Efficacy and safety of polyacrylamide hydrogel for facial soft-tissue augmentation in a 2-year follow-up: a prospective multicenter study for evaluation of safety and aesthetic results in 101 patients

Tissue Reaction to Low-Density Polyacrylamide Gel as a Carrier for Microimplants in the Adipose Fin of Rainbow Trout

The implantation of optical sensors is a promising method for monitoring physiological parameters of organisms in vivo. For this, suitable hydrogels are required that can provide a biocompatible interface with the organism's tissues. Amorphous hydrogel is advantageous for administration in animal organs due to its ease of injection compared to resilient analogs. In this study, we investigated the applicability of a semi-liquid 2.5% polyacrylamide hydrogel (PAAH) as a scaffold for fluorescent polyelectrolyte microcapsules (PMs) in rainbow trout. The hydrogel was injected subcutaneously into the adipose fin, which is a small, highly translucent fold of skin in salmonids that is convenient for implanting optical sensors. Using histological methods, we compared tissue organization and in vivo stability of the applied hydrogel at the injection site after administration of uncoated PMs or PMs coated with 2.5% PAAH (PMs-PAAH) for a period of 3 to 14 days. Our results showed that the introduction of PMs into the gel did not have a masking effect, as they were recognized, engulfed, and carried away by phagocytes from the injection site. However, both PMs and PMs-PAAH were found to provoke chronic inflammation at the injection site, although according to cytokine expression in the fish spleen, the irritating effect was local and did not affect the systemic immunity of the fish. Therefore, our study suggests low applicability of 2.5% polyacrylamide as a scaffold for injectable sensors within a timeframe of days.

Management of Complications in 257 Cases of Breast Augmentation with Polyacrylamide Hydrogel, using Two Different Strategies: A Retrospective Study

BACKGROUND

Polyacrylamide hydrogel (PAAG) has been used globally for breast augmentation, leading to long-term clinical complications. However, whether the infiltrated fibrotic capsule should be removed with PAAG to alleviate the complications remains unclear. This study aimed to ascertain different causes of complications and proper management strategies for PAAG removal in augmented breasts.

METHODS

From July 2015 to December 2019, patients who underwent breast augmentation with PAAG and in whom surgical intervention was undertaken for PAAG-associated adverse events at Shanghai Ninth People's Hospital were retrospectively reviewed. Patients were categorized into two groups according to whether the fibrotic capsule was removed (RFC) or not (NRFC). Aesthetic outcomes, PAAG residues, and adverse events were evaluated post-operatively to assess whether important issues pertaining to these arose following fibrotic capsule removal. Tissue histology and PAAG degradation analysis were implemented to investigate immune response, degradability, and toxicity of PAAG.

RESULTS

Altogether, 257 patients (88 RFC and 169 NRFC patients) were enrolled. 73.4% and 79.5% of the RFC and NRFC groups showed fairly good outcomes, with no significant difference, respectively. (X²= 0.0804, p = 0.79) Significant differences were found between two surgical techniques upon patient satisfaction, respectively. (X²= 3.529; p = 0.0301). Predictor of poor outcomes identified scar (OR, 4.555, p = 0.0019) and PAAG residue (OR, 5.379, p = 0.0003). Predictor of patient satisfaction identified post-operative outcomes (OR, 3.797; 95% CI, 1.860-8.923; p = 0.0002) and surgical technique (NRFC) (OR, 2.519; 95% CI, 1.449-4.434; p = 0.0008).

CONCLUSIONS

Both treatment strategies showed good results in our study. Removal of the fibrotic capsule from infiltration of PAAG largely depends on the individual psychological condition, aesthetic expectations, complications, and magnetic resonance imaging results. While PAAG does not degrade in the host's body over time, it may elicit immune reactions and chronic inflammation in the long term.

