Vulvar migration of injected polyacrylamide hydrogel following breast augmentation: a case report and literature review

BACKGROUND

Vulvar migration is a rare complication of filler injection for breast augmentation, generally presenting as repeated pain and fever. We will report a case of woman with polyacrylamide hydrogel breast injection develops vulvar abscess.

CASE PRESENTATION

A woman with a history of polyacrylamide hydrogel breast injection was noted to have vulvar abscess due to migration of filler materials. Filler removal surgery and vacuum sealing drainage was performed for this patient. The patient was discharged from the hospital with no further complications. After a review of pertinent literature, only four previous case reports are found. Local inflammatory response, infection, large volume injections, inframammary fold destruction, hematogenous or lymphatic migrate, trauma, gravity and external pressure could play essential parts in the migration of injected filler.

CONCLUSION

Polyacrylamide hydrogel migration poses a worldwide challenge, necessitating personalized solutions. Our case study underscores the importance of comprehensive examinations for individuals with a history of filler breast injection when suspecting vulvar filler migration.

[Augmentation mammaplasty using injected polyacrylamide hydrogel: Report of a recent case and literature review]

Polyacrylamide hydrogel (PAAG) is a filler that has been strictly prohibited in France for many years. It first appeared on the market in 1980, used as an injectable for breast and facial augmentation, mainly in Asia and Eastern Europe. Like many other materials, it has shown unfavourable results and complications due to a foreign body reaction. It was banned in 2006, but continues to be injected illegally. With the influx of migrants, we are faced with the problem of how to manage complications, which can occur more than a decade later. We report our experience of a recent case in our department that required complete removal of the product and iterative lipofilling, with a result that remains sub-optimal, and we systematically review the literature.

Application of magnetic resonance imaging with intraoperative color Doppler ultrasound in the treatment of patients with polyacrylamide hydrogel injected for breast augmentation: a retrospective study of 204 cases for 12 years

Purpose

Polyacrylamide hydrogel (PAHG), which had been used widely for breast augmentation, has been banned for more than 15 years. Patients who had been injected PAHG for breast augmentation need evacuation surgery to remove as much as possible. To provide a series of diagnosis and treatment process MRI and intraoperative color Doppler ultrasound are combined for maximal removal of PAHG.

Methods

The patients who received evacuation surgery in Peking University Third Hospital from 2010 to 2022 after PAHG injection for breast augmentation were included in this research. MR scanning was performed preoperatively and postoperatively in some of these patients and color Doppler ultrasound was applied to help evacuate PAHG intraoperatively. The mean clearance rate of PAHG was calculated according to the MRI outcomes.

Results

Two hundred and 4 patients had received evacuation surgery after PAHG injection for breast augmentation with an average age of 42.8 years and an average body mass index of 21.2 kg/m2. The average PAHG retention time was 13.5 years. Among them, 52 patients underwent pre- and postoperative MRI scanning. The mean three-dimensional (3D) volume of PAHG was 684.8 mL (range, 350.0-1,123.9 mL), and the average residual 3D volume of PAHG was 53.7 mL (range, 12.4-98.3 mL). The mean clearance rate was 92.1%.

Conclusion

MRI and intraoperative color Doppler ultrasound can provide effective and precise location information of PAHG for evacuation surgery, which is a reliable method to ensure the maximal removal of PAHG.

Quality of life and sexual function after tension-free vaginal tape and polyacrylamide hydrogel injection for primary stress urinary incontinence: 3-year follow-up from a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

To assess quality of life (QoL) and sexual function outcomes at 3 years after tension-free vaginal tape (TVT) and polyacrylamide hydrogel injection (PAHG) for stress urinary incontinence (SUI).

METHODS

In this randomized trial comparing TVT (n = 104) and PAHG (n = 108), we assessed changes in QoL and sexuality using the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire, Short Form (IIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and RAND-36 Item Health Survey (RAND-36) at baseline and at 3 years. This is a secondary analysis of a randomized, noninferiority trial comparing patient satisfaction after TVT and PAHG.

