Polyacrylamide gel breast augmentation: report of two cases and review of the literature

Injection mammoplasty: Normal imaging appearances, complications, and implications for mammographic screening

BACKGROUND

The normal imaging appearances of the common agents used in injection mammoplasty and the challenges of mammography screening will be reviewed.

METHODS

The local database from a tertiary hospital was accessed for imaging cases of injection mammoplasty.

RESULTS

Free silicone is seen as multiple high-density opacities on mammograms. Silicone deposits can often be seen within axillary nodes due to lymphatic migration. Sonographically, a snowstorm appearance is seen when the silicone is diffusely distributed. On MRI, free silicone is hypointense on T1-weighted and hyperintense on T2-weighted images, with no contrast enhancement. Mammograms have a limited role in screening due to the high density of silicone. MRI is often required in these patients.Polyacrylamide gel and hyaluronic acid are seen as multiple collections on mammography. Polyacrylamide gel collections are of the same density as cysts, while hyaluronic acid collections are of higher density but less dense than silicone. On ultrasound, both can appear anechoic or show variable internal echoes. MRI demonstrates fluid signal with hypointense T1-weighted and hyperintense T2-weighted signal. Mammographic screening is possible if the injected material is located predominantly in the retro-glandular space without obscuring the breast parenchyma.On mammograms, autologous fat locules appear as lucent masses. Rim calcification can be seen if fat necrosis had developed. On ultrasound, focal fat collections can demonstrate varying levels of internal echogenicity, depending on the stage of fat necrosis. Mammographic screening is usually possible for patients after autologous fat injection as fat is hypodense compared to breast parenchyma. However, the dystrophic calcification associated with fat necrosis may mimic abnormal breast calcification. In such cases, MRI can be utilized as a problem-solving tool.

CONCLUSION

It is important for the radiologist to recognize the type of injected material on the various imaging modalities and recommend the best modality for screening.

Hydrogels for Tissue Engineering: Addressing Key Design Needs Toward Clinical Translation

Collapse

Radiologic Findings of Polyacrylamide Gel Mammoplasty and Its Complications: A Report of Four Case Series and Review of Literature

Polyacrylamide gel (PAAG) has been used for augmentation mammoplasty in certain countries, such as China or Eastern European countries. However, owing to various complications, its use is currently banned in most countries. Nevertheless, because of the migratory stream of female from these countries, we also encounter patients with PAAG mammoplasty in Korea. Owing to the various imaging features of PAAG mammoplasty, it may interfere with the identification of malignancy or other pathologic conditions. Therefore, it is important to identify the imaging findings related to PAAG mammoplasty. However, there is limited literature on the radiologic findings of complications related to PAAG mammoplasty in Korea. Herein we report four cases of PAAG mammoplasty, the complications faced, and depict various radiologic features through multimodality imaging.

Injected Breast Materials: Review of Imaging Features and Characteristics

In the United States, silicone and saline breast implants with their familiar radiologic appearance are the mainstays of breast augmentation. However, less well-known sequelae of unconventional injected materials introduced for cosmetic and noncosmetic purposes may also be encountered on breast imaging-for example, free silicone, paraffin and/or oil, polyacrylamide gel, autologous fat, and hyaluronic acid, which are encountered in the setting of breast augmentation. Breast injection of go-yak is not cosmetic but also results in characteristic imaging findings. Breast changes due to extravasation of chemotherapy or interstitial brachytherapy can mimic the appearance of injected noncosmetic materials. Because many of these materials can mimic or obscure imaging findings of breast cancer, it is important to recognize their varied appearances and the limitations of imaging alone in delineating breast injection material from cancer. Given the relatively uncommon incidence of injected materials into the breast, this article aims to review the imaging appearance in order to aid radiologists in maximizing cancer detection and ensuring optimal patient management.

Classification and Management of Polyacrylamide Gel Migration After Injection Augmentation Mammaplasty: A Preliminary Report

BACKGROUND

Polyacrylamide gel (PAAG) migration after esthetic breast injection is clinically variable and complex, and thus, the rate of incomplete removal after debridement is high.

OBJECTIVES

We aimed to describe a practical classification system for PAAG migration after breast injection and evaluate the outcome of our management.

METHODS

A retrospective review of medical records was conducted for patients who presented to our institution for the management of PAAG migration after injection augmentation mammaplasty from June 2013 to November 2018. PAAG migration was evaluated by MRI examination and classified based on the migrating direction outside the breast contour. Surgery was performed to remove the material completely through different incisions.

RESULTS

Seventy-eight women met the study criteria, with 106 breasts identified as showing PAAG migration. Patients were classified as having superior (22%), lateral (25%), inferior (34%), medial (10%) or complex (9%) PAAG displacement. The mean follow-up was 9 months (range 3-18 months). Postoperative complications included seroma (n = 3), delayed wound healing (n = 2), occasional breast pain (n = 5) and paresthesia or numbness at the migrated site (n = 2). MRI re-examination revealed that most of the injected material was removed, and no patient needed a secondary debridement operation.

CONCLUSION

PAAG migration after injection augmentation mammaplasty can be clinically characterized into different types based on the migrating direction. It is helpful to perform MRI examinations preoperatively to fully evaluate PAAG migration. Under the guidance of our classification system, the injected material could be effectively eradicated with an acceptable complication rate.

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 .

