Efficacy and safety of polyacrylamide hydrogel for facial soft-tissue augmentation

BACKGROUND

Polyacrylamide is a nonabsorbable soft-tissue filler that has been used for body contouring for more than 10 years. Aquamid is a soft-tissue filler containing polyacrylamide hydrogel. Safety and aesthetic results after injection of polyacrylamide hydrogel for facial soft-tissue enhancement were assessed at a 1-year follow-up.

METHODS

In a prospective, multicenter study, 251 patients were enrolled and assigned for injection of polyacrylamide hydrogel (Aquamid) as a means of facial augmentation and enhancement of facial contours. Subjects with facial contour deformities or soft-tissue deficiencies caused by aging, acne, trauma, surgery, or other causes were included. Persons presenting with connective tissue disorders, skin disorders affecting the face, uncontrolled diabetes mellitus, compromised immune functions or acute inflammatory diseases, known substance abuse, or mental disorders were excluded from participation in the study, as were those who had experienced treatment with any nonabsorbable filler within 6 months before the start of the study. To assess the safety and efficacy of the treatment, follow-up visits were scheduled for day 7, day 28, and 3 months, 6 months, and 12 months after the first injection. Standardized photographs were taken before treatment and during month-3 and month-12 visits. Blood and urine samples were collected and analyzed before injection and at 6 and 12 months after injection. The most common sites of injection were the nasolabial folds (48 percent) and lips (25 percent) followed by glabella folds (8 percent) and other sites. The amount of injected gel ranged from 0.2 to 12 ml.

RESULTS

Two hundred twenty-eight patients were followed for 12 months after treatment. In 93 percent, results were judged to be good or very good by the investigators and satisfactory or very satisfactory by the patients. Adverse events that could be ascribed to the treatment were observed in 37 cases, most commonly presenting as transient swelling, hematoma, redness, and pain or itching. In one case, a slight change of skin color at the site of injection was reported. No severe adverse events related to the gel were observed. In one case, neutropenia was detected in month-12 blood samples. The other values were within the normal ranges.

CONCLUSIONS

Aquamid is an easy-to-use soft-tissue filler. The effect of tissue enhancement lasted over the entire study period. Transient local tissue reactions observed were attributable to the injection procedure rather than the chemical properties of the gel. During the first year after treatment, no permanent soft-tissue reaction was observed. Long-term results need to be evaluated in the future.

Postoperative sensitivity in Class I composite resin restorations in vivo

PURPOSE

This study evaluated the postoperative sensitivity of posterior Class I composite resin restorations, restored with a self-etching or a total-etch one-bottle adhesive system.

MATERIALS AND METHODS

One hundred four restorations were replaced by one clinician in 52 patients. Each patient received two restorations. After cavity preparations were completed under rubber-dam isolation, they were restored using Clearfil SE Bond or Single Bond and a resin-based restorative material (Filtek Z250). Sensitivity was evaluated at 0 and 7 days and 6 months using cold stimuli, and recorded using a visual analogue scale. If sensitivity was experienced on day 7, patients were also contacted on days 14 and 30 to assess the degree of sensitivity. The scores were analyzed as nonparametric data by means of the Friedman and Wilcoxon tests.

RESULTS

No statistically significant differences in sensitivity were found between the two adhesives systems at days 0 and 7 or at 6 months. No spontaneous postoperative sensitivity was reported.

CONCLUSIONS

The adhesives systems used in this study showed no differences in postoperative sensitivity, and did not show spontaneous sensitivity after 6 months.

Late opacification of hydroview intraocular lenses: report of 11 cases

PURPOSE

To report on the clinical and light microscopic analyses of Hydroview intraocular lenses (lOLs) explanted for late postoperative IOL opacification.

MATERIAL AND METHODS

Retrospective study of all cases with secondary lensimplantation performed at the University Hospital Leuven during a period of one year (2003-2004) for postoperative opacification of Hydroview IOLs. Further analyses on some of the explanted IOLs included gross and light microscopic evaluation.

