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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 50  |  Issue : 2  |  Page : 77-80

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


1 Department of Diagnostic Radiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
2 Department of General Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
3 Department of Plastic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
4 Department of General Surgery, Lohas Clinic, Taipei, Taiwan

Date of Submission13-Aug-2016
Date of Decision13-Sep-2016
Date of Acceptance20-Oct-2016
Date of Web Publication18-Apr-2017

Correspondence Address:
Chun-Hung Ko
Department of General Surgery, Lohas Clinic, No. 12, Shida Road, Da'an District, Taipei City 106
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_24_17

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  Abstract 

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.

Keywords: Complication, gel migration, mammoplasty, polyacrylamide gel, sneezing


How to cite this article:
Peng HL, Cheng YH, Lin YH, Ko CH. Unusual presentation of a late complication in a polyacrylamide gel-injected breast. Formos J Surg 2017;50:77-80

How to cite this URL:
Peng HL, Cheng YH, Lin YH, Ko CH. Unusual presentation of a late complication in a polyacrylamide gel-injected breast. Formos J Surg [serial online] 2017 [cited 2019 Mar 21];50:77-80. Available from: http://www.e-fjs.org/text.asp?2017/50/2/77/204663


  Introduction Top


Polyacrylamide gel (PAAG) is a jelly-like transparent substance, containing approximately 2.5% cross-linked polyacrylamide and 97.5% water. PAAG is used as a permanent filler for soft-tissue contour correction or breast augmentation.[1] Injection of PAAG is minimally invasive and convenient. It has been commonly used for breast augmentation in China, Eastern Europe, and South America for more than 10 years.[2] However, an increasing number of complications have been reported for PAAG-injected breasts. This report describes a 46-year-old woman presenting with gel migration 10 years after bilateral breast augmentation with PAAG injections. In this patient, distant gel migration manifested as abdominal pain after severe sneezing. The unusual presentation of this complication, together with an undisclosed history of breast augmentation with PAAG, delayed accurate diagnosis. Our case represents a diagnostic challenge in this rare occurrence.


  Case Report Top


A 46-year-old Taiwanese woman presented to the emergency room with abdominal pain. The patient claimed that she started experiencing severe pain in the right upper abdomen 2 days before presentation, after an episode of violent sneezing. The abdominal pain subsequently extended to the right lower quadrant and the suprapubic area. She denied any previous trauma or surgery. Physical examination revealed tenderness in her right abdomen and suprapubic area with muscle guarding. An ultrasound revealed a large, well-defined, hypoecho subcutaneous mass in the right abdomen. A Doppler study indicated avascularity. A computed tomography scan revealed a large hypodense mass extending from the right upper abdominal wall to the pelvic wall [Figure 1]. Based on the relevant clinical history, an abdominal wall injury with hematoma formation was initially suspected, possibly caused by the incidental force of severe sneezing. Conservative treatment was then started, and the patient was referred to an outpatient clinic for follow-up. Two months later, she continued to experience pain in the right lower abdomen. At the same time, progressive shrinkage of the right breast with the development of a lump in the right upper abdomen was observed. The history of breast augmentation with PAAG injections 10 years earlier in China was then exposed. Physical examination revealed asymmetry in the contours of bilateral breasts. The shrunken right breast was nontender. A subcutaneous lump with mild tenderness was palpable in the right upper quadrant. A magnetic resonance imaging (MRI) scan revealed fluid-filled sacs in the retroglandular areas of both breasts, and a part of the contents appeared to have leaked out from the sac of the right breast [Figure 2]. A large amount of the contents had spread extensively from the right breast through the retropectoral and preperitoneal spaces to the right abdomen and suprapubic area [Figure 3]. Diagnosis of gel migration from the PAAG-augmented breast was made, and subsequent surgery was arranged.
Figure 1: Enhanced computed tomography revealing a hypodense mass below the rectus abdominis muscle (white arrow) extending from the right upper abdomen (a) to the pelvis (b)

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Figure 2: An axial magnetic resonance imaging depicting a collapsed right augmented breast. The signal intensity of polyacrylamide gel is similar to that of water, appearing as a fluid-filled sac with a low signal intensity in T1-weighted images (a) and high signal intensity in T2-weighted images (b). The volume of polyacrylamide gel in the right breast decreased significantly

