Polyacrylamide Gel Injection Research Articles

Breast contracture and skin sclerosis following 20\xa0years of polyacrylamide hydrogel migration in a patient with familial vitiligo: a case report

BackgroundBreast augmentation with polyacrylamide gel (PAAG) injection was approved in China in 1998 and later banned in 2006. The ban ensued numerous complaints from patients such as pain, induration, deformation, infection, displacement, and milk deposition associated with PAAG injection. To date, no study has investigated the long-term effect of PAAG migration on autoimmune diseases.Case presentationWe report a rare case of a 49-year-old female patient with familial vitiligo who receiving PAAG injection for breast augmentation. The patient reported to have felt persistent movement of PAAG in her thoracoabdominal area for almost 20 years. Furthermore, the PAAG-induced chronic inflammation that aggravated vitiligo, which in turn promoted skin sclerosis. This damaged the breast contracture, increased chest tightness and induced mild breathing problems.ConclusionHere, we present a rare case in which a patient with a family history of vitiligo experienced long-term complications after receiving PAAG injection for breast augmentation. This case highlights the relationship between vitiligo, migration of PAAG and tissue hardening and skin contraction.Level of evidence: Level V

Breast Reconstruction with Silicone Prosthesis Immediately Following Polyacrylamide Gel Removal.

To determine the feasibility and efficacy of breast reconstruction with silicone prosthesis immediately following polyacrylamide gel removal. An observational study. Department of Breast and Thyroid Surgery, the Second Affiliated Hospital of Soochow University, Suzhou, China, from November 2013 to May 2017. Twenty-seven patients with serious complications resulting from polyacrylamide gel (PAAG) injection were operated in our hospital. Using an inframammary fold incision, the PAAG and surrounding tissues were completely removed. All patients were received mastopexy and immediate breast reconstruction. Of all patients, 26 reported relief of preoperative complications, without obvious postoperative complications. Only one patient developed recurring infections after surgery and removed the prostheses. After removal of PAAG, mastopexy followed by immediate breast reconstruction allows the patient to obtain a satisfactory appearance without serious complications. The key to successful breast reconstruction with prostheses first lies with the complete excision of PAAG and surrounding tissues.

Unusual presentation of a late complication in a polyacrylamide gel-injected breast

Implant migration is a known complication of hydrophilic polyacrylamide gel (PAAG) mammoplasty. We report the case of a female patient with an undisclosed history of bilateral breast augmentation with PAAG injections 10 years ago. The patient presented with abdominal pain and rapid gel migration into the abdominal and pelvic walls after sneezing. Computed tomography and sonography were performed, but the results were inconclusive. The diagnosis of PAAG migration was not made until the patient complained of progressive shrinkage of her right breast and disclosed the history of PAAG mammoplasty. A subsequent magnetic resonance imaging study confirmed the diagnosis. Gel migration was successfully treated using endoscopic lavage and breast debridement. Familiarity with the radiological features of PAAG migration and a thorough examination of the patient's history are mandatory for the accurate diagnosis of this complication.

Transanal submucosal polyacrylamide gel injection treatment of anal incontinence: a randomized controlled trial.

The efficacious and safe use of transurethral injections of polyacrylamide hydrogel (Bulkamid(®)) in women with stress urinary incontinence suggests that it may be suitable also for treatment of anal incontinence. We aimed to determine the effectiveness and safety of polyacrylamide hydrogel when used as a transanal submucosal bulking agent in women with anal incontinence. Thirty women with a diagnosis of anal incontinence and a Cleveland Clinic Incontinence Score (CCIS) >10 were randomized to three different techniques of transanal submucosal injections using polyacrylamide hydrogel. Follow up was performed at 2, 6 and 12 months using CCIS and the Fecal Incontinence Quality of Life scale (FIQL). In all, 29 of the 30 women completed the follow up. Approximately half of the women requested a re-injection at the 6-month visit. The overall CCIS improved significantly from baseline (14.7. SD 2.5) to 1 year (12.4. SD 3.1) (p = 0.003). There was a significant improvement with regard to the occurrence of loose fecal incontinence (p = 0.014) but not for solid fecal incontinence (p = 0.28). At 1 year the FIQL domains of coping-behavior, depression, and embarrassment showed significant improvements (p = 0.012, p = 0.007 and p = 0.007, respectively). We recorded no adverse events related either to the injection technique or the biomaterial. There were no significant differences between the treatment groups in either CCIS or FIQL scores. Transanal submucosal injection of polyacrylamide hydrogel resulted in a modest although significant overall improvement in anal incontinence symptom scores with corresponding improvements in several domains of quality of life, regardless of injection volume.