RESULTS

In both groups, incontinence-related QoL improved from the baseline (p < 0.00), except for difficulty emptying the bladder and pain/discomfort. Total scores of UDI-6 and IIIQ-7 were lower for TVT compared to PAHG (p < 0.00) indicating better QoL at 3 years. Urinary incontinence with sexual activity or fear of incontinence restricting sexual activity improved in both groups (p < 0.00), with higher scores for physical section subscale in PISQ-12 (p = 0.02) for TVT. Physical and social functioning (RAND-36) improved from the baseline in both groups (p < 0.01) with a better outcome in the TVT group for physical functioning (p = 0.00).

CONCLUSIONS

Both TVT and PAHG improve QoL and sexual function in primary SUI with better incontinence and health-related QoL scores in the TVT group compared to the PAHG group at 3 years.

SERS detection of thiram using polyacrylamide hydrogel-enclosed gold nanoparticle aggregates

The development of sensitive and long-term signal-stable plasmonic substrates is vital to the in-field application of the surface-enhanced Raman spectroscopy (SERS) technique. The colloidal gold nanoparticles (AuNPs) system is commonly used in SERS detection, but it shows less signal stability and reproducibility due to the uncontrollable aggregation of nanoparticles by adding aggregating agents in SERS detection. In this study, we developed a new SERS detection platform based on polyacrylamide hydrogel-enclosed plasmonic gold nanoparticle aggregates (PAH-AuANs). In the system, the formation of PAH can rapidly stabilize the gold nanoparticle aggregates, avoiding the over-aggregation or precipitation of AuNPs. With the PAH concentration in the range of 6-10 % and AuNPs at the concentration of 0.2 nM, the resulting PAH-AuNAs platform exhibited both sensitive SERS activity and excellent SERS signal stability. The relative standard deviation of the 4-MBA probe SERS signal collected from the PAH-AuNAs platform was lower than 3 %. The limit of detection for the pesticide thiram was down to 0.38 μg/L with a handheld Raman spectrometer. Moreover, the procedure for preparing the PAH-AuNAs platform was easy to handle, offering a new strategy for in-field detection of environmental contaminants with a handheld Raman spectrometer in the future.

Immediate prosthetic breast reconstruction after removal of the polyacrylamide hydrogel (PAAG) through a small areolar incision assisted with an endoscope

Background

To identify the feasibility, safety, cosmetic outcomes and patient satisfaction of immediate prosthetic breast reconstruction after removal of Polyacrylamide Hydrogel (PAAG) through a small areolar incision assisted with an endoscope.

Methods

This was a retrospective study. Medical records of 87 patients who underwent PAAG removal were reviewed retrospectively from February 2010 to December 2019. These patients were dichotomized based on whether they accepted immediate prosthetic breast reconstruction after PAAG removal or not. A comprehensive analysis on the data was conducted to observe the surgical results, cosmetic outcomes, health-related quality of life (HRQOL) and patient satisfaction.

Results

Sixty-two patients underwent PAAG removal through a small areolar incision assisted with an endoscope, while another 25 patients underwent further immediate prosthetic breast reconstruction after PAAG removal. All the patients recovered smoothly after operation. In the immediate breast reconstructed group, most of the breasts were natural in appearance, but one patient had mild nipple and breast asymmetry, and another had mild breast asymmetry. Three patients had PAAG residual, and one of them accepted fine needle aspiration. The cosmetic satisfaction rate was 88% and 92% by surgeons and patients, respectively. In the other group, seven patients suffered from PAAG residual, one patient suffered from postoperative bleeding, and five patients suffered from skin laxity. The BREAST-Q scores revealed that patients who accepted immediate breast reconstruction had significant better outcomes in psychosocial well-being (p = 0.030), satisfaction with breasts (p = 0.021), when compared to patients who only accepted PAAG removal, while similar in sexual well-being (p = 0.081), physical well-being chest (p = 0.124), and satisfaction with outcomes (p = 0.068), and satisfaction with care (p = 0.077).

Conclusion

Immediate prosthetic breast reconstruction after PAAG removal through a small areolar incision aided with an endoscope might be a viable and safe technique, with better psychosocial well-being and satisfaction with breasts.

