Dermal Filler Linked to Patient Death in Rio de Janeiro

Elioenai Paes

August 01, 2018

SÃO PAULO — Brazilian physician Denis Cesar Barros Furtado, MD — known on social media as Dr Butt — has been accused of injecting a large amount of polymethyl-methacrylate (PMMA) into the buttocks of a patient in Rio de Janeiro, potentially causing her death and causing consternation among physicians, other clinicians, and patients in Brazil.

Dr Denis Cesar Barros Furtado. (AP Photo/Leo Correa)

Furtado, who had more than half a million followers on Instagram, performed the aesthetic procedure on Lilian Calixto, a 46-year-old bank employee, in the apartment where he lived, not in an outpatient or hospital environment.

The patient lived in midwestern Brazil and traveled to Rio de Janeiro for her "bioplasty," as the procedure is known. According to reports in the press, Lilian told her family that she would return home right after the procedure.

However, 6 hours after the procedure, Furtado personally took Calixto to the emergency room, as recorded on a video posted on social media by Furtado himself, but within a few hours she experienced cardiac arrest and died.

A venous thromboembolism due to the dermal filler is the suspected cause of death, but the official cause of death has not yet been disclosed.

Furtado went on the run for 4 days with his mother, a former medical doctor who lost her license after being sued for malpractice. They were finally arrested on July 19 in Rio de Janeiro, where they were indicted on a first-degree murder charge for the death of Lilian Calixto.

Furtado's Attorney Responds

Medscape Medical News spoke by phone yesterday with Naiara Baldanza, the attorney representing Furtado.

Baldanza said that she has not yet had access to all the documents of the official medical examination, so it is still not possible to confirm whether the doctor applied PMMA to the patient. But regardless of the result of the investigation, she said, Furtado used only Biossimetric products from MTC Medical, and the manufacturer produces the product following strict quality standards.

According to the lawyer, Furtado was qualified to use PMMA in bioplasties, but he is not a plastic surgeon, so the procedures performed by him were not invasive.

Baldanza noted that it is premature to attribute the death of Lilian Calixto to the procedure done by the doctor, and that it is possible that the patient had a pre-existing condition that may have contributed to her death. She also said that the report on Lilian's cause of death was inconclusive.

When questioned about next steps, Baldanza said the defense will continue to press for Furtado's release from custody so that he can more effectively respond to the charges. According to Baldanza, pretrial custody is justified only in the case of maintenance of public order or if the accused creates embarrassment to the procedural instruction, which, she says, is not the case here.

She pointed out that his medical license has been suspended and he cannot practice medicine. Because of that, "I see no legal reasons for keeping him in jail."

The tragedy has raised a dispute about the safety of PMMA, the material allegedly used in the procedure. Although this substance is approved by Brazil's regulatory authority Anvisa, experts consulted by Medscape Medical News recommended caution in its use.

Recommended for Facial Lipodystrophy

The vice chair of the Brazilian Society of Dermatology, Sérgio Palma, MD, said that use of PMMA should be limited to small amounts, as it is typically done in the setting of AIDS-associated facial lipodystrophy repair.

Márcio Soares Serra, MD, a dermatology fellow member of the Brazilian Society of Dermatology, has been performing filling procedures with PMMA in patients with HIV for the last 2 decades. According to Serra, the success of the application relies greatly on the physician's skills, and the substance is not indicated for application in large quantities.

There are no long-term studies showing PMMA's efficacy or safety. In studies using small amounts, such as 22 mL, dermal filling can be safe ( J Eur Acad Dermatol Venereol. 2012;27:990-996), as long as the physician is qualified to use the product correctly.

According to Serra, this dermal filler should be used only subcutaneously.

"In my own experience, all of the problems I've seen with PMMA happened when the product was injected either too deeply, into the muscle, or very superficially," he said.

Marcela Cammarota, MD, a plastic surgeon and assistant secretary of the Brazilian Society of Plastic Surgery, warned that using PMMA in areas besides the face, such as the buttocks, calves, and thighs, is not recommended because the odds of developing complications are very high.

In the case of aesthetic filling for gluteal enlargement, the amount of PMMA needed can vary from 400 mL up to 1.5 L, which exponentially increases the unpredictability of the potential adverse outcomes, and is absolutely not recommended, Cammarota advised.

Problems Related to Proper Use of PMMA

Wendell Uguetto, MD, a plastic surgeon and member of the Brazilian Society of Plastic Surgery, said that even when used in small quantities PMMA is not free of adverse outcomes, even many years after injection. Potential adverse effects include edema, injection-site infection, granuloma, and displacement of the substance to another part of the body.

When a dermal filler complication occurs, surgical intervention is necessary to try to remove as much product from the body as possible. Not all of it can be removed because PMMA may mingle with the patient's tissues.

Palma explained that in most cases subsequent complications of PMMA use are not life-threatening, but can have an effect on the patient's self-esteem because effects such as edema and granuloma are visible.

"Some patients may need corticosteroids to control immune and inflammatory reactions. It's often appropriate to provide cycles of anti-inflammatory drugs to overcome the problem," Palma explained, adding that because PMMA is a definitive dermal filler problems may recur after some time.

Larissa Montanheiro, MD, a dermatologist based in Rio, also worries about the risks associated with the procedure.

"The risk escalates when the clinician does not have good technique, abilities, training, and excellent knowledge of the local anatomy," she pointed out.

Multiple brands of PMMA are on the market in Brazil. Anvisa banned pharmaceutical manipulation of this product in 2007, so the commercial product comes in ready-to-use syringes.

Uguetto, the plastic surgeon, believes PMMA should not have been approved by Anvisa because of the complications that may happen years later. He prefers to use safer alternatives that provide similar results, such as hyaluronic acid — although its effects last 18 months at most and it costs up to 10 times more than PMMA.

This article was originally published on Medscape Portuguese .

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