LEVEL OF EVIDENCE IV

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Highly Conductive, Stretchable, and Cell-Adhesive Hydrogel by Nanoclay Doping

Electrically conductive materials that mimic physical and biological properties of tissues are urgently required for seamless brain-machine interfaces. Here, a multinetwork hydrogel combining electrical conductivity of 26 S m^-1 , stretchability of 800%, and tissue-like elastic modulus of 15 kPa with mimicry of the extracellular matrix is reported. Engineering this unique set of properties is enabled by a novel in-scaffold polymerization approach. Colloidal hydrogels of the nanoclay Laponite are employed as supports for the assembly of secondary polymer networks. Laponite dramatically increases the conductivity of in-scaffold polymerized poly(ethylene-3,4-diethoxy thiophene) in the absence of other dopants, while preserving excellent stretchability. The scaffold is coated with a layer containing adhesive peptide and polysaccharide dextran sulfate supporting the attachment, proliferation, and neuronal differentiation of human induced pluripotent stem cells directly on the surface of conductive hydrogels. Due to its compatibility with simple extrusion printing, this material promises to enable tissue-mimetic neurostimulating electrodes.

Clinical and color Doppler ultrasound evaluation of polyacrylamide injection in HIV patients with severe facial lipoatrophy secondary to antiretroviral therapy

BACKGROUND/PURPOSE

Facial lipoatrophy in HIV patients, secondary to antiretroviral therapy (ART) with thymidine analogs, has been related to important psychosocial alterations and poor adherence to treatment. Polyacrylamide gel (PAAG) is a filler that has been used for treating facial lipoatrophy in HIV patients. The aim was to assess the clinical and sonographic anatomical changes after injection of PAAG in HIV patients with facial lipoatrophy secondary to ART.

METHODS

HIV patients receiving ART and suffering from severe facial lipoatrophy were recruited and underwent clinical and color Doppler ultrasound evaluation prior to PAAG application (AQUAMID^® ) and sonographically monitored at 18 months and clinically followed up for 36 months after the procedure. Adverse effects were recorded based on occurrence and complexity.

RESULTS

A total of 33 patients were evaluated, 30 men (91%) and 3 women (9%) with an average age of 49.6 years (±8.4). Clinical improvement assessed by a dermatologist had an average score of 5.9 (±0.7) on a scale of 1-7. On color Doppler ultrasound there was a significant increase of the thickness of the subcutaneous tissue (SCT) in both nasofold lines when comparing before and after PAAG injection (P < 0.01) and no signs of inflammation (hypervascularity). User satisfaction was qualified as excellent or good in all cases. Only two patients experienced adverse effects (hematoma and puncture site infection), which was successfully managed without consequences.

CONCLUSION

Treatment of facial lipoatrophy with PAAG seems to be effective in HIV patients and no signs of complications were observed in the monitoring at 36 months after injection. Color Doppler ultrasound can identify the filler deposits and the anatomical changes of the SCT non-invasively.

Emerging permanent filler technologies: focus on Aquamid

A plethora of soft tissue fillers have been developed within the past decade to correct the cutaneous changes that occur with photoaging. Such fillers, whether nonpermanent, semipermanent, or permanent, are widely used to fill undesired facial rhytides. In addition, fillers are employed to correct atrophy of the face as well as other parts of the body such as the dorsum of the hands through volumization and contouring. The extensive long-term safety outcomes reported with fillers and the ease with which they are administered make them an ideal choice to correct rhytides and to contour the face. However, as with any cosmetic procedure, in order to ensure high patient satisfaction and a safe outcome, proper training in injection techniques, the choice of the proper candidate, and awareness of potential adverse events are essential. This review article focuses on the permanent filler, Aquamid, which is composed of polyacrylamide hydrogel.

Facial gel complication after dental injection: a case report

Injectable gel is becoming increasingly popular for cosmetic reasons. The polyacrylamide gel (PAAG) is a permanent filler material used worldwide. In spite of the fact that the filler materials used today are considered quite safe, various complications have been reported in the literature. Hence PAAG use in the United States is not popular. As the area is very close to the dental field, a large complication potential is relatively considered following buccal dental injections. The aim of this article is to highlight a rare complication observed following a local anesthetic administration of a simple molar restoration in a healthy 33-year-old woman who had history of a filler augmentation in her cheek approximately 6 years ago.