Histological Appearance of the Synovial Membrane after Treatment of Knee Osteoarthritis with Polyacrylamide Gel Injections: A Case Report

Knee osteoarthritis (OA) caused by cartilage damage and synovitis is a painful disease, for which the only effective treatment today is total knee replacement. Polyacrylamide hydrogel (PAAG) is a synthetic non-degradable and non-toxic tissue filler, which allows host cell integration with formation of a scaffold of fibrous tissue inside the gel. A histo-pathological pilot study using this gel for intra-articular injection in rabbit and horse joints has shown that it forms an integrated layer within the upper part of the synovial membrane, and clinical studies of horse joints and human knee joints with OA has shown promising long-term results in pain reduction. It has therefore been the hope that this type of treatment could prolong the time leading up to total knee replacement more effectively than today. The current case report from one of the patients included in the clinical study mentioned above describes, for the first time in a human, how biopsies obtained during meniscectomy after 9 months display the same type of synovial augmentation as seen in horse joints with OA, and that the filler effect from the integrated gel persists in spite of areas with chronic synovitis and microscopic fibrosis.

Letter: Position Statement of Korean Academic Society of Aesthetic and Reconstructive Breast Surgery: Concerning the Use of Aquafilling® for Breast Augmentation

In the article entitled ‘Correcting shape and size using temporary filler after breast augmentation with silicone implants’ published at October 2015 of the Archives of Aesthetic Plastic Surgery, Shin et al. [1] states that ‘Aquafilling is a new option for the correction of minor problems after breast augmentation surgery with implants’. According to the article, Aquafilling is composed of 98% of water and 2% of copolyamide. However, In the document submitted to Korean Food and Drug Administration (KFDA), the exact ingredient of Aquafilling is 2% of poly (acrylamide-co-N,Nʹ-methylene-bisacrylamide) and 98% of sodium chloride solution 0.9%. Historically, there have been many attempts to augment breasts using injectable materials including paraffin, liquid silicone, polyacrylamide gel (PAAG) and so on [2]. Up-to-date, all materials resulted in some form of complications such as chronic inflammation, lumps due to foreign body granulomas and even skin ulcerations. For these reasons, U. S. Food and Drug Administration (FDA) unapproved use of fillers for breast augmentation [3]. There have been numerous reports that augmentation mammoplasty with PAAG filler injection results in serious adverse complications [2,4-6]. Specifically, it can result in local and systemic fever, breast swelling, redness, nipple bulging, tenderness and pain, asymmetry, deformity and even loss of ability for breastfeeding [7-9]. Although Shin et al. described that it is different from the previous problematic PAAG fillers such as Amazing Gel or Aquamid, the major component of Aquafilling is polyacrylamide in itself, no different from the existing fillers that have been commercially available. Furthermore, explanations in regards to how the same chemical constituents can be altered by some changes in the physical properties such as bonding reaction, are obscure if not totally lacking in evidence. In this regard, members of the Korean Academic Society of Aesthetic and Reconstructive Breast Surgery express serious concerns over the use of Aquafilling for breast augmentation, more so considering the short six months follow up from initial procedures. There have been previous reports that in the early period of PAAG use, it is well tolerated to breast, and migration resistant [10]. However, this report has become totally out of date and, unacceptable and abandoned at present. Especially, considering the late onset of serious complications after PAAG injection to breast, it is too hasty conclusion that Aquafilling is new option for correction of unfavorably resulted augmentation mammoplasty. KFDA only permitted the use of Aquafilling for temporary improvement of facial wrinkle, asymmetry and shape and volume of lip. Not abiding by the permitted use as in augmentation of breasts requires much more volume, leading to potential complication and patients suffering where treatment is not easy [4]. Many cases of breast deformity after Aquafilling injection is irreversible and even requires breast reconstruction [4]. The Korean Academic Society of Aesthetic and Reconstructive Breast Surgeons obviously opposes the use of Aquafilling for breast augmentation until sufficient evidences of long term safety are accumulated, and verified. We also caution against commercial utilization of the unapproved filler relying on the preliminary report by Shin et al. More strict regulations must be applied in the human use of new or unproven injectable fillers. Only the highest standards of medical ethics can insure the health of our patients. Received: Feb 11, 2016 Revised: Feb 14, 2016 Accepted: Feb 15, 2016 Correspondence: Tai Suk Roh Department of Plastic and Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea. E-mail: rohts@yuhs.ac