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

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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Quality of life and sexual function after TVT surgery versus Bulkamid injection for primary stress urinary incontinence: 1 year results from a randomized clinical trial

Introduction and hypothesis

To assess changes in quality of life (QoL) and sexual function outcomes at 1 year after tension-free vaginal tape (TVT) versus polyacrylamide hydrogel injection (PAHG).

Methods

In a randomized trial comparing TVT (n = 111) and PAHG (n = 113) treatments of stress urinary incontinence (SUI), we compared urinary incontinence and health-related QoL using the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire, Short Form (IIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and RAND-36 Item Health Survey (RAND-36) at baseline and 1 year.

Results

UDI-6 and IIQ-7 showed improved incontinence-related QoL (p = 0.001) from baseline in both groups except for difficulty emptying the bladder and pain/discomfort. At 1 year, TVT patients experienced less urinary symptom-related distress compared to PAHG (p < 0.001). Sexual function improved in both groups (p < 0.001 for TVT and p = 0.01 for PAHG) with higher scores for the physical section subscale (p < 0.001) for TVT. Health-related QoL (RAND-36) improved from baseline in both groups in physical and social functioning (p < 0.001) with better outcome in the TVT group for physical functioning (p < 0.001). Increase in pain from baseline (p = 0.02) was detected for TVT, but not for PAHG. However, there was no difference between the groups (p = 0.78).

Conclusions

In primary SUI, TVT and PAHG treatments both improved QoL and sexual function at 1 year. However, incontinence and health-related QoL scores were better in the TVT group. More pain compared to the baseline was reported after TVT, although there was no difference between groups. Clinical significance needs to be evaluated in long-term follow-up.

Application of Periareolar Mammaplasty with the Tissue Folding Technique in Breast Reshaping following Polyacrylamide Hydrogel Removal

Background

Polyacrylamide hydrogel (PAAG) was used as an injectable implant for augmentation mammoplasty for over 30 years, but its use was ceased due to various related complications. The only way to treat these complications is PAAG removal, but this causes breast ptosis, nipple retraction, breast asymmetry, and skin laxity.

Objectives

This article reports a new technique for breast reshaping after PAAG removal without prosthesis implantation.

Method

From January 2015 to June 2018, twenty-three patients underwent periareolar mammoplasty with the tissue folding technique (PMTFT) for breast reshaping after PAAG removal. Postoperative breast shape and the degree of satisfaction of the patients were evaluated during follow-up.

Results

All patients recovered well without severe complications. All patients were satisfied with their postoperative breast shape and their symptoms were relieved after surgery.

Conclusions

PMTFT provides satisfactory postoperative breast shape results. Economical, practical, and technical advantages were found over traditional prosthesis-mediated breast reconstruction. PMTFT can be an ideal surgical choice in appropriate cases.

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.

Synovial incorporation of polyacrylamide hydrogel after injection into normal and osteoarthritic animal joints

OBJECTIVE

Polyacrylamide hydrogel (PAAG) is a non-toxic, non-degradable synthetic product, used for years in the augmentation of soft tissues. Preliminary results in animals and humans have suggested long-lasting beneficial effects on symptoms of osteoarthritis (OA). The aim of this histopathological study was to investigate whether intra-articular injection of PAAG is integrated into synovial tissue in normal and OA animal joints, and if this integration is sustained.

METHODS

(A) A prospective, controlled, longitudinal study of normal knee joints injected with PAAG was performed in 10 rabbits, following the animals up to 1 year, and (B) a post mortem examination was carried out up to 2 years post-injection on 18 horse joints which had previously been treated with 1-2 injections of 2 ml PAAG for clinically and radiologically diagnosed OA.

RESULTS

Integration of the injected gel was evident at day 10 in the rabbit and by day 14 in the horse, with proliferation and invasion of synovial cells into the gel. By day 90 in rabbit joints and day 30 in horse joints, the gel had formed a sub-synovial layer, which was traversed by thin strands of connective tissue with vessels and covered by a synovial lining facing the joint cavity. This histological appearance persisted up to 2 years post-injection in horse joints.

CONCLUSION

Intra-articular injection of PAAG results in a stable, long-lasting sub-synovial layer of gel traversed with thin strands of connective tissue. Further studies to explore potential effects on synovial inflammation and pain are warranted.