Clinical data on injectable tissue fillers: a review

Treatment with injectable tissue fillers for aesthetic purposes is increasingly popular. In parallel with this success, questions related to the safety of these treatments and the products involved are being raised more prominently. To gain insight in the safety aspects of injectable tissue fillers, we performed a literature review to collect studies reporting clinical data of injectable tissue fillers. We found several case reports where serious complications after more than three years are described. However, there are only a limited number of well-defined prospective clinical studies available with follow-up periods longer than three years. Furthermore, causes of complications, that is, treatment or product related, are often not specified in literature. Considering the intended functional period of fillers in combination with the known occurrence of long-term complications, there is a need for well-defined prospective clinical studies. In order to be able to discriminate between product failure (a product safety issue) or application methodology (a physician expertise or training issue), better identification of observed complications and whether they are product or treatment related, is needed. For the safe use of the fillers it is important that treatment with injectable tissue fillers is performed by a trained physician, who knows the product specifications and its applications.

Inflammatory nodules following soft tissue filler use: a review of causative agents, pathology and treatment options

Nodule development is a common complication following the use of fillers for soft tissue augmentation and is commonly categorized as inflammatory or non-inflammatory in nature. Inflammatory nodules may appear anywhere from days to years after treatment, whereas non-inflammatory nodules are typically seen immediately following implantation and are usually secondary to improper placement of the filler. Although inflammatory nodules are more common with permanent fillers such as silicone, inflammatory nodule development following administration of temporary fillers such as hyaluronic acid and collagen has also been reported. Treated many times with corticosteroids due to their anti-inflammatory properties, inflammatory nodules may be secondary to infection or biofilm formation, warranting the use of alternative agents. Appropriate and prompt diagnosis is important in avoiding delay of treatment or long-term complications for the patient. This paper addresses the etiology, development, and studied treatment options available for inflammatory nodules secondary to each of the major classes of fillers. With this knowledge, practitioners may expeditiously recognize and manage this common side effect and thus maximize functional and aesthetic benefit.

Delayed gel indurations as an adverse effect of polyacrylamide filler and its easy treatment

Background. The more increasing use of permanent soft tissue fillers such as polyacrylamide hydrogel (PAAG) for aesthetic purposes, the more adverse events resulting from them are reported. Occasionally, nonserious complications and misdiagnosis result in unnecessary surgeries and sequels. Objective. To introduce delayed gel indurations (DGIs) as a late onset complication of PAAG and its easy treatment. Patient and Methods. Twenty patients (17 females and 3 males) referred to us with subcutaneous mass at injected site of PAAG. We diagnosed DGI based on clinical and sonography findings and treatment was performed with a hole by 16-gauge needle and squeezing. Results. From 20 patients with 21 cases of DGI, 5 (23.8%), 5 (23.8%), and 5 (23.8%) cases in cheeks, glabella, and lips were seen, respectively. The time range between PAAG injection and presentation of patients was 10-28 months (mean = 17.5%). All of the patients responded very well to treatment without recurrence and any complications. Conclusion. DGI is a nonserious, late onset, and easily treated complication of PAAG that is probably induced due to water exchange between gel and surrounding tissue and modest host immune reaction to gel.

Bulking agents: a urogynecology perspective

A bulking agent is a material injected into the wall of the urethra to improve urethral coaptation in women suffering from stress incontinence. The concept was initially described in the 1930s when sodium morrhuate and paraffin were used to augment urethral resistance. Sclerosing agents were also used for inducing permanent urethral scaring to improve urinary leakage. Eventually, collagen and autologous fat were found to be efficacious, and only collagen demonstrated proven safety and endured extensive testing, becoming the gold standard for injectable agents. Since then, multiple other products have been developed by the industry, each with its particular success rates and complications.