RESULTS

Lens exchange for late-onset IOL opacification was performed in eleven eyes of eight patients. IOL opacification became apparent between 12 and 24 months after uneventful phacoemulsification and lens implantation. Visual acuity varied from < 0.05 to 0.6 before explantation. In 9 out of the 11 eyes postoperative visual acuity improved to the pre-opacification level. Light microscopic analyses showed a granular anterior lenssurface morphology composed of calcium.

CONCLUSION

Late postoperative opacification of Hydroview IOLs may cause severe visual impairment, requiring explantation. Calcium is involved in the formation of these opacifications. Reporting on this type of complications is mandatory according to the Belgian and European directives for medical devices.

[Analysis of complications induced by polyacrylamide hydrogel injection for augmentation mammaplasty]

OBJECTIVE

To analyze the complications induced by polyacrylamide hydrogel injection for augmentation mammaplasty, explore the reason of the complication.

METHODS

Twenty three patients with complications after polyacrylamide hydrogel injection were classified by signs and symptoms, ultrasound and pathologic examinations were made.

RESULTS

The main complications were pain, hard nodule, asymmetry and breast deformation. The injected material was distributed diffusely behind gland, in gland, in muscles subcutaneous, even out of breast, caused some pathologic changes and it's hard to be cleaned completely from normal tissue.

CONCLUSIONS

The complications were caused mainly by incorrect manipulation during operation, others might be relative to the injected material. The reliability of this injection method for augmentation should be cautiously observed.

Management for postoperative complications of breast augmentation by injected polyacrylamide hydrogel

Polyacrylamide hydrogel, a new biomaterial, has been used for injected breast augmentation in China since 1997. A series of 30 patients with various complications after injected polyacrylamide hydrogel visited the author's department. Most of these patients had undergone injection of both breasts. The average age of the patients was 27.6 years, and the time of consultation for the complications was from 3 to 36 months postopertively. Nearly all the patients had breast lumps and other common complications including breast pain, disfigurement, and infection. Ultrasound examination showed diffuse, irregular, anechoic zones of mammary tissue. Pathologic results indicated inflammatory cell infiltration and fibrous capsular formation. An open suction technique and partial mastectomies via periareolar incisions were performed for the all patients. Most of their symptoms were relieved after removal of the polyacrylamide hydrogel. Only one patient had undergone immediate breast reconstruction with implants, whereas five patients had received breast implants secondarily via an axillary incision. The authors conclude that polyacrylamide hydrogel should be prohibited for injected breast augmentation before more scientific data are available about the long effect of the gel in breast tissue.

Cranioplastie par lambeau libre ostéomusculaire temporo-pariétal

PURPOSE

Advances in composite materials for craniofacial reconstruction surgery has tended to limit indications for osteomuscular free flaps which nevertheless must be used for certain septic patients. The purpose of this report was to illustrate the usefulness of the free temoroparietal osteomuscular flap in this particular situation.

CASE REPORT

A 47-year-old man underwent surgical repair of an aneurysm of the anterior communicating artery complicated by acute hydrocephaly treated by external then ventriculoperitoneal bypass. The fronto-pteryonal approach was used. The early postoperative period was complicated by osteitis of the cranial piece requiring revision. The revision procedure, performed at the end of the septic period, involved cranioplasty with acrylic cement. Recurrent infection contraindicated any new attempt for prosthetic repair. The patient was treated with a controlateral free temporoparietal osteomuscular flap to achieve cranioplasty. The postoperative period was uneventful with no infection and satisfactory healing. Flap vitality was very satisfactory. The patient's neurological status improved and no further complication developed.

DISCUSSION

In certain therapeutic situations, several diffent techniques may be required to overcome postoperative complications or manage particularly difficult cases. A free osteomuscular flap can be a useful alternative for cranioplasty. This technique is rarely used but can offer an optimal solution in selected patients, particularly for second intention revision after failure of prosthetic repair.

Complications from injectable polyacrylamide gel, a new nonbiodegradable soft tissue filler

BACKGROUND

Polyacrylamide gels, containing a hydrogel composed of polyacrylamide and water, are used for soft tissue augmentation and contour correction. There are no reports of significant complications after injection of this material into the face.

OBJECTIVE

We report an inflammatory reaction after injection of polyacrylamide gels for zygomatic facial augmentation.

