules that promote the "inflammatory state" of adipocytes and can significantly change normal tissue behavior
.
Therefore they are more sensitive to cytokine stimulation
.

4

Finally, the inflammation of rheumatoid arthritis also has end-of-organ effects, such as exocrine glands, including parotid glands (secondary Sjogren’s syndrome)
.
In addition, the doctor also believes that it is very likely that this patient has subclinical mumps before the injection
.

5

On the other hand, because this mumps is unilateral and is not completely suppressed by prednisone
.
Other considerations include the possibility of direct puncture of the parotid gland or the possibility of Kybella spreading in the parotid gland, although there are no obvious complications at the time of surgery
.
Sleeping habits are also thought to be a factor in the swelling of the face, but the patient denied any tendency to sleep on the affected side
.

I hope that this complication case will attract everyone's attention, because Kybella has been on the market abroad not long ago, so I think it is the right way to pay more attention to the complication
.