Lip augmentation: discussion and debate

Brian P. Maloney, William Truswell IV, and S. Randolph Waldman, address questions for discussion and debate:

Urethral bulking: a urology perspective

Urethral bulking therapy (UBT) is a minimally invasive procedure for stress urinary incontinence that is beneficial for properly selected patients. Many different materials are available for UBT, although none fulfill all the qualities of an ideal agent. In general, short-term clinical results are encouraging; however, over longer follow-up, results are disappointing and retreatment is often necessary. Proper patient selection and management of patient expectations are paramount to successful application of UBT.

Polyacrylamide hydrogel injection for breast augmentation: another injectable failure

BACKGROUND

Increasing complications of polyacrylamide hydrogel (PAAG) augmentation mammoplasty, such as chronic persistent infection, have recently caught the attention of both the medical field and the general public.

MATERIAL/METHODS

A total of 96 patients with severe chronic infection following PAAG augmentation mammoplasty were treated in the present study including 63 cases with infection confined to the breast and 33 with systemic infection. Endoscopy and surgery were performed to completely remove the materials and clear the infected tissues followed by drug-irrigation and vacuum-assisted closure for several days.

RESULTS

In patients with severe infection there were large amounts of PAAG, fibers and infiltration of numerous neutrophils and macrophages. The infection-inducing materials were extensively dispersed in the mammary and subcutaneous tissues, pectoral fascia and intermuscular space. In addition, there was scattered distribution of PAAG materials in the armpit, chest wall and abdominal wall, which were mixed with necrotic tissues and surrounded by lymphocytes, giant cells, macrophages and other inflammatory cells, forming chronic granulomatous and fibrous lesions. Infection was controlled following surgical intervention. No residual infectious foci or recurrent infections were noted among these patients. Although the severe infection did not result in mastectomy, patients had breast atrophy and various degrees of deformation.

CONCLUSIONS

Chronic infection following PAAG augmentation mammaplasty usually causes systemic infection and other devastating adverse reactions. This study confirms PAAG augmentation mammaplasty is another failed attempt. More attention should be paid to the injection of large doses of liquid filler.

Contouring of the gluteal region in women: enhancement and augmentation

Techniques for improving the appearance of the gluteal region are important elements in body contouring. In all cultures and communities, this aspect of the physique holds a special place among the elements comprising the ideals of physical beauty. Recent studies described the aesthetics of the gluteal region in terms of shape, volume, and projection. Accumulation of fat at the supragluteal, lower paralumbar, infragluteal, and/or trochanteric areas often disturbs the natural shape of the buttocks. The problem is accentuated by the lack of lateral projection. This study was designed to find a method for contouring of the gluteal region. This method is based on the enhancement of the shape by liposculpture of the areas around the buttocks, and lipoinjection to achieve the volume and projection. Between July 2008 and December 2009, the study included 40 female patients complaining of disfigurement of the gluteal region. With 1 year follow-up period, 36 patients showed high satisfaction with the results. Pre- and postoperative perimeters of the gluteal regions showed good improvement in proportion and projection. The study concluded that liposuction of the areas around the buttocks could enhance the shape of the gluteal region. Lipoinjection could add a balanced shape, size, and projection. A pleasing gluteal appearance could be achieved by the combination of enhancement and augmentation.

