Adverse reactions to injectable soft tissue permanent fillers

Adverse Effects Associated with Dermal Filler Treatments: Part II Vascular Complication

Vascular complications arising from dermal filler treatments pose significant risks, including ischemia, tissue necrosis, and severe outcomes like blindness and pulmonary embolism. This study investigates the mechanisms of vascular complications, categorizing them into extravascular compression and intravascular emboli. Extravascular compression occurs when injected fillers compress adjacent blood vessels, leading to ischemia and potential necrosis, while intravascular emboli result from fillers entering blood vessels, causing blockages. The study emphasizes the importance of anatomical knowledge, careful injection techniques, and early intervention. Management strategies include the use of hyaluronidase to dissolve HA fillers, vasodilators to improve blood circulation, and hyperbaric oxygen therapy. The regions most susceptible to complications align with major arterial pathways, particularly the nasolabial folds and nasal region. The study also highlights the need for meticulous injection techniques, the use of cannulas over needles in high-risk areas, and the aspiration test to detect vessel penetration. Early detection and immediate intervention are crucial to mitigate adverse outcomes. Continuous education and training for practitioners, along with advancements in filler materials and injection methods, are essential for improving the safety of cosmetic procedures. This comprehensive understanding aids in preventing and managing vascular complications, ensuring better patient outcomes. The field of dermal filler treatments is advancing with new techniques and technologies, such as High-Resolution Ultrasound, Infrared Imaging, self-crossing hyaluronic acid filler, biodegradable microspheres, and microinjection.

A treatment algorithm for hyaluronic acid filler related complications of the face

BACKGROUND

Throughout the last decade, a notable increase in HA-filler-related complications have been observed, owing to the increase in demand for filler injections and availability of multiple products.

OBJECTIVES

The aim is to provide practical advice on the best way to prevent and treat HA-filler-related complications.

METHODS

Thirty patients who experienced visible and/or symptomatic complications localized within the facial area were treated according to our algorithm. Patients with inflammatory lesions underwent antibiotic and anti-inflammatory therapy, followed by hyaluronidase injections. Patients with abscesses were treated with antibiotics, incision, and drainage. Each patient completed the dermatology-specific quality of life questionnaire (DLQI) at the first and last examinations.

RESULTS

Among the 29 patients who received antibiotic therapy, 3 healed without further treatment. However, 18 received hyaluronidase injections, 9 underwent incision and drainage, and 5 presented with fistulas and developed retracted scars. Moreover, 80% of the patients were completely healed, 13% significantly improved, and 3% did not show any improvement. The DLQI scores analysis showed a notable impact of patients' diseases on their quality of life, mainly in the terms of personal relationships and symptoms, with minor impacts on intimate relationships, ability to work, and study. We demonstrated that our algorithm resulted in a significant improvement in the overall quality of life at the last follow-up (p < 0.001).

CONCLUSIONS

The use of filler injections requires caution and specific training because they can lead to serious complications. If these complications are recognized promptly, healing can be optimized. Our treatment algorithm demonstrated high rate of healing and significant improvement in the patients' quality of life.

The Research Trend of Soft Tissue Filler Injection from 2000 to 2022: A Bibliometric and Visualized Analysis

Background

The demand for soft tissue filler injections has experienced a significant increase in recent years. Therefore, this study used bibliometric analysis to identify prominent research areas and emerging trends within the field.

Methods

Publications concerning research on soft tissue filler injections were collected from the Web of Science Core Collection database. Subsequently, VOSviewer 1.6.18 and CiteSpace 6.2.R4 software were used to analyze the co-authorship, co-occurrence, and citations of countries, institutions, authors, hotspot keywords, and journals associated with these studies.

Results

A total of 1370 records pertaining to filler injection research conducted between 2000 and 2022 were identified. The United States (524 publications) emerged as the country with the highest number of publications in this field, with Mayo Clinic (37 publications) making the most substantial contribution. Dermatologic Surgery emerged as the leading journal in this field, publishing the highest number of research articles (151 publications) and also being the most frequently co-cited. Cotofana proved to be the most prolific author with 51 publications, and Lemperle emerged as the most frequently co-cited author with 628 citations (including total link strength: 6587). The most popular keywords, in descending order of popularity, were "dermal filler," "injection," "soft-tissue augmentation," "complications," and "hyaluronic acid."

Conclusions

The findings of this study offer a comprehensive overview of the main directions in filler injection research. Furthermore, they underscore the imperative of intensifying efforts to prevent complications linked to filler injections.

Aesthetic Surgical Pathway in Permanent Facial Filler Removal

Although permanent fillers have been introduced in order to get long-lasting results, many studies have shown numerous severe and disfiguring complications. Nonsurgical procedures may mitigate those adverse events but the only way to remove the filler previously injected is represented by surgical excision. We present a pathway of facial surgical accesses to be performed achieving two goals: permanent filler removal and restore facial aesthetic balance. The proposed surgical accesses are already standardized in aesthetic surgical practice in order to avoid direct excision and unpleasant facial scar. A total of 231 patients underwent surgery for permanent filler removal and aesthetic restoration of the involved facial area, represented by forehead, glabella, nose, cheeks, eyelids, chin, jawline, and lips. Magnetic resonance evaluation was performed with the exception of lip patients who were evaluated with ultrasound. Postoperative follow-up was 12 months to 6 years. Subjective and objective methods were used for outcome evaluation according to the FACE-Q questionnaire. Functional and aesthetic correction was scored using the patient-graded Global Aesthetic Improvement Scale (GAIS), overall patient satisfaction was assessed by a five-point scale questionnaire. Functional and aesthetic restoration was globally recognized as improved according to the GAIS. Patients reported high levels of satisfaction assessed by a five-point scale questionnaire. A very good satisfaction level was registered in both subjective and objective judgment scores. To the best of our knowledge, we present the largest case series regarding surgical removal of permanent facial fillers. A proper preoperative evaluation, filler removal followed by restorative facial aesthetic surgery technique is paramount to approach challenging cases.

Biofilm formation is a risk factor for late and delayed complications of filler injection

Introduction

Biofilm formation is a major cause of delayed-graft complications. Similarly to implants, dermal fillers carry the risk of biofilm formation, which can lead to the development of nodules, chronic inflammatory reactions, abscesses and other complications. In this study, we investigated the late or delayed complications associated with biofilm formation on dermal fillers.