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Figure 3: Coronal (a) and sagittal (b) magnetic resonance imaging scans; T2-weighted images revealing extensive spread of polyacrylamide gel (white arrow) from the right breast into the abdominal and pelvic walls

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An inframammary approach was used to remove the PAAG from the right breast. The migrated gel in the cavities of the abdominal and pelvic walls was evacuated using cannula suction under endoscopic guidance through the open wound. As much as possible of the yellow, granular, jelly-like, PAAG was then extirpated [Figure 4]. The surrounding tissues and the spaces, emptied by the removal of the filler, were rinsed several times with normal saline. The postoperative course was uneventful. Two months later, she received a second-stage breast reconstruction with a saline-filled implant in the right breast. Debridement surgery, followed by immediate saline-filled implant placement in her asymptomatic left breast, was also performed. The patient's recovery was uneventful, and she remained healthy during the 2-year follow-up.
Figure 4: Endoscopic view of the cavities in the abdominal and pelvic walls: (a) Yellow, granular, jelly-like appearance of the migrated gel, (b) mixture of gel and surrounding tissues

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  Discussion Top


PAAG is an injectable permanent soft-tissue filler that has been used for facial corrective surgery and breast augmentation for several years.[1] Injected PAAG was initially considered safe, nontoxic, nonirritable, and well-contained within tissue. It has been widely used in China for augmentation mammoplasty since 1997. The ease of PAAG injection, which can be performed in a clinic setting with the patient under local anesthesia, has increased the use of this procedure.[2] Over time, many types of complications associated with the use of PAAG have been reported. In 2006, the Chinese State Food and Drug Administration banned PAAG for use in breast augmentation.[3] Although PAAG injections are rarely used currently, their consequences and long-term complications are crucial. The clinical presentations of the complications are varied; including breast induration and lump formation, persistent breast pain, infection, glandular atrophy, and gel migration. These complications can appear simultaneously in one patient and even in one breast.[2],[3]

Apparently, PAAG does not induce as much foreign body reaction as do other injectable augmentation materials. Therefore, PAAG is not encapsulated by a thick fibrous capsule.[4] Cheng et al. reported that the injected PAAG is not encapsulated in the muscle but is encapsulated by thin fibrous tissue only in the skin and mammary glands. Consequently, the filler material can migrate easily because of muscular activity or the effect of gravity, particularly when the capsule is ruptured because of incorrect massage or incidental force.[5] The mobility of PAAG along the intermuscular gap has been confirmed in animal experiments.[6] It is suggested that PAAG should not be injected into muscular tissues or subcutaneous areas with active movement.[5] Because PAAG injection is performed without imaging guidance, the risk of gel migration is high if the gel has been inadvertently injected outside the retroglandular space.[4] The migrated gel may pass through subcutaneous tunnels and present distantly in the axilla, abdomen, or even pubic area. The reported incidence of distant gel migration is 8.9%.[3]

The radiological features of PAAG injection mammoplasty often pose a diagnostic challenge for radiologists. Among the imaging modalities, MRI is considered the most sensitive technique for assessing PAAG mammoplasty with gel migration. MRI scans clearly display the volume and the distribution of the gel within the breasts and the location, extent, and spread of the injected PAAG outside the breast.[2],[4],[7] Moreover, contrast medium enhancement enables the delineation of areas of infection and abscess formation.[2],[4] Because 95%–97.5% of PAAG is water, its MRI signal intensities are similar to those of water; therefore, PAAG images are best displayed using the T2-weighted technique. Turbo spin-echo, T2-weighted, with or without the fat suppressing sequence is the most suitable sequence to delineate the location or extent of PAAG.[2]

Removal of PAAG is an effective treatment for most of the complications following PAAG mammoplasty. However, because PAAG is distributed diffusely in the breast tissue and even penetrates deep into pectoralis muscle, complete gel evacuation using aspiration or blind suction is very difficult, despite several sessions of the suction procedure. Evacuation of the majority of the gel is possible by performing open surgery through periareolar and inframammary incisions.[7] To remove all PAAG and the damaged tissue, a subcutaneous mastectomy may be the last option.[1] In patients whose breast contours require restoration after debridement surgery, a two-stage procedure with initial debridement, followed by delayed breast reconstruction, is preferable.[8] Alternatively, immediate breast reconstruction can be considered if the patient does not exhibit signs of acute inflammation and massive or multifocal gel migration.[9]