Late hematoma, seroma, and galactocele in breasts injected with polyacrylamide gel

Late hematoma or seroma and galactocele caused by augmentation mammaplasty have been reported in patients with silicon breast prostheses but are extremely rare in patients injected with polyacrylamide gel (PAAG). In a retrospective survey, the incidence, clinical manifestations, and management of late hematoma, seroma, and galactocele in 28 of 2,610 patients who underwent breast augmentation with PAAG injection were investigated, and 5 typical cases are presented. The diagnostic and managing methods for this complication have been assessed. The incidence of late hematoma or seroma was 0.65% and that of galactocele was 0.35% among patients with PAAG-injected breast augmentations. The clinical onsets of such late PAAG complications were of two types: rapid enlargement in 17 patients and progressive expansion in another 11 patients. Aspiration, ultrasound, and magnetic resonance imaging (MRI) are useful and sensitive tools for diagnosis. Foreign body reaction, PAAG-related tissue necrosis and fibrosis, and granuloma were shown, and the bacterial cultures in all 12 cases were negative. Needle aspiration with pressure dressing has been advocated as a reliable method for small diseases, and surgical exploration with irrigation-vacuum drainage and evacuation with capsulectomy have been considered more effective for recurrent, large, and long-term cases. In conclusion, these late complications rarely present after large-volume injections of PAAG for breast augmentation. The PAAG-related pathologic inflammatory tissue changes are suggested as the pathogenesis for the complication. Trauma and breastfeeding are considered to be stimulating factors.

Cost of surgical intervention for reconstructive therapy of HIV-associated facial lipoatrophy

This study aims to assess direct cost of reconstructive interventions with facial fillers for treatment of HIV (human immunodeficiency virus)-associated facial lipoatrophy (FLA). Evaluation was performed on data from patients enrolled in one arm of a comparative study of immediate versus delayed reconstructive treatment of facial lipoatrophy. Median costs were standardized for efficacy, estimated using data reported by physicians and patient reported outcomes. The variations of the results were evaluated with a sensitivity analysis. Evaluation was performed on 66 patients characterized by significant differences in terms of severity of FLA. Total cost resulted of €140,416.15, with a median cost per patient of €2126.04 (interquartile range [IQR]: 1599-2822). Taking into consideration severity of disease, median costs were €1641.67 (IQR: 1326.67-2126.04) and 2557.12 (IQR: 1939.34-2872.04) (P = 0.0) respectively for patients with low and high severity scores at baseline. Significant differences in term of cost-effectiveness ratios were also found between patients with different severity of FLA, and sensitivity analysis showed that these ratios increase with higher severity scores at baseline and vary widely depending on the costs of filler. Although these results cannot be considered representative because of important limitations, the present study suggests the severity of disease as an important determinant of costs.

Our strategy in complication management of augmentation mammaplasty with polyacrylamide hydrogel injection in 235 patients

Polyacrylamide hydrogel (PAAG) was once widely used in breast augmentation in China. Although it had been banned for augmentation mammaplasty in 2006, a large number of patients whose breasts were augmented with the gel injection have continued to seek medical advice because of its complications. The clinical management of these complications has never been standardised. The data of a total of 235 patients with complications following PAAG-injected breast augmentation have been summarised and the types and causations analysed. Magnetic resonance imaging (MRI) was undertaken in 228 patients with palpable masses, breast pain or tenderness, asymmetry or deformity and functional or psychological problems to eliminate neoplasm, infection and to delineate the diseases. The surgical gel evacuation via periareolar incisions was performed for all patients and immediate silicone breast prostheses were implanted in 108 patients and were delayed in 28 cases by 6 months. Most patients (214/235) of the group were satisfied with the treatment, and symptoms disappeared after removal of the gel. The gel distribution and involved tissue were well defined and neoplasm was ruled out by MRI. Postoperative MRI in 68 patients revealed that no obvious PAAG remaining. In either immediate or delayed reconstructive patients with silicone breast implants, good breast contour presented. A diagnosis and management strategy for these complications is proposed. In conclusion, the breast masses, pain and deformity are major complications after PAAG-injected breast augmentation. Psychological problems should be paid attention to. MRI is a sensitive and accurate method for diagnosis and treatment evaluation. Surgical removal of injected gel is the preferred method for complication management. The implantation of silicone prostheses for breast contour restoration after PAAG evacuation is effective for patients under strict selection. Our strategy for treating PAAG-related complications proved useful.