Methods

In this retrospective analysis, we analyzed all cases of complications caused by filler injections at a single center between January 2017 and December 2022, the majority of which comprised nodule formation and chronic persistent inflammatory reactions. The risk of biofilm formation with fillers was summarized and analyzed based on the results of bacterial culture and pathological examination.

Results

Sixty-one patients were enrolled, including 42 cases of nodule formation, 15 of chronic inflammatory reactions, and 4 of active infection. Bacterial culture of the tissue samples obtained from seven patients after surgical treatment were positive, and comprised four cases of Staphylococcus aureus, one case of Staphylococcus epidermidis, one case of Staphylococcus saprophyticus and one case of Mycobacterium abscessus. The corresponding histopathological results indicated extensive mononuclear lymphocyte infiltration, with a giant cell reaction in the fibrous connective tissue.

Conclusion

The results of this study suggest that biofilm formation is a significant risk factor for late and delayed complications following filler injection, and is caused by the contamination of resident bacteria and recessive infection at the injection site.

Treatment of acne in the aesthetic patient: A round table update

BACKGROUND

The popularity of social media appears to be increasing the acceptance of cosmetic treatments, prompting more consumers to seek cosmetic treatments. As the estimated prevalence of acne vulgaris among adult women may be as high as 54%, acne is commonly observed among patients presenting for cosmetic treatments. Concomitant treatment of acne in the aesthetic patient population will improve overall clinical outcomes.

AIMS

The goal of this work was to deliver a high-quality ethical and evidence-based educational program to physicians and adjunctive health care providers to advance patient care.

METHODS

This paper is based on a webcam presentation with roundtable discussion by several notable experts in their field.

RESULTS

A range of topical medications, injectable products, chemical peels, and energy-based devices are available for treating acne vulgaris. In most instances, these are compatible with rejuvenation procedures in the aesthetic patient.

CONCLUSION

The growth of social media is raising awareness of aesthetic procedures and appears to be increasing the number of patients seeking aesthetic treatment. Educating patients about the importance of treating acne vulgaris can improve overall treatment outcomes. In most instances, the presence of acne is not a barrier to aesthetic care.

Complications of severe breast deformities after a silicone injection over 20-year and a successful surgical treatment

Breast deformities caused by silicone injections affect aesthetic results and cause irreversible complications in patients. In the treatment, it is necessary to entirely remove silicone particles and infiltrated and fibrous breast tissues. The maximal preservation of healthy breast tissues is also critical. This report presents a case of severe breast deformities as complications 20 years after silicone injections at an unreputable aesthetic center. During the surgery, the authors separately removed fluid (silicone) masses and reconstructed mammary glandular tissues. Breast reconstruction was performed by the anchor breast lift along with the functional preservation of the nipple-areola complex and the superomedial pedicle. The surgery entirely addressed complications after injecting a large amount of silicone. 6 months postoperatively, the surgical outcomes were satisfactory. The surgical excision should be done to remove silicone-infiltrated tissues as much as possible before the reconstructive surgery. The combination of radical surgical excision and reconstructive surgery using the anchor breast lift as a single-stage procedure brought good aesthetic results.

Surgical Removal of Foreign Material by Suction Curettage After Injection Rhinoplasty: Patient-Reported Outcomes

BACKGROUND

Though generally safe, injection rhinoplasty with synthetic non-hyaluronic fillers may lead to various deformities, which impose a psychological burden on the patients. As the injected material is technically hard to be fully cleared in the nose, the surgery is primarily chosen to address the patients' psychological distress caused by injection. Unfortunately, there is a paucity of data regarding patient-reported outcomes of this procedure.

METHODS

From August of 2017 to June of 2021, the authors retrospectively reviewed all cases who underwent the foreign material removals by suction curettage after injection rhinoplasties. The relevant demographic, treatment characteristics and complication details were collected. The modified Rhinoplasty Outcome Evaluation (ROE) questionnaires were prospectively completed before and 6 months after the surgery.

RESULTS

Of the 46 patients, four cases developed minor surface irregularities on the nasal dorsum postoperatively; two cases who had recurrent nasal dorsum redness and swelling before the surgery still exhibited the redness with a less degree after the surgery; no patients needed secondary revision. There was a significant improvement in any of patient-reported outcomes at 6-month follow-up, relative to the preoperative baseline scores.

CONCLUSION

The injected foreign material in the nose could be effectively removed by suction curettage with minimal complications. The patients' satisfaction and quality of life, which was severely impaired preoperatively, could be significantly improved after the surgery.

LEVEL OF EVIDENCE IV

Therapeutic study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Complications following Permanent Filler Injection: A Prospective Cohort Study and Protocol of Management

Permanent filler (PF) substances are increasingly utilized in aesthetic procedures. Concurrently, complications related to fillers have also risen. This study aims to determine the rate of complications secondary to PF injections and develop a therapeutic approach for treating such complications.

METHODS

This cohort study was conducted by distributing a checklist form among all patients aged 18 years or older who arrived for a new cosmetic consultation between 2015 and 2019. The primary outcome was the occurrence of complications, which are defined as symptoms induced by the PF. The demographics, type of PF, injection site, the time for the complication to occur, and signs and symptoms were recorded and followed up.

RESULTS

In this study, 325 out of 503 (64.61%) patients presented with PF-related complications. About 92.8% were women. All patients with PF-related complications presented with a lump (n = 325, 100%). In regard to the anatomical area of injection, the most common areas were the cheeks (66.6%). The time it took for the complication to occur most commonly ranged from 1-5 years (39.2%, P < 0.001). Complications were significantly higher among patients who received the injection in a nonmedical facility (P < 0.0002). Seventy-seven cases (15.3%, P < 0.0001) underwent PF removal.

CONCLUSIONS

PF-related complications in the body exhibit a wide range of onset and adverse events. The best method to prevent complications caused by permanent filling materials is to avoid them altogether. When it comes to permanent filling agents, we suggest extreme caution.