METHODS

A retrospective chart review of single case is presented.

RESULTS

An inflammatory reaction at the sites of polyacrylamide gels injection was noted at 1 month after initial injection. Despite two ensuing courses of broad-spectrum antibiotics, the patient presented to us with persistent draining nodules. Intralesional steroid injections resulted in prompt resolution and no recurrence.

CONCLUSION

Inflammatory reactions have been noted in patients receiving polyacrylamide gels for breast augmentation. Facial polyacrylamide gels injections may also be associated with an inflammatory reaction that responds to intralesional steroids. With increasing availability of a variety of soft tissue fillers, dermatologists should be aware of this delayed complication from polyacrylamide gels.

Adverse reactions to injectable soft tissue permanent fillers

BACKGROUND

Synthetic injectable facial fillers with a permanent effect are widely atoxic and nonimmunogenic, but they differ with respect to composition and in chemical and biologic characteristics. Yet, they all act as foreign bodies in the tissues eliciting a host response that try to remove the gel. Inflammatory nodules may develop at the sites of injection-for some fillers, many years later, for others, not. Why is that?

METHODS

Biopsies were contributed by various plastic surgeons from Europe and Australia after requests were made at international congresses and workshops. The study was based on (a) 5 biopsies from unreactive tissue obtained at different times after injection of polyacrylamide hydrogel (Aquamid); (b) 28 biopsies from intermediate or late inflammatory nodules after injection of polyacrylamide hydrogel (Aquamid) (20 cases), a hyaluronic acid-polyhydroxyethylmethacrylate/ethylmethacrylate gel (Dermalive) (2 cases), and a gel consisting of polylactic acid in mannitol/carbomethoxycellulose (New-Fill) (6 cases); and (c) a review of the literature on adverse reactions after injection with permanent fillers.

RESULTS

Clinically unreactive tissues after injection with Aquamid showed modest or no host reaction. Inflammatory nodules showed an increased foreign body reaction and a bacterial infection after injection with Aquamid, and a combination of moderate foreign body reaction, fibrosis, and in some cases also bacterial infection after injection with Dermalive and New-Fill. According to the literature, inflammatory nodules occur no later than 1 year after injection with polyacrylamide hydrogel, but up to 6 years after injection of combination gels (Artecol), and up to 28 years after injection of silicone gel.

CONCLUSIONS

Inflammatory nodules are likely to be caused by a low-grade infection maintained within a biogfilm surrounding the hydrophobic silicone gel and the combination gels. Aquamid gel may prevent formation of a biofilm through its high water-binding capacity, explaining why late inflammatory nodules are not seen after injection of this polyacrylamide hydrogel product.

Clinical and histologic evaluation of a new injectable implant: hydrophilic polyacrylamide gel

Hydrophilic polyacrylamide gel is a new, jellylike transparent implant that consists of 95% water and 5% polyacrylamide, and it has been applied in many countries for many years as a sort of injectable implant. However, there are no data regarding human tissue reaction to hydrophilic polyacrylamide gel to date. Thirty-one patients who had undergone the injection of hydrophilic polyacrylamide gel for soft-tissue augmentation from September 1998 to November 2001 wanted to remove the implant. Hematoxylin-eosin-stained sections from each cyst of tissue sample were investigated and analyzed with light microscopy. The tissue slices of 12 patients who had received an injection of silicone from 1988 to 1994 were reviewed. The difference in histologic features was assessed. The inflammatory reaction of hydrophilic polyacrylamide gel was characterized by the presence of more foreign body giant cells. The cellular response ranged from moderate or marked (4 to 18 months) to mild (>18 months). The difference was statistically significant (P <0.05). Little lymphocyte infiltration was shown in all slices of hydrophilic polyacrylamide gel. There were clusters or diffuse lymphocyte infiltration on histologic observation of the liquid silicone. The difference was significant (P <0.001). In summary, hydrophilic polyacrylamide gel may evoke a human tissue inflammatory response similar to other foreign materials. Lumpy subcutaneous nodules, mastodynia, and difficult removal may limit its application in breast augmentation.