Evacuation of Complicated Polyacrylamide Gel With the Help of Ultrasonographic Markings and Fat-Transfer Cannula

Background: Polyacrylamide gel (PAAG) has been used extensively for soft tissue augmentation. Complications of PAAG injection mandate evacuation of filler. Objectives: This study aimed to introduce a new method of evacuating PAGG with the help ultrasonography markings on face. Patients and Methods: We enrolled patients who were unsatisfied with the results of injection or had developed complications such as induration, gel migration, or infection referred to our clinic to evacuate the filler since 2011. Patients were examined by ultrasonography and a radiologist reported the volume, place, and depth of gel as well as fibrosis and marked them on the patients' face or its photographs. We used Barikbin's tumescent solution to facilitate the evacuation of concentrated gel and reduce the risk of injury to vital tissues. We inserted a 16G-fat-transfer cannula through a hole on the nasolabial folds and evacuated the gel by vacuum force and milking. We also used a Barikbin's blunt subcision blade to dissect fibrosis. The evacuated region was irrigated by tumescent solution. Patients' satisfaction was assessed by visual analogue scale (VAS). The procedure was repeated at four-week interval until achieving favorable results. Results: We treated 173 patients, including 164 females (94.8%), with the mean (SD) age of 43.75 (10.62) years. According to VAS, 95.4% of patients reported complete satisfaction while 2 (1.2%) were unsatisfied with the results. Patients reported no complication of therapy. Conclusions: Our method provided good results and performing evacuation under the guide of bedside ultrasonography is recommended.

Breast Reconstruction and Treatment Algorithm for Patients with Complications after Polyacrylamide Gel Injections: A 10-Year Experience

An algorithm for breast reconstruction for patients with complications after polyacrylamide gel (PAAG) injections is presented, and the outcomes of surgery using the adopted treatment protocol are evaluated. We reviewed the clinical records of consecutive patients who were treated for PAAG complications with breast reconstruction at two surgical centers between 2000 and 2010 (n=154). All patients had one or more complications from PAAG injections and underwent gel removal and breast reconstruction with implants. One hundred women who underwent conventional breast augmentation with implants matching the study cohort comprised a reference group. Of the total of 154 patients, 121 (79%) women had no signs of acute inflammation and underwent a single-stage surgery comprising gel removal and immediate breast reconstruction (group I). The remaining 33 (21%) patients had signs of acute inflammation (group II) and underwent two-stage surgery with delayed reconstruction. Subgroup analysis of group I revealed that submuscular implant placement was associated with a lower probability of capsular contracture (CC) than was subglandular placement (17 vs. 36%, p<0.05). The rate of CC in patients with textured implants (n=81) was 24.8%, whereas no CC was registered among patients with micropolyurethane surface implants (n=40). The rate of early surgical complications in group I, group II, and the reference group was 39, 51.5, and 9%, respectively. The probability of reoperation after breast reconstruction in group I and in group II was 34 and 42%, respectively. Complications and subsequent breast reconstruction in patients after PAAG injection pose a challenge to the surgeon; however, satisfactory results can be achieved in the majority of patients. The reconstruction algorithm described here may serve as a useful tool for breast surgeons dealing with PAAG complications. 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 .

