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

Introduction

Polyacrylamide hydrogel (PAAG) is a stable, nontoxic and nonbiodegradable hydrogel composed of polyacrylamide and water for injection in a specific proportion (1). In the 1980s, PAAG was widely used in biomedical research and for breast augmentation and facial corrections in Eastern Europe and the former Soviet Union (2). In 1997, it was approved for using in restoring contours in China and subsequently became popular for facial depression, limb deformity, and breast augmentation in local hospitals and private beauty clinics (3). Despite the immediate effects of PAAG injection in breast augmentation, numerous late complications have been observed, including breast lumps, inflammation, firmness, disfigurement, displacement, migration, unrest, and pain (3-5).

A case was reported where a woman who underwent breast augmentation with PAAG experienced increased breast size, pain, and difficulty breastfeeding during pregnancy, leading to a mastectomy and immediate breast reconstruction (6). Additionally, cases of breast cancer following PAAG injection have been reported (7-10). Although the Chinese State Food and Drug Administration prohibited the production, sale, and use of PAAG in 2006 (10,11), many women had already received PAAG injection, leading to long-term complications over a considerable period of time. PAAG migration is a common complication, but distant migration is relatively rare, with only a few cases reported (12). Currently, treatments for large cavities caused by PAAG migration often involve several incisions to thoroughly clear the filler and capsule (13). However, this approach would result in increased incision scars and potentially compromising aesthetic outcomes. This case report presents a lumboabdominal migration following breast PAAG injection and the treatment approach used. We present this case in accordance with the CARE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-24-311/rc).

Case presentation

Patient

A 51-year-old patient presented with a large, fluctuating mass in the right-sided lumboabdominal region for one year. She had undergone bilateral breast augmentation with PAAG injection 18 years prior. The lumboabdominal mass spanned approximately 35 cm × 20 cm, with ill-defined edges and a soft texture (Figure 1). The breasts were asymmetrical, with the right breast sagging and the left breast being hard in texture (Figure 1). The patient has not received any prior therapeutic treatments. A chest computerized tomography (CT) scan indicates that the breast augmentation material on the left side was significantly more pronounced than on the right side, with multiple leaks in the subcutaneous area of the anterior chest wall (Figure 2). An abdominal CT scan revealed several abnormal densities in the abdominal wall, likely to be breast augmentation material (Figure 2). The patient was diagnosed with distant migration of breast implant material. Following thorough expert consultation and patient’s consent, the decision was made to perform an extraction of the breast augmentation material from the lumboabdominal wall and breasts, along with a robot-assisted excision of the lumboabdominal wall capsule and closure of the fistula. The treatment plan also included the immediate breast reconstruction with prosthesis and mesh.

Figure 1 Preoperative and postoperative views of patient. (A,B) Preoperative and 1-month postoperative anterior views. (C,D) Preoperative and 1-month postoperative 45-degree lateral views. (E,F) Preoperative and 1-month postoperative posterior views.

Figure 2 Preoperative chest and abdominal CT scan of patient. (A,B) Chest CT scan. Arrows indicate breast augmentation material. (C,D) Axial images of the abdominal CT scan. Arrows indicate migrating breast augmentation material. (E,F) Coronal images of the abdominal CT scan. Arrows indicate migrating breast augmentation material. CT, computed tomography.

Operative methods

Preoperatively, the approximate area for waist and abdomen surgery was delineated with the patient in a standing position (Figure 3). Following general anesthesia, the patient was repositioned into the lateral decubitus position (Figure 3), and the surgical site was disinfected and prepared. A solution of epinephrine saline was injected into the cavity where the PAAG was densely localized. A metal suction tip with lateral apertures was employed to meticulously scrape and aspirate the fillers. Throughout the procedure, the solution was extricated (Figure 3), and the cavity was meticulously irrigated and suctioned. A transverse incision, approximately 5 cm in length, was performed at the anterior superior iliac spine. After dissecting through the subcutaneous tissue to expose the capsule, a single-port skin retractor was introduced, and cover it with a sterile glove. The tips of the glove fingers were cut off, and two trocars were inserted; an additional trocar was placed on the lateral incision (Figure 3). A subcutaneous tunnel was fashioned, converging at three points, and the laparoscope, Maryland bipolar forceps, and monopolar coagulation scissors were deployed, completing the robotic interface. The PAAG capsule in the lumboabdominal region was meticulously and thoroughly excised (Figure 3). The patient was then repositioned to a supine position, and the surgical area was disinfected and prepared. Incisions of approximately 5 cm were made in both axillary regions, where the breast PAAG in both breasts was carried out using the same method described above. A single-port was inserted into the axillary incision, with two trocars in place; a third port was established via a 1 cm incision along the midaxillary line, level with the nipple, to introduce an additional trocar. Residual PAAG nodules anterior and posterior to the pectoral muscles were meticulously cleared. A sinus tract was found, approximately 1.5 cm in diameter, connecting the right and left breast implant cavities anterior to the sternum (Figure 4). This tract was subsequently sutured and sealed (Figure 4). Post-irrigation, 180 cc prostheses were implanted within both breast cavities to achieve the desired contour, and the postoperative breast morphology was notably improved compared to the preoperative state (Figure 5). The postoperative pathological examination of the abdominal wall capsule suggested fibroblast proliferation and hyaline degeneration, with a few blue-stained amorphous substances accompanied by a foreign body giant cell reaction (Figure 6). One-month postoperative views were presented in Figure 1.

Figure 3 Operative views. (A,B) Preoperative markings were shown. (C) The patient’s surgical position was lateral decubitus position. (D) Aspirated fillers from lumboabdominal wall. (E) The capsule (arrow) can be seen during cavity construction. (F-H) Da Vinci Robot-assisted excision of capsule in the lumboabdominal and dorsal was performed. Arrow indicates capsule under the robotic view. (I,J) The intact capsule after lumboabdominal and dorsal wall resection.