Complications of foldable intraocular lenses requiring explantation or secondary intervention--2003 survey update

The sixth annual survey of complications associated with foldable intraocular lenses (IOLs) requiring explantation or secondary intervention was sent to members of the American Society of Cataract and Refractive Surgery and the European Society of Cataract and Refractive Surgeons. Preoperative data about visual acuity, patient signs and symptoms, and complications requiring IOL removal were evaluated. Complications were then tabulated for each of the following major foldable IOL groups: 3-piece monofocal silicone, 3-piece hydrophobic acrylic, 1-piece hydrophobic acrylic with haptics, 3-piece hydrophilic acrylic (hydrogel), 1-piece hydrophilic acrylic (hydrogel), 1-piece plate-type silicone, 3-piece multifocal silicone, and Collamer. Two hundred seventy-three surveys were returned for evaluation. Dislocation/decentration, incorrect lens power, IOL calcification, and glare/optical aberrations were the most common reasons for removing foldable IOLs. Good surgical technique, accurate IOL power measurements, and high manufacturing standards for foldable IOL materials and designs are the most important factors in avoiding complications with foldable IOLs.

Polyacrylamide gel in cosmetic procedures: Experience with aquamid

Polyacrylamides have been used in tissue augmentation since 1980. AQUAMID injections amounting to 40,000 have been done for facial and body corrections in cosmetic and reconstructive medicine and surgery. Possible neurotoxic and carcinologic effects of acrylamide and their stability are reported. The most important complications are infection, granuloma, and migration. All actual studies and results are reported. Main indications are lips, nasolabial fold, and malar area.

Biocompatibility and tissue interactions of a new filler material for medical use

Filler materials for medical use present limits, such as the induction of chronic inflammation and fibrosis. In the search for synthetic materials with improved biocompatible properties, a new polyacrylamide hydrogel, Aquamid (Contura SA, Montreux, Switzerland), has been investigated in preclinical systems. In cell cultures (endothelial cells and fibroblast), no or only transient biological effects were associated with 10% Aquamid exposure. The Aquamid-host interactions were examined in mice (10 mice per group) implanted subcutaneously or in the mammary fat pad with a very large volume (1.5 ml) of the material. Blood analysis, performed after 15 and 94 days (five mice per time for each group) to detect acute or late manifestations of toxicity, did not reveal relevant abnormalities in either group of Aquamid-bearing mice compared with control mice, except for a transient thrombocytopenia and a mild leukocytosis. Histological analysis of the pellet showed the presence of a thin, poorly vascularized cyst wall in implants. Only mild mesenchymal reparative and inflammatory processes were observed, even at longer observation times (more than 400 days). No alterations in any organ were detected. Despite the large volume implanted (approximately 5 percent of mouse body weight), the Aquamid pellet maintained its original size and shape without spreading or sticking to surrounding tissues. In conclusion, the study indicated a good tolerability of the new biopolymer in preclinical systems. The clinical utility of this new compound, if confirmed by clinical randomized trials showing its atoxic properties, could be in the field of aesthetic plastic surgery as a filler material for body contouring and in reconstructive surgery and above all in cancer patients to restore surgical defects.

Comparison of posterior capsule opacification between the 1-piece and 3-piece Acrysof intraocular lenses: two-year results of a randomized trial

PURPOSE

To compare intensity of posterior capsule opacification (PCO) between the 1-piece and 3-piece haptic designs of an open-loop hydrophobic acrylic intraocular lens (IOL).

DESIGN

A randomized, patient- and examiner-masked clinical trial with intraindividual comparison.

PARTICIPANTS

Fifty-two patients with bilateral age-related cataract (104 eyes).

METHODS

Each patient had cataract surgery in both eyes and received a 1-piece Acrysof IOL in one eye and a 3-piece Acrysof IOL in the fellow eye. Follow-up examinations were at 1 week, 1 month, 6 months, 1 year, and 2 years. Patients were examined at the slit lamp, visual acuity (VA) was determined, and standardized high-resolution digital retroillumination images of the posterior capsule were taken. The intensity of PCO was assessed subjectively at the slit lamp and objectively using automated image analysis software.

MAIN OUTCOME MEASURE

Posterior capsule opacification score (scale, 0-10).