Unacceptable results with an accepted soft tissue filler: polyacrylamide hydrogel

BACKGROUND

Polyacrylamide hydrogel, considered a safe and biocompatible soft tissue filler, is widely used in cosmetic procedures. Its use for facial contouring and breast augmentation in Iran has increased dramatically in recent years. Most patients and many doctors are unaware of possible and reported adverse effects related to its administration.

METHODS

This study enrolled 98 patients experiencing unsatisfactory results and complications of polyacrylamide hydrogel. Adverse effects related to gel administration were documented for all the patients. Lab values were requested together with related medical care and surgical treatments, and gel was extracted by incision, milking, and irrigation.

RESULTS

The most common findings at the time of presentation were inflammation (n = 51), asymmetry (n = 31), irregularity (n = 18), infection and abscess formation (n = 11), and gel migration (n = 8). In one patient, severe anaphylactoid reaction was observed 1 week after gel injection, which led to significant complications for the patient. Histologic findings showed granuloma formation (n = 17), fat necrosis (n = 9), and fibrosis (n = 17). Macroscopic gel-related complications resolved after extraction of the injected material, except for skin necrosis and hyperpigmentation, which remained unchanged. For eight patients, the gel could not be extracted by squeezing and irrigation entirely. Three patients experienced gel reaccumulation after seemingly complete removal of the gel.

CONCLUSIONS

A wide range of complications seen among our patients showed that polyacrylamide hydrogel may not be as safe and biocompatible as it was thought previously. Both patients and physicians must be aware of the potential side effects of polyacrylamide hydrogel before gel administration.

Immediate versus delayed surgical intervention for reconstructive therapy of HIV-associated facial lipoatrophy: a randomized open-label study

We assessed the safety and efficacy of reconstructive therapy with facial fillers for the treatment of HIV-associated facial lipoatrophy (FLA) through a randomized, controlled, open-label single-center study. A total of 134 HIV-infected patients with severe FLA were randomly assigned to receive immediate (67 patients) or delayed (67 patients) facial injections of poly-l-lactic acid (PLA) or polyacrylamide gel (PAIG). Outcome measures included changes in physician and patient FLA severity scale, adverse events, and changes in health-related quality of life (HRQoL) and anxiety using validated measures. The mean average study follow-up was 27 weeks for the immediate and 25 weeks for the delayed subjects. Adverse events were mild and resolved after a mean of 4 days. Compared to patients randomized to the delayed treatment group, patients assigned to the immediate treatment group had significantly lower physician-rated (0.0 versus -3.0; p < 0.0001) and patient-rated (0.1 versus -1.8; p < 0.0001) FLA severity scores. By contrast, measures exploring HRQoL and anxiety did not show any significant difference between patients randomized to the immediate and deferred groups. Reconstructive therapy with facial fillers was effective and safe and led to significant improvements in FLA severity. However, no significant gains in HRQoL, relational and psychological consequences of body changes, and anxiety-related concerns were observed. Studies should be performed to identify patients who could maximally benefit from filling interventions for FLA.

Body shaping and volume restoration: the role of hyaluronic acid

Driven by the rising popularity of minimally invasive techniques, the demand for cosmetic procedures is increasing. Cosmetic body-shaping procedures can be categorized into those that remove tissue and those that add volume. This review focuses on the latter of these categories, particularly on the use of resorbable hyaluronic acid gels specifically developed for minimally invasive volume enhancement. Pilot studies of hyaluronic acid involving its injection to contour various body deformities and its recent use in female breast augmentation are discussed. Injectable hyaluronic acid is effective and well tolerated. It represents an attractive treatment option for volume restoration or augmentation by providing predictable long-lasting results after minimally invasive administration. Alternative treatment options for volume enhancement also are summarized including fat transfer, silicone implants, and the use of injectable nonresorbable products such as silicone, polyalkylimide, and polyacrylamide gels. As patients continue to opt for nonsurgical procedures that offer predictable results, the development of minimally invasive products such as hyaluronic acid is increasingly important.