Long-Term Efficacy and Safety of Polyacrylamide Hydrogel Injection in the Treatment of Human Immunodeficiency Virus–Related Facial Lipoatrophy

Facial lipoatrophy, a human immunodeficiency virus-related wasting of the facial soft tissues, can compromise patients' quality of life. Injection of different materials in the cheeks can improve this condition. Concern regarding potential long-term complications of nonbiodegradable fillers remains. The authors investigated the long-term efficacy and safety of polyacrylamide gel injections. Human immunodeficiency virus-infected patients treated with polyacrylamide gel for moderate to severe facial lipoatrophy with a minimum of 5 years' follow-up were included. Aquamid (1 ml) was injected monthly into each cheek until adequate correction was obtained. Outcome measures were ultrasound measurement of cheek soft-tissues thickness, evaluation of aesthetic improvement, and self-evaluation of satisfaction and psychological consequences of treatment (visual analogue scale for the face, Assessment of Body Change and Distress questionnaire, and Beck Depression Inventory score). Adverse events were classified as acute (<1 week), early (1 week to 1 month), midterm (1 month to 1 year), or late (>1 year). One hundred forty-one patients completed the treatment as of June of 2005; 38 (32 men; mean age, 42 years) were available for follow-up of more than 5 years (mean, 62 months). The mean number of treatment sessions was seven over a mean period of 8 months. Significant improvement of cheek thickness and aesthetic result and highly significant satisfaction and psychological improvement were obtained. No serious adverse events occurred during the follow-up period. The long-term efficacy and safety of polyacrylamide gel injection for the treatment of human immunodeficiency virus-related facial lipoatrophy were shown over a period of 5 years. : Therapeutic, IV.

Polyacrylamide Gel Injections for Breast Augmentation: Management of Complications in 106 Patients, a Multicenter Study

Polyacrylamide gel (PAAG) was first manufactured in Ukraine in the late 1980s and introduced as a biomaterial for "breast augmentation without surgery." Since it is prohibited in most countries, PAAG injections are rare nowadays, but their consequences and long-term complications can be crucial. We identified 106 patients consecutively operated on for PAAG complications at three teaching Ukrainian hospitals between 1998 and 2009. All relevant sociodemographic, clinical, and treatment characteristics were collected. Forty-five (42%) patients were available for clinical follow-up. The majority (88%) had had bilateral PAAG injections. The mean volume of injected PAAG was 230ml/breast (range=50-400). Mean age at injection was 29years (range=17-49) and the mean time from the injection to complications was 6.1years (SD=4.1). Symptoms preceding debridement were pain in 85 patients (80%), breast hardening in 79 (74%), breast deformity in 77 (73%), lumps in 57 (54%), gel migration in 39 (37%), fistulas in 17 (16%), and gel leakage in 12 (11%). The surgical interventions in 199 breasts included gel evacuation alone in 107 (54%) or in combination with partial mastectomy in 65 (33%), partial mastectomy and partial pectoralis muscle resection in 12 (6%), or subcutaneous mastectomy in 15 (7%). Of the 199 operated breasts, 86 (43%) immediate and 58 (29%) delayed implant-based breast reconstructions were performed. Injections of PAAG can cause irreversible damage to the breast necessitating complex debridement procedures, even mastectomy and breast reconstruction. Despite numerous surgical interventions, gel remnants are still found on subsequent breast imaging. Although PAAG is prohibited in many countries, different types of injections with unknown long-term effects are currently being used. Making the public aware of the problems of injectables for breast augmentation is warranted.