RESULTS

There was no significant difference between IOL styles in best-corrected VA, rhexis/IOL overlap, capsular folds, and amount of anterior capsule opacification during the follow-up period. One year postoperatively, the amount of regeneratory PCO was higher for the 1-piece Acrysof eyes (image analysis software score: 1.3) than for the 3-piece Acrysof eyes (score: 0.9; P = 0.002). However, 2 years postoperatively, there was no significant difference between the 2 IOL styles (1-piece: 1.5; 3-piece: 1.3; P = 0.3). Neodymium:yttrium-aluminum-garnet capsulotomy was not performed in the study.

CONCLUSION

One year postoperatively, the 1-piece Acrysof showed slightly more regeneratory PCO than the 3-piece Acrysof. However, 2 years postoperatively, the barrier effect of the 1-piece design was comparable to that of the 3-piece haptic design, with low PCO intensity.

Severe granulomatous inflammatory response induced by injection of polyacrylamide gel into the facial tissue

Facial soft tissue augmentation has been performed using different materials. We describe a woman who received polyacrylamide gel injections for cosmetic reasons and developed a severe granulomatous inflammation paranasally. Because the patient did not mention the cosmetic intervention, the diagnosis of polyacrylamide gel-induced granuloma was complicated. The distinctive histopathological findings led to the correct diagnosis despite sparse clinical information. Since complete surgical excision was not feasible, she was treated with repeated multiple local injections of triamcinolone acetonide. Polyacrylamide gel may have favorable properties for facial tissue augmentation, but a severe granulomatous inflammatory response induced by injection of polyacrylamide gel may occur. Before treatment with polyacrylamide gel injection this complication should be disclosed to the patient.

[Immunological effects of polyacrylamide hydrogel injection in human body]

OBJECTIVE

To observe the immunologic changes in patients who have complications after polyacrylamide hydrogel (HPG) injection.

METHODS

To compare the patients in the HPG injection group and the control group, the expressions of immunoglobulin IgG, IgM, IgA and complement C3, C4 of serum were measured by immunoturbidimetry.

RESULTS

The expressions of IgG and C3 in the injection group were lower than the control group with extremely significant difference (P < 0.01). The expressions of IgM were higher than the control group with significant difference (P < 0.05). The expression of IgA and C4 had no significant differences between the two groups. The immunologic changes had no relation to the injection doses.

CONCLUSIONS

Clinical application of HPG as a soft tissue filling material may cause foreign-body rejection reaction. The long-term immunologic effect of HPG needs further observation in more cases.

[Clinical and histological evaluation of the injectable hydrophilic polyacrylamide gel]

OBJECTIVE

To investigate the clinical and histological features of the complications after hydrophilic polyacrylamide gel injection.

METHODS

Fifty-two patients were included in this study, who had undergone hydrophilic polyacrylamide gel injection in other units from 1998 to 2003 and later came to our department for removal of the injected gel. The tissue samples taken from each cyst were sectioned and stained with hematoxylin and eosin. The sections were investigated and analyzed under light microcopy. The tissue sections of 12 patients who had ever received liquid silicone injection from 1988 to 1994 were used as the control group. The difference in histological features was assessed.

RESULTS

The inflammatory reaction of the hydrophilic polyacrylamide gel was characterized by an increased number of foreign-body giant cells. The mild lymphocyte infiltration was shown in the slides of hydrophilic polyacrylamide gel. On the contrary, there were much more clusters or lymphocyte infiltration in the slides of liquid silicone. The differences between the hydrophilic polyacrylamide gel and liquid silicone were significant in terms of thickness of the fibrous capsule.

CONCLUSIONS

The security of hydrophilic polyacrylamide gel injection for soft tissue augmentation is in doubt.

FEMIC (Fibromes Embolis�s aux MICrosph�res calibr�es): Uterine Fibroid Embolization using Tris-acryl Microspheres. A French Multicenter Study

PURPOSE

A French multicenter registry was set up to confirm the safety and efficacy of large calibrated tris-acryl gelatin microspheres for embolization of symptomatic fibroids.