Delayed hypersensitivity reaction from microneedling twenty years after silicone fillers

Skin rejuvenation procedures have increasingly flooded the aesthetic market, one of which includes microneedling. In microneedling, multiple fine punctures of the skin are performed with a needle to induce neocollagenesis. Microneedling has increasingly been used to treat inflammatory acne, acne scarring, photodamaged skin, and even radiation dermatitis. We present a patient with a stable history of liquid injectable silicone (LIS) given 20 years prior who developed chronic periocular and facial hypersensitivity after undergoing microneedling at a medi-spa. Long-term steroids and immunosuppressants were needed for control. The patient's severe reaction and resistance to treatment highlights the potential complications of microneedling administered by a non-medical professional in the setting of prior injectable silicone.

Late inflammatory reactions (LIRs) in patients with soft tissue fillers after SARS-CoV-2 infection and vaccination: A systematic review of the literature

INTRODUCTION

Soft tissue fillers are used for cosmetic and reconstructive purposes, and soft tissue filler procedures are among the most common nonsurgical procedures in the USA. Although soft tissue filler procedures are relatively quick and safe, adverse events such as late inflammatory reactions have been reported with every filler product. Infections and vaccinations have been proposed as potential triggers for late inflammatory reactions (LIRs), and it is therefore not surprising that these adverse events have been reported after SARS-CoV-2 infection and vaccination. Therefore, this review aims to give a detailed overview of these cases.

MATERIALS AND METHODS

A literature search was undertaken on LIRs in patients with a history of soft tissue filler use after SARS-CoV-2 infection or vaccination. This systematic review was reported according to the PRISMA guidelines. We searched the electronic database PubMed from January 2020-August 2021. Data on patient characteristics, filler characteristics, clinical findings and treatment options were included.

RESULTS

This review included 7 articles with a total of 19 patients with LIRs after SARS-CoV-2 infection or vaccination. Three patients with postinfection LIRs and 16 patients with postvaccination LIRs were reported. These LIRS mainly occurred in females who had HA injections for cosmetic purposes. Three patients with postinfection LIRs had symptoms of facial swelling and/or lip angioedema in a matter of weeks. Sixteen patients reported reactions after SARS-CoV-2 vaccination (13 following Moderna vaccination and 3 after Pfizer vaccination, after both the first and second doses) from 13 hours up to three weeks. These patients presented with similar clinical symptoms as patients with postinfection LIRs. All patients were treated in a conservative manner.

DISCUSSION

This review shows a relationship between LIRs and SARS-CoV-2 infection and vaccination. In the case of vaccination, these adverse events have been reported only after Moderna and Pfizer vaccinations. The reported adverse events are generally minor and self-limiting, and we encourage patients with soft tissue fillers to participate in vaccination programs.

Improvement of palmoplantar pustulosis after excision of polyacrylamide injected into the nasal region

We report a patient in whom polyacrylamide hydrogel injected into the nasal region caused palmoplantar pustulosis. We report this case because few cases of autoimmune syndrome induced by adjuvants caused by polyacrylamide have been reported.

Filler-induced complications of the lips: 10 years experience with intralesional laser treatment and refinements

BACKGROUND

The number of minimally invasive cosmetic procedures has steadily increased every year. In the last decade, the rates of filler injection reactions have also increased. This study presents our experience in the management and treatment of permanent filler complications to the lips. Undoubtedly, in these adverse reactions, the lips are the hallmark that most stigmatizes an unnatural look of the face.

METHODS

One hundred and eighty-one patients (168 female and 13 male) with permanent filler complications to the lips were treated from September of 2009 to September of 2019 at the University Hospital of Modena. One hundred and thirty-five patients underwent intralesional laser treatment (ILT). Forty-six patients underwent a stab incision and drainage and 10 of these patients had solid and calcified nodules and therefore underwent a combined technique. Thirty-three patients underwent further cosmetic procedures.

RESULTS

In 95% of patients there was a clinical improvement of which complete resolution in 38.7% and partial improvement in 34.2% of cases. Nine patients stopped the treatment because they were not satisfied. No patient was considered to have worsened after the treatment. Thirty-three patients underwent further treatments.

CONCLUSIONS

A systematic combined approach between antibiotic therapy and treatments (ILT and a stab incision) represents the best therapeutic approach in dealing with permanent fillers complications to the lips. This treatment modality allows both the removal of the foreign material and the inflammatory reaction with low morbidity and little cosmetic disfigurement. Further cosmetic procedures may be applied to improve aesthetic appearance once most of the non-resorbable substance has been removed.

Lipofilling after Laser-Assisted Treatment for Facial Filler Complication: Volumetric and Regenerative Effect

BACKGROUND

Nonresorbable substances are still injected to enhance soft-tissue volumes and fill subcutaneous defects. The minimally invasive intralesional laser treatment can remove foreign substances and the inflammatory reaction, eventually leaving depression and scar tissue in the treated area. Fat grafting can restore volume loss and improve scar tissue.

METHODS

From March of 2010 to February of 2017, 33 patients were studied. All of them had suffered from inflammatory reactions to permanent facial fillers and had been treated with the 808-nm diode laser at the authors' institution. The evacuation of material had left facial asymmetry and visible depression. To restore facial aesthetic units, fat grafting was performed. The minimum follow-up was 6 months.

RESULTS

Volume restoration was recognized (according to the Global Aesthetic Improvement Scale) as significantly improved in 22 patients, moderately improved in eight patients, and slightly improved in three patients. Improvement in atrophic and scarred tissues (with an apparent thickening of the skin or even elimination of scars) was also assessed with the following results: 25 patients were very much improved and eight were moderately improved.

CONCLUSIONS

This is the first study on filler-induced complications of the face treated by intralesional laser treatment followed by lipofilling. A systematic approach to volume restoration is proposed to patients who had filler removal of the face. There was a high degree of patient satisfaction with this technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comparative Evaluation of Safety and Efficacy of a Novel Hyaluronic Acid-polynucleotide/Poly-L-lactic Acid Composite Dermal Filler

BACKGROUND

Poly-L-lactic acid (PLLA) is widely used in tissue engineering. The natural polymer hyaluronic acid (HA) shows excellent biocompatibility and affects cell signaling, proliferation, and differentiation. In addition, a polynucleotide (PN) induces cell growth of human skin fibroblasts and osteoblasts.

OBJECTIVE

In this study, we evaluated the properties, safety, and efficacy of a novel composite filler consisting of cross-linked HA with PN in combination with monodisperse PLLA microspheres manufactured using Inventage Lab Precision Particle Fabrication method.