Tissue integration of polyacrylamide hydrogel: an experimental study of periurethral, perivesical, and mammary gland tissue in the pig

BACKGROUND Polyacrylamide hydrogel (PAAG) is a nondegradable water-based polymer with high viscoelasticity. The gel is used as a tissue filler, the only risk being prolonged infection with anaerobic, contaminating microorganisms if not treated early with broad-spectrum antibiotics. OBJECTIVE With silicone gel as reference, PAAG tissue integration and migration was studied in a longitudinal study of the pig. MATERIALS AND METHODS Forty-one pigs were used. PAAG and silicone gel were injected into mammary tissue, and PAAG was injected into urethral or bladder wall or the anal canal. Tissues and regional lymph nodes were examined at 1, 1(1/2), 3, 3(1/2), 6, 12, and 14 months, and other lymph nodes and organs were examined at 1, 6, 12, and 14 months. RESULTS PAAG was invaded by macrophages and giant cells that were gradually replaced by a network of fibrous tissue. Silicone gel was seen inside these cells or as large vacuoles, surrounded by a fibrous capsule. Regional lymph nodes contained PAAG only at 1 1/2 months and silicone gel at 12 months. CONCLUSION PAAG is a stable, viscoelastic bulking agent, which unlike silicone gel is slowly integrated within its host tissue via a thin fibrous network. Long-term risk of fibrosis and migration is minimal.

Complications from repeated injection or puncture of old polyacrylamide gel implant sites: case reports

Polyacrylamide gel has been used for soft tissue augmentation outside the United States since 1997. Despite some adverse events, the long duration of the augmentation and the tangible filling effect has increased its use in Asia and the Middle East. In this era of mesotherapy and fillers, patients are more likely than ever to have additional injections. The response of old polyacrylamide gel implant sites to puncture or repeated injection has not been reported previously. A total of 12 cases were treated for acute inflammation after puncture of polyacrylamide gel implants with injection needles or minor surgical intervention. The duration of augmentation after the initial injection was from 6 months to 4 years. Acute inflammation followed a certain pattern. Patients presented with pain, swelling, redness, and significant induration after puncture of the dormant implant. Resolution was achieved gradually with drainage, empirical antibiotics, and antiinflammatory agents in 1 to 2 weeks. Cultures of removed gel were negative. The cause of inflammation was difficult to define, but a definite link to puncture of the implant could be found in all patients. Puncture of the implant violates the tissue-implant barrier and induces inflammation or introduces bacteria that are not detectable in culture but may contribute to inflammation in the presence of the filler material. Further research is needed to assess the inflammation observed with repeated puncture of old polyacrylamide gel implants and its implications. In the meantime, patients should be warned about the possibility of inflammation in the case of puncture or surgery to the implant site, even years after the polyacrylamide gel injection.

Using permanent implant materials for cosmetic enhancement of the perioral region

The aging of the perioral region continues to challenge facial plastic surgeons. Numerous rejuvenating surgical techniques, resurfacing methods, fillers, augmenters, and implants have been and continue to be developed. The drive for minimally invasive procedures that have a lasting effect has led to the development of several permanent injectable materials and implants to soften the melolabial grooves and marionette lines and augment the lips. These devices and their availability, usefulness, and practicality are examined.

Review of Non–FDA-Approved Fillers

The number of commercially available injectable soft tissue fillers has increased dramatically worldwide over the past decade. In the United States, a variety of temporary non-collagen-based fillers have been approved. However, no permanent soft tissue injectable fillers are currently approved by the US Food and Drug Administration. This article discusses some of the more popular soft tissue fillers, such as Restylane Fine Line, Restylane SQ, Perlane, Artecoll, Dermalive, Dermadeep, Bioalcamid, Bioplastique, Evolution, Outline, Argiform, and Aquamid, which are all available outside of the United States.