Polyacrylamide Gel Injection for Treatment of Human Immunodeficiency Virus-Associated Facial Lipoatrophy: 18 Months Follow-Up

Lipoatrophy of the face affects the quality of life and body image of individuals receiving antiretroviral therapy. The objective of this study was to assess the safety and efficacy of a permanent nonbiodegradable polyacrylamide gel filler, used for facial wasting rehabilitation. Thirty-two individuals positive for the human immunodeficiency virus (HIV) were enrolled in the study between January 2007 and January 2009 and treated using nonbiodegradable polyacrylamide gel injections for a facial wasting rehabilitation. Local infection, foreign body reaction, and migration of the product were not observed during follow-up (18 months). Small, palpable, nonvisible nodules were recorded in 13 cases at the end of follow-up. Polyacrylamide hydrogel is an appropriate treatment option in restoring facial contours in immunocompromised people with HIV. Injections of large volumes of polyacrylamide gel (8 to 12 mL) are not associated with a high rate of complications such as infection and foreign body reaction and allow improvement in quality of life in a limited time.

Breast Fibromatosis after Hydrophilic Polyacrylamide Gel Injection for Breast Augmentation: a Case Report and Review of the Literature

REAST fibromatosis is a rare kind of lesion. The average incidence is about 2-4 per million every year. So far there have been about 100 cases reported altogether. In this report, we describe a case of breast fibromatosis developed after hydrophilic polyacrylamide gel (HPG) injection for breast augmentation. By reviewing the literature, the possible pathogenesis of this case and the proper treatment strategy are investigated.

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.

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.

Diagnostic cytological features of polyacrylamide gel injection augmentation mammoplasty

To study the cytological features of breast lesions associated with hydrophilic polyacrylamide gel (PAAG) injection augmentation mammoplasty and to determine the specific diagnostic features. Fine needle aspiration (FNA) cytology smears from 14 patients who presented with breast lump and a clinical history of PAAG injection were reviewed. The staining properties of the PAAG material in Papanicolaou (Pap), Haematoxylin and Eosin (H&E) and Diff-Quik stains, as well as the cellular background, were studied. Cell blocks were also studied with H&E, periodic acid-Schiff (PAS), periodic acid-Schiff with diastase digestion (PASD) and mucicarmine (MC) stains. PAAG was stained consistently pinkish with a homogenous smooth texture on H&E (100%), polychromasia on Pap (100%) and magenta violet with bubbly vacuoles on Diff-Quik (100%). Half (7) of the cases showed sharp borders. The presence of foreign body type giant cells with histiocytes (5 cases, 36%) and scanty clusters of benign ductal cells (4 cases, 29%) were seen in the background of a minority of the cases. PAAG was represented by blocks of homogenous grey-purplish acellular material with a sharp border on cell block sections, which were negative for PAS, PASD and MC. PAAG shows a consistent staining pattern in various common cytological staining preparations. Blocks of acellular gelatinous material, stained homogenous pinkish on H&E, polychromasia on Pap and magenta violet with bubbly vacuoles on Diff-Quik, are the reliable cytological features of PAAG.

Evaluation of MRI Findings After Polyacrylamide Gel Injection for Breast Augmentation

Polyacrylamide gel injection mammoplasty has recently been used for breast augmentation. However, many complications have been reported including complications that in some patients resulted in the need for mastectomy. This article reviews the MRI appearances of various complications of polyacrylamide gel injection mammoplasty including breast asymmetry; intramammary or extramammary gel displacement, including intrathoracic extension; and glandular atrophy, inflammation, and infection resulting in mastectomy. Because poly acrylamide gel has a high water content, we found that sagittal and axial T2-weighted are the best sequences to use to detect complications.