MATERIALS AND METHODS

The composition of the filler and characteristics of the microspheres were examined via scanning electron microscopy, particle size analysis, gel permeation chromatography, and rheology and osmolality measurement. Additionally, safety and efficacy of HA-PN/PLLA composite filler were conducted in in vitro and in vivo.

RESULTS

Analysis of PLLA microspheres revealed spherical surfaces and a narrower particle size distribution than that in PLLA filler. HA-PN/PLLA composite filler had higher viscosity and elasticity values and similar osmolality as compared to those of HA and PN fillers. The nontoxicity in in vitro and in vivo tests reflected that the composite filler may be safe for human use. In addition, the composite filler maintained a more stable volume than did HA filler for 24 weeks after administration in HWY/Slc hairless rats. Furthermore, the results support the effect of HA-PN/PLLA in restoring skin structure.

CONCLUSION

Altogether, these data suggest that the novel composite filler might be a safe and effective option in terms of tissue integration, clinical management during delivery and high esthetic durability.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Aetiopathogenesis of Late Inflammatory Reactions (LIRs) After Soft Tissue Filler Use: A Systematic Review of the Literature

Background

Late inflammatory reactions (LIRs) are the most challenging complications after filler use. The immune system plays a prominent role in its etiology, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for LIRs. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of LIRs.

Methods

We undertook a systematic literature review focused on immunological factors and microbiota in relation to LIRs after filler use. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE and the Cochrane databases were searched from inception up to August 2019. Included studies were assessed for the following variables: subject characteristics, number of patients, primary indication for filler injection, implant type/amount and injection site, type of complication, follow-up or injection duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors.

Results

Data on immunological factors and bacterial contamination were retrieved from 21 included studies. Notably, the presence of histocytes, giant cells and Staphylococcus epidermidis within biopsies were often associated with LIRs.

Conclusion

This review provides a clear overview of the immunological factors associated with LIRs and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with LIRs has been provided. Follow-up research may result in clinical recommendations to prevent LIRs.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors-www.springer.com/00266..

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02306-3.

Immediate nor Delayed Type Hypersensitivity Plays a Role in Late Inflammatory Reactions After Hyaluronic Acid Filler Injections

Purpose

The exact etiology of late inflammatory reactions (LIRs) to hyaluronic acid (HA) fillers is currently unknown. Some argue that these result from a hypersensitivity reaction, although evidence to support this is very scarce. Most reports on such reactions are not substantiated by positive skin tests. The purpose of our study was to determine whether immediate or delayed type hypersensitivity reaction follows hyaluronic acid (HA) filler injections.

Patients and Methods

Twelve patients were referred for general allergic screening (patch tests), as well as specific intradermal testing (injection of 0.1cc boluses) on the medial upper arm with a selection of several currently available hyaluronic acid (HA) fillers on the market. A positive allergic reaction was defined as erythema, firmness or swelling.

Results

During the 4 month follow-up, no reactions to any of the tested HA fillers were reported. No correlation was found between results from the general allergic screening and a history with LIRs to HA fillers.

Conclusion

The results suggest that neither type I nor type IV hypersensitivity plays a role in late inflammatory reactions (LIRs) to hyaluronic acid (HA) fillers.

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RGD-Modified Alginate-GelMA Hydrogel Sheet Containing Gingival Mesenchymal Stem Cells: A Unique Platform for Wound Healing and Soft Tissue Regeneration

Soft tissue reconstruction has remained a major clinical challenge in dentistry and regenerative medicine. Although current methods have shown partial success, there are several disadvantages associated with these approaches. Gingival mesenchymal stem cells (GMSCs) can be simply obtained in the oral cavity for soft tissue augmentation. Regenerative potential of mesenchymal stem cells (MSCs) encapsulated in hydrogels is well documented. Here, an alginate-gelatin methacrylate (GelMA) hydrogel formulation is developed encapsulating GMSCs within the developed hydrogel. The results confirm that the encapsulated MSCs remain viable within the hydrogel with enhanced collagen deposition. An excisional wound model in mice is utilized to evaluate the in vivo functionality of the GMSC-hydrogel construct for wound healing and soft tissue regeneration. The histology and immunofluorescence analyses confirm the effectiveness of the GMSC-hydrogel in expediting wound healing via enhancing angiogenesis and suppressing local proinflammatory cytokines. Altogether, the findings demonstrate that GMSCs encapsulated in an engineered hydrogel sheet based on alginate and GelMA can be used to expedite wound healing and soft tissue regeneration, with potential applications in plastic and reconstructive surgery as well as dentistry.

Penile girth augmentation by injectable fillers: a comprehensive review of imaging features and inflammatory complications

Despite the extensive controversy and debate of penile girth augmentation, high demands for such procedures are increasing. Penile inflammation is not common sequel after penile filler augmentation, but when it occurs, it has serious complications that sometimes necessitate emergency surgical intervention. Imaging with a variety of modalities, including ultrasonography, magnetic resonance imaging, and ascending urethrogrphy plays a paramount role in the detection and assessment of these conditions. Inflammatory conditions after penile girth augmentation using injectable fillers are ranging from local granuloma to penile abscess formation or diffuse cellulitis that may extend to the scrotum, perineum or deep pelvic organs. Rapid diagnosis and evaluation of extensions are important to avoid associated morbidity and permanent deformity. Our purpose is to provide a practical review of relevant penile anatomy, imaging appearance and injection technique of different types of subcutaneous fillers used in penile girth augmentation, and inflammatory complications that may occur after these procedures. Brief descriptions of patient clinical information and imaging features of inflammatory complications will be included and correlated in actual cases.

Safety of Copolyamide Filler Injection for Breast Augmentation

Although injections with copolyamide fillers (Aquafilling/Los Deline and Aqualift/Activegel) are currently used widely for breast augmentation, many complications have been reported. A recent position statement by a Korean aesthetic/reconstructive breast surgery society indicated these fillers are the same as polyacrylamide gel (PAAG), which is widely prohibited due to complications. To test this statement, this retrospective cohort study examined the clinical complications after breast augmentation with copolyamide fillers. Nuclear magnetic resonance (NMR) analysis of copolymer and PAAG fillers was also conducted.

Actinomyces Infection after Permanent Fillers Lip Augmentation: Diagnosis and Treatment

Background:

Although dermal filler injections are a widespread and secure practice, early or late complications may nonetheless occur.