Figure 4 The sinus tract between right and left breast implant cavities. (A) Sinus tract in the view of the right breast before suturing. Arrow indicates the sinus tract. (B) After suturing. (C) Sinus tract in the view of the left breast before suturing. Arrow indicates the sinus tract. (D) After suturing.

Figure 5 Immediate postoperative views before and after bilateral breast prosthesis implantation. (A) Immediate view after bilateral breast augmentation fillers removal. (B) Immediate view after bilateral breast prosthesis implantation.

Figure 6 Histological features of capsule. (A) A capsule structure was formed. HE staining ×40. (B) Fibroblast proliferation and hyaline degeneration. HE staining ×200. (C) Some PAAG blend in the fat. HE staining ×40. (D) Blue-stained amorphous substances accompanied by foreign body giant cell reaction. HE staining ×200. HE, hematoxylin and eosin; PAAG, polyacrylamide hydrogel.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Hydrophilic polyacrylamide, a non-absorbable synthetic polymer derived from polymerization of acrylamide monomers, was considered to maintain breast softness and pliability after injection and favored by women because it was a simple operation (14). However, acrylamide has been proven to be a neurotoxin in humans and has been confirmed as a potential carcinogen in animal testing (15). Animal studies involving subcutaneous injection of PAAG in rats have demonstrated significant cytotoxicity (16). Many women have experienced both immediate and long-term complications following the injection of PAAG, including the migration of fillers, infections, lumps, difficulties in breastfeeding, and even the development of breast cancer (8,17,18). Despite the China Food and Drug Administration’s prohibition on PAAG injection nearly two decades ago, complications arising from PAAG injections remain prevalent, causing considerable distress to patients. The current conventional surgical methods for treating PAAG-injection complications involve the removal of PAAG followed by debridement or capsulectomy, and in some cases, partial pectoralis muscle resection, partial or total mastectomy, and breast reconstruction (19,20).

PAAG migration is a common complication after injection, with various mechanisms involved, including gravity and muscle activity, which can cause the fibrous capsule surrounding the injected material to thin and rupture, leading to migration through subcutaneous tissues or tissue spaces. After breast augmentation with PAAG, the main areas of migration include chest wall migration, abdominal wall migration, and even vulvar migration (13,21). Our patient discovered the right-sided lumboabdominal lump approximately 17 years after augmentation mammoplasty, and the specific time when the filler began to migrate was unknown. Reports of extensive migration of breast fillers like our case are relatively rare. PAAG migration of breast fillers can often be detected through imaging examination, but some patients opt not to undergo treatment because it has not affected their daily life or due to economic factors (22,23). However, from both aesthetic and health perspectives, surgical intervention should be considered. For patients with distant migration of the filler, several incisions should be made at the sites where fillers are migrated to remove the filler as much as possible, and surrounding capsule tissue should be thoroughly excised, achieving rapid tissue healing (13,20). However, multiple incisions can lead to an excessive amount of scarring, especially when the migration occurs in areas such as the chest and abdominal walls, where scars are more pronounced and can affect aesthetics (24).

The patient we reported had extensive migration of the breast fillers to the lumboabdominal wall. If the traditional surgical incision method is followed, the scar would be long and conspicuous. Robot-assisted surgery offers several advantages, including seven degrees of freedom, tremor elimination, 3D magnified vision, ergonomic positioning, and enhanced resolution, which can improve surgical techniques limited by human anatomy (25). The freedom and precision of movement afforded by the robotic assistance system have led to its rapid application across various medical departments (26). In this case report, in order to expand the surgical operating space and prevent the rupture of the capsule wall during surgery, which could lead to the leakage of PAAG and affect the surgical view, we first aspirated the breast augmentation agent before performed a robot-assisted PAAG capsulectomy of the lumboabdominal region. The capsule was completely and thoroughly excised, and the incision was strategically concealed in an area that can be covered by pants. Moreover, the sinus tract between the left and right breasts was also discovered and closed under robotic assistance. We did not find a sinus tract between the right breast and the right-sided lumboabdominal region, possibly due to prolonged healing or other reasons. To prevent the potential for future implant displacement that could result from tissue laxity between the patient’s right breast and lumboabdominal wall caused by an inframammary fold incision, and considering aesthetics, we chose to make the incision between the outer edge of the pectoralis major muscle and the anterior edge of the latissimus dorsi muscle, two fingerbreadths below the axillary crease, to perform the breast surgery. The retrospective study by Trignano et al. explored the immediate implant breast reconstruction following the removal of hyaluronic acid cysts due to complications in patients who had undergone hyaluronic acid breast augmentation and all patients achieved good aesthetic outcomes (27). In this case report, the patient is satisfied with the incision on their abdomen and rated that the shape of their breasts has also improved significantly.

Long-distance migration of PAAG is a rare and complex problem that requires an individualized treatment plan. Understanding the migration patterns of breast fillers and their associated complications is crucial for effective diagnosis and treatment. For patients experiencing extensive migration of fillers, the precision and flexibility offered by robot-assisted surgery can significantly minimize tissue damage and reduce scarring.

Conclusions

This case report describes the right-sided lumboabdominal migration of breast fillers following PAAG injection. The patient underwent extraction of the breast augmentation material from the lumboabdominal wall and breasts, along with a robot-assisted excision of the lumboabdominal wall capsule and prosthetic breast reconstruction. The patient was satisfied with the abdominal scarring and the reconstructed breasts, which was crucial to the success of this procedure. Further follow-up is needed to determine the long-term effects.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-24-311/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-24-311/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-311/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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