Unlike previously reported cases of gel migration, our patient manifested acute abdominal pain rather than breast pain, lump formation or changes in breast appearance, thereby making this case clinically remarkable. As described, the capsule surrounding the PAAG filler is usually thin, may be attenuated with time, and is vulnerable to rupture.[5],[6] The mean force exerted on the sternum might be as high as 41 kg during a sneeze.[10] Hence, the weak capsule of PAAG can be easily ruptured after violent sneezing, leading to subsequent PAAG displacement. Rapid and extensive gel migration into the abdominal wall may cause acute abdominal pain. Without disclosure of the history of PAAG mammoplasty, connecting gel migration to the abdominal pathology is difficult. Radiological evaluation of the abdominal lesion alone may be inconclusive if the PAAG-augmented breast is not included in the imaging study.


  Conclusion Top


Although the experience with the use of PAAG for breast augmentation is limited in our country, surgeons without any experience in these procedures may have to manage patients with the associated complications because of the migratory streams. Discussing medical and surgical histories and performing thorough physical examination are essential for diagnosing PAAG migration. Knowledge of the radiological appearances of PAAG-augmented breasts, as well as its complications, is useful for making an accurate diagnosis in these patients. Our case should increase awareness among surgeons about the possibility of this condition in patients with similar symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ghasemi HM, Damsgaard TE, Stolle LB, Christensen BO. Complications 15 years after breast augmentation with polyacrylamide. JPRAS Open 2015;4:30-4.  Back to cited text no. 1
    
2.
Lui CY, Ho CM, Iu PP, Cheung WY, Lam HS, Cheng MS, et al. Evaluation of MRI findings after polyacrylamide gel injection for breast augmentation. AJR Am J Roentgenol 2008;191:677-88.  Back to cited text no. 2
    
3.
Luo SK, Chen GP, Sun ZS, Cheng NX. Our strategy in complication management of augmentation mammaplasty with polyacrylamide hydrogel injection in 235 patients. J Plast Reconstr Aesthet Surg 2011;64:731-7.  Back to cited text no. 3
    
4.
Wong T, Lo LW, Fung PY, Lai HY, She HL, Ng WK, et al. Magnetic resonance imaging of breast augmentation: A pictorial review. Insights Imaging 2016;7:399-410.  Back to cited text no. 4
    
5.
Cheng NX, Xu SL, Deng H, Ding XB, Zhang XM, Wu DH, et al. Migration of implants: A problem with injectable polyacrylamide gel in aesthetic plastic surgery. Aesthetic Plast Surg 2006;30:215-25.  Back to cited text no. 5
    
6.
Chen L, Sha L, Huang SP, Li SR, Wang ZX. Treatment for displacement of PAAG mixture after injection augmentation mammoplasty. Int J Clin Exp Med 2015;8:3360-70.  Back to cited text no. 6
    
7.
Do ER, Shim JS. Long-term complications from breast augmentation by injected polyacrylamide hydrogel. Arch Plast Surg 2012;39:267-9.  Back to cited text no. 7
    
8.
Unukovych D, Khrapach V, Wickman M, Liljegren A, Mishalov V, Patlazhan G, et al. Polyacrylamide gel injections for breast augmentation: Management of complications in 106 patients, a multicenter study. World J Surg 2012;36:695-701.  Back to cited text no. 8
    
9.
Patlazhan G, Unukovych D, Pshenisnov K. Breast reconstruction and treatment algorithm for patients with complications after polyacrylamide gel injections: A 10-year experience. Aesthetic Plast Surg 2013;37:312-20.  Back to cited text no. 9
    
10.
Adams J, Schmid J, Parker RD, Coast JR, Cheng D, Killian AD, et al. Comparison of force exerted on the sternum during a sneeze versus during low-, moderate-, and high-intensity bench press resistance exercise with and without the valsalva maneuver in healthy volunteers. Am J Cardiol 2014;113:1045-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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