Objective:

In this paper, the authors report an unusual asymptomatic late filler infection caused by Actinomycetes in a patient having received liquid silicone and acrylate filler injections for lip enhancement, seeking treatment for upper lip macrocheilia.

Methods:

The case report is about a patient who complained of recurrent lip region edema and denied any infective episodes. Preoperative analysis was in the normal range. Sonographic exam showed two fillers in the upper lip, suggestive of silicone and polyacrylamide gel. A conservative macrocheilia reduction was performed; healing was uneventful.

Results:

Histology report confirmed the preoperative sonographic diagnosis, together with an actinomycetes infection, clinically unsuspected. Many microorganisms have been reported to cause abscesses or granuloma after dermal filler treatments, sterile abscesses were reported as well, suggesting a biofilm infection as causative granuloma origin.

Conclusion:

This study differs from previous filler complication reports because of the occasional finding of a silent actinomyces infection, a commensal of the oral cavity but responsible for suppurative diseases in the soft tissues. This occasional finding seems to support the biofilm origin of dermal filler granuloma.

A pure molecular drug hydrogel for post-surgical cancer treatment

Local drug delivery systems, especially hydrogels, show superior strengths in postoperative recurrence prevention. Despite great advances, clinical translation of the hydrogels has been largely restricted as these drug delivery systems generally require chemical modification or additional carrier molecules to form hydrogels, which results in side effects correlative with local inflammation and systemic toxicity. Here, we developed a pure molecular anticancer drug hydrogel that reduced post-surgical tumor recurrence. The macroscopic pure molecular hydrogel was generated via ultrasonication of anticancer drug raltitrexed in aqueous solution, which was facile and environmentally friendly without involving chemical synthesis. Molecular dynamics simulations confirmed that raltitrexed self-assembled into a nanofibrous hydrogel through hydrogen bond and π-π interaction. Delivered as a hydrogel, raltitrexed could effectively decrease tumor recurrence rate and promote the inhibition of tumor growth in vivo. This raltitrexed self-delivery hydrogel has the potential to serve as a powerful auxiliary implement for preventing postoperative local tumor recurrence.

Beauty is only mucosa deep: a retrospective analysis of oral lumps and bumps caused by cosmetic fillers

Introduction The injection of dermal fillers into orofacial tissues is becoming increasingly popular for cosmetic purposes, in particular for lip augmentation. Both natural and synthetic filler materials are available, producing a spectrum of clinical and histological appearances.Aims The aim of this study was to review the clinicopathological characteristics of dermal filler cases from 2006 to 2016, reported at a specialist oral pathology unit.Methods An archival search of the pathology database was performed to retrieve cases reported as being consistent with cosmetic fillers.Results Ten cases of orofacial cosmetic fillers were retrieved. Of these cases, 100% were from female patients and the mean age of presentation was 47.6 years (range 24-68 years). The lips were the most frequently involved site (80%, n = 8). The majority of provisional diagnoses were related to salivary gland disease, including neoplasms (30%, n = 3), cysts (20%, n = 2) or inflammatory disease (10%, n = 1). Only two cases (20%) were clinically thought to be related to previous cosmetic injections. A variety of filler materials were seen, including collagen, hydroxyapatite and silicone. However, hyaluronic acid-based materials were the most common (50%, n = 5).Conclusions Complications of cosmetic dermal fillers are becoming more common and should be considered within a differential diagnosis for unusual orofacial swellings.

Cutaneous complications associated with breast augmentation: A review

Breast augmentation is one of the most popular and safe cosmetic procedures performed by plastic surgeons worldwide. Although breast implants are available in a number of different materials, silicone-filled implants remain the most common type. However, prior to the development of breast implants, various materials were injected into the soft tissues of the breasts to increase breast volume, which caused cutaneous complications and disfigurement. This review details the history of breast augmentation, the current methods used in augmentation surgery, and associated cutaneous complications.

Treatment of late bacterial infections resulting from soft-tissue filler injections

Purpose

Late bacterial infections (LBIs) after esthetic facial augmentation using hyaluronic acid (HA) fillers are relatively rare yet severe complications that are difficult to treat. No adequate treatment standards have hitherto been formulated. We have bridged this gap by formulating a treatment scheme based on the principles of treating foreign-body implantation-related infections and treating bacterial growth in the form of biofilm. The objective of this study was to evaluate the efficacy of a comprehensive scheme for treating LBI complications after facial augmentation using cross-linked HA fillers.

Methods

A total of 22 patients with LBI symptoms at a site of cross-linked HA injection underwent treatment and observation. The comprehensive treatment scheme formulated by Marusza and Netsvyetayeva (M&N scheme) comprised draining the lesion, dissolution of cross-linked HA with hyaluronidase, broad-spectrum antibiotic combination therapy, and use of probiotics. While 17 patients underwent the M&N scheme, the remaining five were treated with other schemes. Statistical analysis of the data was performed using Mann–Whitney U and χ² nonparametric tests with SAS 9.4 software.

Results

All 17 patients who underwent the M&N scheme experienced resolution of symptoms, with no recurrence of infection at the HA-injection sites.

Conclusion

To treat LBI at a site of cross-linked HA administration, the principles applicable to infections resulting from implantation of a foreign body must be followed. The treatment period should be sufficiently long for complete resolution of symptoms. The efficacy of treatment is considered proven if 2 months have elapsed without recurrence since the symptoms resolved. The M&N scheme is recommended for use as the first therapeutic option for treating LBI related to soft-tissue fillers.

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Development of Poly(HEMA-Am) Polymer Hydrogel Filler for Soft Tissue Reconstruction by Facile Polymerization

The number of breast reconstruction surgeries has been increasing due to the increase in mastectomies. Surgical implants (the standard polydimethylsiloxane (PDMS) implants) are widely used to reconstruct breast tissues, however, it can cause problems such as adverse immune reactions, fibrosis, rupture, and additional surgery. Hence, polymeric fillers have recently garnered increasing attention as strong alternatives for breast reconstruction materials. Polymeric fillers offer noninvasive methods of reconstruction, thereby reducing the possible adverse effects and simplifying the treatment. In this study, we synthesized a 2-hydroxylethylmethacrylate (HEMA) and acrylamide (Am) copolymer (Poly(HEMA-Am)) by redox polymerization to be used as a biocompatible filler material for breast reconstruction. The synthesized hydrogel swelled in phosphate buffered saline (PBS) shows an average modulus of 50 Pa, which is a characteristic similar to that of the standard dermal acrylamide filler. To investigate the biocompatibility and cytotoxicity of the Poly(HEMA-Am) hydrogel, we evaluated an in vitro cytotoxicity assay on human fibroblasts (hFBs) and human adipose-derived stem cells (hADSCs) with the hydrogel eluate, and confirmed a cell viability of over 80% of the cell viability with the Poly(HEMA-Am) hydrogel. These results suggest our polymeric hydrogel is a promising filler material in soft tissue augmentation including breast reconstruction.