Repeated lumps and infections: A case report on breast augmentation complications

BACKGROUND

Polyacrylamide hydrogel (PAAG) injections were once common in breast augmentation and have been prohibited for augmentation mammaplasty in China since a large number of patients who underwent breast augmentation with PAAG injections have continued to seek medical advice as a result of related complications. Among all these complications, distant migration is relatively rare.

CASE SUMMARY

A 49-year-old female presented at the hospital with a one-year history of a vulvar lump. The sonography of the lump showed several subcutaneous fluid-filled regions from the left vulva to the pubic symphysis, which suggested possible fat liquefaction. An enhanced magnetic resonance imaging (MRI) revealed a cystic area, which was considered a benign lesion. Intraoperative observations showed that the mass did not have an obvious capsule, the subcutaneous tissue presented as a cavity, and some yellow material came out of this cavity. A culture of the drainage did not show bacterial contamination. Histopathology revealed a foreign body granuloma. After resection and closed drainage, lumps were successively observed in the left lower abdomen and the bilateral hypochondriac region with infections. Sonography found that the hypoechoic areas in the bilateral hypochondriac region seemed continuous with deep in the breasts. The patient reported that she had undergone surgery with PAAG injections 20 years ago after she was repeatedly asked about her past history. Finally, a diagnosis of distant migration of PAAG was made.

CONCLUSION

PAAG gel can migrate after long periods of time. A diagnosis should not be limited to the area where the symptom develops.

Clinicopathological Analysis of 90 Cases of Polyacrylamide Hydrogel Injection for Breast Augmentation Including 2 Cases Followed by Breast Cancer

Background

Although polyacrylamide hydrogel (PAAG) injection for breast augmentation has been prohibited for many years, the long-term complications will be significant for a long period. Few research articles have focused on the clinicopathological analysis.

Materials and Methods

We summarized clinical and pathological features of 90 cases after PAAG-injected breast augmentation, including 2 cases of breast cancer developed following PAAG injection.

Results

All patients were females between the ages of 30 and 64 years (mean, 44 years). The complications included masses (75.58%), pain (45.35%), migration (22.09%), deformation (18.60%), infection (16.28%), induration (4.65%), and psychological fear (2.33%). Microscopically, the PAAG presented as purple gel pools, and the foreign body reaction was noted in all 90 patients. The proportion of fibrous component exceeded 90% in 26 cases (28.89%). Chronic and acute inflammation was noted in 70 (77.78%) and 9 (10%) patients, respectively. The mammary gland around the gel displayed atrophy in 18 cases (20.00%), adenosis in 33 cases (36.67%), ductal carcinoma in situ in 1 case (1.11%), and invasive carcinoma in 1 case (1.11%).

Conclusion

The long-term complications of PAAG-injected breast augmentation are various and complex. Pathologically, these complications are associated with foreign body reaction, fibrosis, and inflammation.

Recurrent complications of PAAG implants during lactation

A 35-year-old lactating woman with pre-existing polyacrylamide gel (PAAG) implants for 10 years presented on numerous occasions following both her pregnancies with bilateral recurrent breast infection, pain and finally massive breast enlargement with a ruptured galactocoele necessitating surgical intervention. As the safety of PAAG for the breastfeeding baby is not known, breastfeeding with PAAG implants is not recommended.

Breastfeeding difficulty after polyacrylamide hydrogel (PAAG) mediated breast augmentation

INTRODUCTION

Breast augmentation using polyacrylamide hydrogel (PAAG) has been routinely used in the past as a minimal invasive procedure. However, several patients undergoing this procedure have started to report complications. We report a case of breast augmentation using PAAG leading to a delayed infection and breastfeeding complication.

CLINICAL CASE

A 36-year-old Danish female who was treated with PAAG fifteen years earlier, presented with difficulty in breastfeeding and fistulation. Clinical evaluation revealed structural deformity of the right breast and a 5×5mm skin defect. Mammography showed diffuse microcalcification density grade 4. Ultrasound and MRI displayed inhomogeneous gelatinous material in both breasts diffused into the pectoralis major muscle. Initial management involved aspiration of the material. The patient developed infection and was subjected to modified radical debridement removing the PAAG. The patient healed without any further complications.

DISCUSSION

The prevalence of PAAG mediated breast augmentation related complications are increasing. The most prominent complication being late infections, breast hardening and subsequent breastfeeding difficulties. In this case, the difficulty in breastfeeding was induced by the PAAG within the breast tissue. The inhomogeneous gelatinous material was surgically removed leading to complete remission.

CONCLUSION

Long-term complications, among others breast feeding difficulty, in women treated with PAAG are increasing and need appropriate management strategy. PAAG mediated breast augmentation may cause irreversible damage to the breast in healthy women necessitating complex debridement.

Engineered Hydrogels in Cancer Therapy and Diagnosis

Over the last decade, numerous investigations have attempted to clarify the intricacies of tumor development to propose effective approaches for cancer treatment. Thanks to the unique properties of hydrogels, researchers have made significant progress in tumor model reconstruction, tumor diagnosis, and associated therapies. Notably, hydrogel-based systems can be adjusted to respond to cancer-specific hallmarks and/or external stimuli. These well-known drug reservoirs can be used as smart carriers for multiple cargos, including both naked and nanoparticle-encapsulated chemotherapeutics, genes, and radioisotopes. Recent works have attempted to specialize hydrogels for cancer research; we comprehensively review this topic for the first time, synthesizing past results and defining paths for future work.