Intraorbital Polyacrylamide Gel Injection for the Treatment of Anophthalmic Enophthalmos

To evaluate the use of orbital polyacrylamide gel injection for the correction of anophthalmic enophthalmos. Noncontrolled clinical trial of 21 patients (14 with ocular implants, 5 with phthisis bulbi, and 2 with dermis-fat graft). Orbital CT was performed to estimate the volume of polyacrylamide gel needed to restore orbital volume. Polyacrylamide gel was injected using a 22-gauge (30 x 0.7 mm) needle transcutaneously inserted in the lateral third of the lower eyelid, directed to the orbital muscle cone. A second injection was administered 15 days later, if necessary. CT was repeated 30 days after the last procedure. Exophthalmometry was performed before and 90 days after the procedure. The mean total volume injected per orbit was 2.4 +/- 0.7 ml (range, 1-3.5 ml). The volume of the enophthalmic orbit increased from 26.9 +/- 5.0 ml to 29.3 +/- 4.9 ml (p < 0.001). The mean difference in exophthalmometry readings was 3.3 +/- 1.6 mm (range, 1.5-8.0 mm) before the procedure and 1.0 +/- 0.9 mm (range, 0.0-3.0 mm) after 3 months (p < 0.001). Adjustment of the ocular prosthesis or fabrication of a new one was necessary in 11 patients (52.4%), and the mean volume of the ocular prosthesis was reduced from 2.0 +/- 0.6 ml to 1.6 +/- 0.6 ml (p = 0.003). All patients were satisfied with the aesthetic results. No serious adverse events were observed. The initial results were maintained 1 year after the procedure. Polyacrylamide gel injection in the orbital space effectively reduces enophthalmos in ocular prosthesis wearers.

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.

Migration of Implants: A Problem with Injectable Polyacrylamide Gel in Aesthetic Plastic Surgery

Polyacrylamide gel (PAAG) has been used as a soft tissue filler material for cosmetic purposes in Europe and China since 1997. The various complications of PAAG have been reported. A total of 15 patients who received PAAG injections at other institutions were treated for gel migration in the authors' hospitals. During treatment, the authors found that the injected PAAG had not formed capsules within the muscle and was encapsulated only by thin fibrous tissue in skin and mammary glands. Consequently, the filler material migrated easily because of muscular activity or the influence of gravity, especially when the capsule was broken by incorrect massage or incidental force. It is suggested that PAAG should not be injected into muscular tissue or subcutaneous areas with active movement, such as joints and muscles involved in facial expression with thin skin. After years of gel implantation, the thinned capsule may result in an increasing incidence of this complication. Management and some clinical findings in relation to the complication also are discussed.

Long-term treatment for lipoatrophy associated or not with HIV infection using ePTFE implants and polyacrylamide gel

HIV-related lipoatrophy (HIVLA) is notable for its increasing incidence, multiple etiologies, relatively low morbidity, apparently irreversible effects, and unequivocal clinical features. The underlying cause of HIVLA is still controversial, but there is an increasing demand for correction. We describe a treatment approach using soft malar implants and polyacrylamide gel injections, separately or in combination. Expanded polytetrafluoroethylene (GORE-SAM, W.L. Gore & Associates, Flagstaff, AZ) malar implants were used for augmentation of the most sunken areas below the eye. They were placed subperiosteally and more medially than conventional implants. After trying sheets and custom-made implants, preshaped GORE-Tex SAM implants are now used systematically. Polyacrylamide gel (Eutrophill, Lab Procytech, Martillac, France) injections were performed continuously and evenly from one side to the other in the deepest part of the sunken area at the subcutaneous level only. A total of 85 consecutive patients were treated using implants alone in 8 cases, injections alone in 65 cases, and both implants and injections in 12 cases. The few adverse effects included 3 cases of chronic inflammation (dental conflict) after placement of sheets and custom-made implants; no such cases occurred using preshaped implants. Some very light bulges developed after polyacrylamide injections, which usually disappeared after a few months. Mean follow-up was 16 months for injections and 29 months for implants. Combination treatment using implants in sunken areas near the bone and fillers in soft tissue areas offers a balanced trade-off between benefits and risks and provides excellent long-term and natural results, as well as notable psychological benefits.