Removal of Polyacrylamide Gel (Aquamid®) from the Lip as a Solution for Late-Onset Complications: Our 8-Year Experience

BACKGROUND

The polyacrylamide hydrogel Aquamid^® has been used as a permanent filler to enhance facial soft tissue volume and correct wrinkles since 2001. Various long-term studies have proved the safety of the product. Nonetheless, if complications such as migration occur, they can be difficult to treat.

METHODS

Eleven patients suffering from late-onset complications after taking Aquamid^® injections in the lips underwent product removal and subsequent labial reconstruction between 2009 and 2017. The reconstruction was performed using a modified bikini reduction technique combined, in eight cases, with immediate autologous fat grafting.

RESULTS

In all the patients, general fibrosis and a diffused distribution of the product within all three layers of the lips resulted in the need for labial reconstruction. Migration, as far as in the mucosa and perioral skin, accounted for macroscopically visible yellowish accumulations. In ten out of eleven cases, an individually modified bikini reduction technique, with or without any combination of autologous fat grafting, led to an esthetically satisfying result. One patient developed a severe upper lip necrosis.

CONCLUSION

Contradictory to several previous studies attesting to the lack of migration after Aquamid^® application to the lips, capsule formation around the product is impaired, allowing for migration even years after the injection. Product aspiration is not possible in these cases, thus necessitating complex lip reconstruction. Bikini reduction and fat grafting are valuable tools for labial reconstruction. Product residuals within the mucosa have to be accepted. Special care has to be taken while treating smokers.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Filler Nodules: Inflammatory or Infectious? A Review of Biofilms and Their Implications on Clinical Practice

BACKGROUND

The numbers of minimally invasive cosmetic procedures performed in the United States have steadily increased each year. Concurrently, the rates of filler complications have also increased. Delayed filler reactions and granulomas have recently been attributed to biofilm infections.

OBJECTIVE

The biology and pathogenesis of biofilms, and their diagnosis, treatment, and prevention will be discussed.

METHODS

The relevant and recent literature on delayed filler reactions and biofilms was reviewed.

RESULTS

Increasing evidence implicates biofilm infections in the pathogenesis of delayed filler reactions. Therapeutic and preventative measures can be taken to minimize the occurrence of these potentially devastating consequences of dermal fillers.

CONCLUSION

Awareness of biofilm infections is key in the assessment of filler reactions in order to ensure timely and accurate diagnosis and treatment.

Dermalive Facial Filler Granulomas Masquerading as Neurofibromas

A 56-year-old woman presented with periocular nodules that were clinically suspected to be neurofibromas. Histopathologic examination of excised nodules revealed a pronounced granulomatous reaction to a foreign material that was composed of glossy polygonal palely eosinophilic fragments. These fragments were outlined in red with Masson trichrome, stained gray with the elastic stain, and were uniformly red with Gomori methenamine silver staining. The histopathologic appearance was consistent with a granulomatous reaction to Dermalive facial filler. Postoperatively the patient admitted that she had filler injections many years earlier in another country, and that nodules appeared 1 year after injection. Treatment with steroids, intralesional immunosuppressive agents and surgery had been previously attempted to eradicate the nodules. The literature pertaining to granulomatous reactions to Dermalive and related hybrid facial fillers is reviewed and treatment options are discussed. This report is the first to illustrate the unique histopathologic staining characteristics of Dermalive, which may be useful to ophthalmic pathologists in identifying this uncommon foreign material.

Late Presentation of Infected Silicone Granulomas in the Lower Limb

Introduction:

Dermal fillers are used for multiple cosmetic indications including gluteal and thigh augmentation. Complications, although infrequent, are increasing due to the dramatic growth of dermal filler use. Our aim was to describe how the complication of infected silicone granulomas can present following lower limb augmentation.

Methods:

Two cases presented with pain, oedema, and erythema at the site of previous silicone filler injection, following a considerable delay after the last injection (range 4-7 years). We collected data on their biochemistry, haematology, histology, microbiology, and imaging at the time of presentation.

Results:

Complications included prolonged cellulitis with recurrent abscesses at sites of previous silicone dermal filler injection. Histology revealed infiltration of chronic inflammatory cells suggestive of silicone granuloma in both cases. Patients were reluctant to divulge use of cosmetic fillers or failed to recognise their significance given the time delay making diagnosis difficult. Delayed or recurring infections can suggest the presence of atypical organisms and we present the first reported case of silicone granuloma infection with Propionibacterium acnes.

Conclusions:

Microorganisms can induce immune-mediated hypersensitivity and are believed to be the trigger for delayed activation of a quiescent foreign body to a granulomatous reaction. The substantial time delay between injection and reaction must be recognised and may be attributable to atypical microorganisms or biofilm formation. Previous antibiotic use can affect expedient microbiological diagnosis and treatment requires close collaboration with microbiologists. It is important that clinicians are aware of these important complications which are becoming more common with increased use of filler augmentation.

Soft tissue fillers for adipose tissue regeneration: From hydrogel development toward clinical applications

There is a clear and urgent clinical need to develop soft tissue fillers that outperform the materials currently used for adipose tissue reconstruction. Recently, extensive research has been performed within this field of adipose tissue engineering as the commercially available products and the currently existing techniques are concomitant with several disadvantages. Commercial products are highly expensive and associated with an imposing need for repeated injections. Lipofilling or free fat transfer has an unpredictable outcome with respect to cell survival and potential resorption of the fat grafts. Therefore, researchers are predominantly investigating two challenging adipose tissue engineering strategies: in situ injectable materials and porous 3D printed scaffolds. The present work provides an overview of current research encompassing synthetic, biopolymer-based and extracellular matrix-derived materials with a clear focus on emerging fabrication technologies and developments realized throughout the last decade. Moreover, clinical relevance of the most promising materials will be discussed, together with potential concerns associated with their application in the clinic.