Delayed active bleeding after radical evacuation of injected polyacrylamide hydrogel and immediate implant based breast reconstruction

Background

Polyacrylamide hydrogel (PAAG) was used in breast augmentation surgery in China during 1997–2006. Its application has led to increasing complications such as localized lumps, asymmetry, diffuse stiffness, infections, and localized tenderness or myalgia. Hence, many patients have sought for surgical gel evacuation in the following years.

Case presentation

A 37-year-old G2P0A2 slim (BMI = 18.3) woman who had received injected PAAG bilateral breast augmentation in China 15 years ago, visited our hospital for gel removal due to left upper quadrant breast tenderness with burning sensation. We performed simple mastectomy and immediate breast augmentation with silicone prostheses. Her postoperative course was uneventful. However, subcutaneous hematoma formed right after she started breast massage on the day 14 post operatively. The patient promptly received a CT-guided drainage followed by exploratory surgery with coagulation of the lesion located at the second intercostal space 2 cm to the right of the sternum.

Discussion

Delayed bleeding in our patient might be contributed to below reasons. First, the usage of PAAG might cause degeneration of muscle tissue structure which made it more fragile than normal muscle tissue. Secondly, the lack of sufficient coverage, cushion and protection of the muscle tissue in slim patient in addition to the external compression and shearing force of massage.

Conclusion

In slim patients, we suggest that the postoperative breast massage should be postponed for months until the tissue is recovered, or delayed breast reconstruction could also be considered.

Blepharoplasty Combined with Fat Grafting: A Treatment of Complications Following Polyacrylamide Hydrogel Injections in Tear Troughs

BACKGROUND

Polyacrylamide hydrogel (PAAG) can cause serious complications during facial augmentation. Previous studies have reported complications following PAAG injections to correct tear troughs.

METHODS

We report a rare case of tear trough deformity following PAAG injections. We developed a comprehensive treatment plan including transcutaneous blepharoplasty and fat grafting to address the presenting complications.

RESULTS

The patient showed flat lower lids and no more complications 1 year after surgery.

CONCLUSIONS

Blepharoplasty combined with fat grafting is an effective approach to eliminate PAAG injection complications in tear troughs.

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.

Treatment for displacement of PAAG mixture after injection augmentation mammoplasty

BACKGROUND

The incidence of serious complications after augmentation mammaplasty with injection of polyacrylamide hydrogel (PAAG) was high.

OBJECTIVE

To design a new method for healing of the cavities and cysts after augmentation mammaplasty.

METHODS

102 patients in whom PAAG exceeded the breast and spread to the thoracic-abdominal walls were enrolled and divided into two groups.

RESULTS

The flowing masses of different sizes exceeded the breast and spread to the thoracic-abdominal walls, and a large number of PAAG showed flowing degenerative mixture in the tissues and were invaded by many inflammatory cells. PAAG deposited extensively in the breast tissues, armpits and space of the thoracic-abdominal wall, and the breast was connected with the abdominal wall through the fistula of different sizes. At 2 weeks, the percentages of decrease in drainage volume and in lesion lacuna size of the thoracic-abdominal wall (82% and 80%, respectively) in patients receiving the multiple incisions combined with radical therapy were significantly different from those who did not receive the multiple incisions (46% and 45%) (Both P<0.01). At 4 weeks, in some of the patients receiving the multiple incisions combined with radical therapy, the lacuna of the thoracic-abdominal wall disappeared completely, and the lesions with flowing masses had been cleared.

CONCLUSIONS

The new method of subareolar incision combined with surgery for inferior segment of mass to clean the mixture and thoroughly eliminate the lacuna of the thoracic-abdominal wall as well as suture to close the intramammary fistula can improve the treatment efficacy.

Vacuum sealing drainage in the treatment of migrated polyacrylamide hydrogel after breast augmentation: a case report

BACKGROUND

Polyacrylamide hydrogel (PAAG) injection for breast augmentation can result in a variety of complications, including implant migration. The migrated PAAG can become colonized by pathogens, resulting in secondary infections which can be extremely difficult to treat.