METHODS

Technical recommendations included embolization using large microspheres (>500 microm) with no secondary embolization agent. Postprocedural pain, clinical improvement and adverse events were prospectively evaluated during a follow-up period of at least 6 months.

RESULTS

Eighty-five women complaining of fibroid-related symptoms entered the study. In seven women, a secondary embolization agent was used in addition to microspheres. Complete resolution of menorrhagia was achieved in 84% of women at 24 months and significant uterine and fibroid volume reductions were noted after 6 months (37% and 73%, respectively). Three women experienced definitive amenorrhea (4%) and two women required hysteroscopic resection of a fibroid. Eight women were treated by hysterectomy because of treatment failure. In seven of these women, treatment failure was explained by an additional cause of symptoms including diffuse adenomyosis, endometrial hyperplasia or ovarian artery supply to the fibroids.

CONCLUSION

Limited uterine artery embolization using large microspheres has good clinical success rate with low postprocedural pain and complications. Women can expect excellent midterm results with a high level of symptom control and significant fibroid volume reduction. Confidence in the end-point recommended here may require the experience of several cases.

New technologies making use of Sulfacrylate in pediatric surgery

Sulfacrylate glue composition was used in surgery for traumatic injuries to parenchymatous organs for attaining hemostasis and hermetic sealing of intestinal anastomoses and hollow organs, in cancer patients, in gynecological and thoracic surgery, and in correction of congenital defects. Glue composition ensures reliable intraoperative hemostasis, hermetic sealing of wounds in parenchymatous and hollow organs, prevents infection of the abdominal and thoracic cavities, thus reducing endotoxicosis and stimulating tissue regeneration. The use of Sulfacrylate optimized surgery, facilitated operative technology in difficult situations, and prevented the development of postoperative complications.

Fatal pulmonary complications after arterial embolization with 40-120- micro m tris-acryl gelatin microspheres

Hepatic arterial embolization is a recognized method of treating primary malignancies and some secondary hepatic malignancies. Particle embolization alone has been shown to be safe and effective and is routinely performed for hypervascular tumors. Tris-acryl gelatin microspheres have been widely acclaimed for their ease of delivery and uniform size, allowing for accurate targeting of particular end arteries. There have been three deaths at the author's institution related to respiratory compromise since the 40-120- micro m particles became available 31 months ago. These complications were never observed with larger tris-acryl gelatin microspheres or polyvinyl alcohol particles. This is an unusual and serious complication of which interventionalists performing embolotherapy need to be aware.

Estimates of lifetime-absorbed daily doses from the use of personal-care products containing polyacrylamide: a Monte Carlo analysis

Estimates of the lifetime-absorbed daily dose (LADD) of acrylamide resulting from use of representative personal-care products containing polyacrylamides have been developed. All of the parameters that determine the amount of acrylamide absorbed by an individual vary from one individual to another. Moreover, for some parameters there is uncertainty as to which is the correct or representative value from a range of values. Consequently, the parameters used in the estimation of the LADD of acrylamide from usage of a particular product type (e.g., deodorant, makeup, etc.) were represented by distributions evaluated using Monte Carlo analyses.((1-4)) From these data, distributions of values for key parameters, such as the amount of acrylamide in polyacrylamide, absorption fraction, etc., were defined and used to provide a distribution of LADDs for each personal-care product. The estimated total acrylamide LADD (across all products) for males and females at the median, mean, and 95th percentile of the distribution of individual LADD values were 4.7 x 10(-8), 2.3 x 10(-7), and 7.3 x 10(-7) mg/kg/day for females and 3.6 x 10(-8), 1.7 x 10(-7), and 5.4 x 10(-7) mg/kg/day for males. The ratio of the LADDs to risk-specific dose corresponding to a target risk level of 1 x 10(-5), the acceptable risk level for this investigation, derived using approaches typically used by the FDA, the USEPA, and proposed for use by the European Union (EU) were also calculated. All ratios were well below 1, indicating that all the extra lifetime cancer risk from the use of polyacrylamide-containing personal-care products, in the manner assumed in this assessment, are well below acceptable levels. Even if it were assumed that an individual used all of the products together, the estimated LADD would still provide a dose that was well below the acceptable risk levels.