Injectable facial fillers: imaging features, complications, and diagnostic pitfalls at MRI and PET CT

Injectable fillers are widely used for facial rejuvenation, correction of disabling volumetric fat loss in HIV-associated facial lipoatrophy, Romberg disease, and post-traumatic facial disfiguring. The purpose of this article is to acquaint the reader with the anatomy of facial fat compartments, as well as with the properties and key imaging features of commonly used facial fillers, filler-related complications, interpretation pitfalls, and dermatologic conditions mimicking filler-related complications. The distribution of facial fillers is characteristic and depends on the anatomy of the superficial fat compartments. Silicone has signature MRI features, calcium hydroxyapatite has characteristic calcifications, whereas other injectable fillers have overlapping imaging features. Most fillers (hyaluronic acid, collagen, and polyalkylimide-polyacrylamide hydrogels) have signal intensity patterns compatible with high water content. On PET-CT, most fillers show physiologic high FDG uptake, which should not be confounded with pathology. Abscess, cellulitis, non-inflammatory nodules, and foreign body granulomas are the most common filler-related complications, and imaging can help in the differential diagnosis. Diffusion weighted imaging helps in detecting a malignant lesion masked by injected facial fillers. Awareness of imaging features of facial fillers and their complications helps to avoid misinterpretation of MRI, and PET-CT scans and facilitates therapeutic decisions in unclear clinical cases.

KEY POINTS

• Facial fillers are common incidental findings on MRI and PET-CT scans. • They have a characteristic appearance and typical anatomic distribution • Although considered as safe, facial filler injections are associated with several complications • As they may mask malignancy, knowledge of typical imaging features is mandatory. • MRI is a problem-solving tool for unclear cases.

Consensus statement on prevention and management of adverse effects following rejuvenation procedures with hyaluronic acid-based fillers

Facial fillers play an important role in the correction of facial changes associated with ageing. They offer quick treatments in the outpatient setting with minimal subsequent downtime that provide predictable, natural-looking, long-lasting results. Adverse reactions after hyaluronic acid injections tend to be mild or moderate and rather temporary. However, as with all injected or implanted biomaterials, severe adverse events can occur and patients must be fully informed of potential risks prior to undergoing treatment. A panel of experts from Germany (D), Austria (A) and Switzerland (CH) developed recommendations, and this study provides the 'DACH Consensus Recommendations' from this group specifically on the use of hyaluronic acid fillers. The aim is to help clinicians recognize potential risks and to provide guidance on how best to treat adverse events if they arise. Contraindications to hyaluronic acid fillers are also detailed, and ways to prevent adverse events occurring are discussed. Hyaluronic acid-based products are claimed to be very close to an ideal tissue augmentation agent; nevertheless, profound medical, anatomical and product knowledge are of paramount importance to minimize the occurrence of adverse reactions.

Delayed onset filler complication: Two case reports and literature review

Soft tissue augmentation by fillers has become a popular cosmetic tool to offer rejuvenation and aesthetic improvement. Its results are comparable to those previously achieved only by plastic surgery. However, marked increase of filler procedures is associated with a great number of complications. Complications associated with filler injection might have early onset (within days) or late onset (after weeks to years). Delayed complications include infections, foreign body granulomatous reaction, migration of filler material, persistent discoloration, and scarring. Here we report two cases of delayed complications: one case of foreign body granuloma with migration and one case of acute inflammation involving a quiescent granuloma.

Calcium hydroxylapatite: A review on safety and complications

BACKGROUND

Radiesse^® , or calcium hydroxylapatite (CaHA), is a biodegradable, biostimulatory soft tissue filler suitable for deeper folds and wrinkles. In the literature, good results have been documented with the use of CaHA and patient satisfaction scores are high. This study reviews the current literature on safety and complications of CaHA.

METHODS

A literature search in MEDLINE/PubMed electronic database was conducted. A total of 21 articles were included and screened for reports of adverse events (AEs).

RESULTS

Twenty-one peer-reviewed articles, published between 2004 and 2015, were included. A total of 5081 treatments with CaHA were performed on 2779 patients. A total of 173 (3%) AEs were reported. The assessed types of AEs consisted of nodules (n=166, 96%), persistent inflammation/swelling (n=4, 2%), persistent erythema (n=2, 1%), and overcorrection (n=1, 1%).

CONCLUSION

Based on the results in this study, CaHA appears to have a good safety profile. Nodules are by far the most common AE. Of the reported nodules, 49% occurred in "dynamic" areas currently known for having a higher tendency for nodules. Several treatment approaches exist for managing CaHA nodules; however, in most cases, CaHA nodules are not visible and resolve without intervention.

Literature Review of Cosmetic Procedures in Men: Approaches and Techniques are Gender Specific

The proportion of men receiving non-surgical cosmetic procedures has risen substantially in recent years. Various physiologic, anatomic, and motivational considerations differentiate the treatments for male and female patients. Nevertheless, research regarding approaches to the male cosmetic patient is scarce. We sought to provide an overview and sex-specific discussion of the most popular cosmetic dermatologic procedures pursued by men by conducting a comprehensive literature review pertaining to non-surgical cosmetic procedures in male patients. The most common and rapidly expanding non-surgical interventions in men include botulinum toxin, filler injection, chemical peels, microdermabrasion, laser resurfacing, laser hair removal, hair transplantation, and minimally invasive techniques for adipose tissue reduction. Important sex-specific factors associated with each of these procedures should be considered to best serve the male cosmetic patient.

Use of a Hyaluronic Acid Soft-tissue Filler to Correct Congenital and Post-traumatic Lip Asymmetry

Background:

The use of hyaluronic acid soft-tissue fillers for enhancement of lip features is a popular and minimally invasive office-based procedure used worldwide due to its relative simplicity and favorable safety profile.

Materials and Methods:

Hyaluronic acid was used in illustrative cases to attempt correction of congenital and acquired lip asymmetries.

Results:

In the cases presented, accurate and cosmetically acceptable results were attained and maintained for the duration of the product life.

Conclusions:

Hyaluronic acid may be used successfully when lip asymmetry is evident and is a relatively simple nonsurgical alternative.

An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment

PURPOSE

The purpose of this study was to provide an overview of infections associated with facial soft tissue fillers.