CASE REPORT

We report the case of a 43-year-old female patient who underwent PAAG injection for breast augmentation. Implant migration was diagnosed 8 years after the initial injection.

CONCLUSION

Here, we report the first use of vacuum sealing drainage as a convenient and effective alternative to manage the complications of extensive PAAG migration after breast augmentation.

An improved tissue-mimicking polyacrylamide hydrogel phantom for visualizing thermal lesions with high-intensity focused ultrasound

A recipe was created to improve the tissue-mimicking (TM) bovine serum albumin (BSA) polyacrylamide hydrogel (PAG) reported in our previous study (Choi MJ, Guntur SR, Lee KI, Paeng DG, Coleman AJ. Ultrasound Med Biol 2013; 29:439-448). In that work, the concentration of acrylamide in TM BSA PAG was increased to make its attenuation coefficient the same as that of a tissue. However, this increase made the PAG stiffer and less homogeneous. In addition, the increase in acrylamide caused a significant increase in temperature over the denaturation threshold of BSA during polymerization, which required forced cooling so that the PAG did not become opaque at room temperature after polymerization. To eliminate those shortcomings, we substituted the increased acrylamide with a viscous polysaccharide liquid (corn syrup). The concentration of corn syrup was optimized to 20% (w/v, tested in the volume of 50 mL), so that the acoustic properties of the PAG would be close to those of human liver. The improved TM (iTM) BSA PAG constructed in this study had a speed of sound of 1588 ± 9 m/s, an attenuation coefficient of 0.51 ± 0.06 dB cm(-1) at 1 MHz and a backscattering coefficient of 0.22 ± 0.09 × 10(-3) sr(-1) cm(-1) MHz(-1). The density and acoustic impedance were 1057 kg/m(3) and 1.68 MRayl, respectively, and the non-linear parameter (B/A) was 5.9 ± 0.3. The thermal, optical and mechanical properties were almost the same as those of the BSA PAG (Lafon et al.2005). Experimental verification indicated that the thermal lesions visualized in the proposed iTM BSA PAG by high-intensity focused ultrasound were highly reproducible. In conclusion, iTM BSA PAG was proven to eliminate TM BSA PAG shortcomings effectively and is expected to be a promising test phantom for clinical high-intensity focused ultrasound device.

Polyacrylamide hydrogel pulmonary embolism--A fatal consequence of an illegal cosmetic vaginal tightening procedure: A case report

Vaginal tightening is a kind of esthetic surgery aimed at enhancing sexual satisfaction during intercourse. Although the injective vaginal tightening procedure is informal, there are already some reports of its application. But pulmonary embolism is a really rare therapeutic complication of this procedure. We report a case of death due to the non-thrombotic pulmonary embolism as a consequence of illegal cosmetic vaginal-tightening procedure using polyacrylamide hydrogel. A 34-year-old woman was hospitalized with paroxysmal abdominal cramps and diarrhea as initial symptoms, while she concealed the genital cosmetic surgery history. Respiratory distress presented only 1.5h before she died. The result of autopsy revealed the cause of death as pulmonary embolism due to the hydrogel which was injected into her vaginal wall. The emboli were confirmed as polyacrylamide hydrogel by Alcian-blue stain and the Fourier transform infrared scanning. It is suggested that pulmonary embolism should not be discarded in the expertise of deaths following cosmetic implant surgeries. It broadens our understanding about death associated with esthetic genital procedures and informs clinicians and medical examiners of the potential death of this type. And detailed investigations of previous medical and surgical history will always play a critical role in the certification of cause of death.

Complications from injectable materials used for breast augmentation

Fewer surgical procedures have a history as fascinating and as terrifying as breast augmentation. Initial efforts at augmentation involved injection of substances such as paraffin or oil into the breast tissue, or the implantation of substances including ivory or glass balls, or rubber. More recent efforts have included the injection of liquid silicone or polyacrylamide hydrogel. The current paper reviews four distinct eras of breast augmentation, and provides the current status of these injection materials. A case report is presented on a woman whose breasts were injected with polyacrylamide hydrogel in Iran. The current status of this group of materials is also presented. During the past 110 years, history has repeated itself during each of the four eras of injection.