MATERIALS AND METHODS

A literature review was performed which evaluated infections associated with facial soft tissue fillers.

RESULTS

Infection rates with soft tissue fillers are low and are estimated at 0.04 to 0.2%. Most of these infections arise when skin contaminants infiltrate the injection site at the time of injection. These infections can occur early, up to several days after treatment, or delayed, occurring weeks to years after treatment. Reactions vary based on the filler absorbability and duration. Early recognition and treatment are important factors in managing our cosmetic surgery patients.

CONCLUSION

Although facial fillers are safe and predictable, infections can still occur. Oral and maxillofacial surgeons need to be able to prevent, recognize, and properly manage infections related to these popular injections.

Streptococcus sanguinis isolated from filler granuloma: Successful treatment with incision and drainage

Filler granuloma is considered to be the result of delayed immune responses; growing evidence suggests that they may be secondary to biofilm formation. Dermal filler is technically a foreign body, and as the development of newer generations of dermal fillers lengthens their duration, it is possible that there is also an increased risk of biofilm formation. Here, we present a case report of a patient with Streptococcus sanguinis isolated from a filler granuloma, suggestive of biofilm formation. This case demonstrates the effective use of antibiotics after incision and drainage on antibiotic resistant biofilm.

A case series and a review of the literature on foreign modelling agent reaction: an emerging problem

Foreign modelling agent reactions (FMAR) are the result of the injection of unapproved high-viscosity fluids with the purpose of cosmetic body modelling. Its consequences lead to ulceration, disfigurement and even death, and it has reached epidemic proportions in several regions of the world. We describe a series of patients treated for FMARs in a specialised wound care centre and a thorough review of the literature. A retrospective chart review was performed from January 1999 to September 2015 of patients who had been injected with non-medical foreign agents and who developed cutaneous ulceration needing treatment at the dermatology wound care centre. This study involved 23 patients whose ages ranged from 22 to 67 years with higher proportion of women and homosexual men. The most commonly injected sites were the buttocks (38·5%), legs (18%), thighs (15·4%) and breasts (11·8%). Mineral oil (39%) and other unknown substances (30·4%) were the most commonly injected. The latency period ranged from 1 week to 17 years. Complications included several skin changes such as sclerosis and ulceration as well as systemic complications. FMAR is a severe syndrome that may lead to deadly complications, and is still very common in Latin America.

Management of Breast Deformity After Removal of Injectable Polyacrylamide Hydrogel: Retrospective Study of 200 Cases for 7 Years

BACKGROUND

Polyacrylamide hydrogel (PAAG), once used as an injection for breast augmentation, has been banned in the medical field for cosmetic purposes for more than 10 years in China. But a large number of breasts have characteristic deformities due to the gel's feature of erosion. Our aim is to explore a retrospective study on PAAG's long-term effects on women, ensuing breast deformity and the strategy for breast plasticity after removing the gel in our center from 2007 to 2014.

METHODS

From 2007 to 2014, 200 patients, whose breasts were injected with PAAG, underwent the operation to remove the injectable material. Complications were summarized. Ultrasound or MRI was performed before the operation to disclose the general distribution of the gel and the muscle and gland infiltration. According to the gel distribution, muscle and gland infiltration, infection, gel residue, and other factors, the patients were treated, respectively, with or without prosthesis implantation surgery after the removal of the gel. According to the decision about whether or when to undergo prosthesis implantation, the patients were classified into three types: group I-prosthesis implantation at the first stage, group II-prosthesis implantation at the second stage, and group III-only removing the material without prosthesis implantation. The scores of the BREAST-Q program were used to evaluate the preoperative and postoperative differences.

RESULTS

Seventy-seven patients underwent prosthesis implantation at the first stage and 61 patients were operated on by placing the prosthesis at the second stage. A total of 62 patients only underwent the PAAG removal operation. By BREAST-Q evaluation, changes are summarized in Tables 1, 2, and 3 between mean preoperative scores and mean postoperative scores through categories of satisfaction with appearance of breasts, psychosocial wellbeing, sexual wellbeing, and physical wellbeing, in which all categories were presented with statistical significance (p < 0.001). Table 1 Patient demographics General patient data Number Number of patients 200 Age range 25-48 Follow-up period 6-12 months Injection material  Domestic material 84 (42 %)  Imported material 93 (46.5 %)  Domestic + imported 23 (11.5 %) Injection site  Regular hospital 47 (23.5 %)  Clinics 153 (76.5 %) Complication  Inflammation 10 (2 %)  Pain 75 (37.5 %)  Induration 155 (77.5 %)  Shift 50 (25 %)  Deformation 17 (8.5 %)  Bilateral asymmetry 48 (24 %)  Deposition milk 2 (1 %)  Psychological fear 150 (75 %)  Systemic symptoms 34 (17 %)  Single complication 25 (16.97 %)  Two or more complications 160 (80 %)  Preoperative aspiration 48 (24 %) Table 2 Group I-changes in mean preoperative scores and mean postoperative scores Category Preoperatively (n = 77) Postoperatively (n = 77) p Satisfaction with appearance of breasts 18.8 ± 16.2 81.6 ± 13.1 <0.001 Psychosocial wellbeing 39.5 ± 20.2 84.5 ± 19.3 <0.001 Sexual wellbeing 38.7 ± 23.1 77.2 ± 20.5 <0.001 Physical wellbeing 42.4 ± 16.3 81.7 ± 10.5 <0.001 Table 3 Group II-changes in mean preoperative scores and mean postoperative scores Category Preoperatively (n = 61) Postoperatively (n = 61) p Satisfaction with appearance of breasts 19.6 ± 15.3 82.5 ± 11.1 <0.001 Psychosocial wellbeing 38.9 ± 19.3 83.6 ± 20.1 <0.001 Sexual wellbeing 37.6 ± 22.4 79.3 ± 20.4 <0.001 Physical wellbeing 41.3 ± 15.1 82.2 ± 9.9 <0.001 CONCLUSIONS: Timely removal is critical for women who have received the PAAG removal operation. However, the surgery may destroy the shape of the breast. It is recommended that preoperative communication and local tissue condition are guidelines for surgeons to choose conservative or aggressive surgery. A balance must be maintained between removing the gel as much as possible and retaining soft tissue to reshape breasts.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .