Jeong Su Shim

Long-term Complications from Breast Augmentation by Injected Polyacrylamide Hydrogel

Currently, the most commonly used injection fillers are broadly classified into hyaluronic acid-based absorbable fillers and semi-permanent fillers. Polyacrylamide hydrogel (PAAG) is classified as a semi-permanent filler and is manufactured under diverse brands including Aquamid, Bio-alcamid, Interfall, Outline, Formacryl, Bioformacryl, Argiform, and Amagingel. The authors experienced a case of a thirty-four-years-old female patient who underwent PAAG injection for breast augmentation and developed complications ten years after the injection. A number of articles have reported complications of PAAG injection for aesthetic purposes, but it was difficult to find any Korean reports on complications that have occurred as long as ten years after breast augmentation with PAAG. The patient presented with breast lumps, which had developed six months earlier. The lumps were palpable in two locations: at the upper outer part of the right breast and at the center of the chest between the breasts. The patient had undergone filler injection for breast augmentation ten years earlier at a local clinic in Shenyang, China. The patient only remembered a filler material called Amazingel was used, but did not recall the quantity of the material injected. Through a tracing investigation, we determined that Amazingel was a PAAG-type of filler material manufactured in China. During physical examination, symptoms such as tenderness and a burning sensation were not observed around the lumps, and there was no discomfort other than contour abnormalities resulting from the lumps. A preoperative magnetic resonance imaging (MRI) scan revealed fluid-filled sacs in the retroglandular areas of both breasts, and part of the contents appeared to have leaked out of the capsules (Fig. 1). The MRI images showed filler material with a low signal on T1 weighted images and a high signal on T2 weighted images. PAAG consists of a large quantity of water and has a tendency to appear dark in T1 weighted images and bright in T2 weighted images [1]. Fig. 1 Axial magnetic resonance images show polyacrylamide hydrogel as a low signal on T1 weighted images (A) and as a high signal on T2 weighted images (B) in the retroglandular spaces of the breasts. The images show nodular lesions in the upper outer quadrant ... The author performed breast implant removal surgery under general anesthesia. Two stab incisions were made in the inframammary folds of the breasts, and dissections were made below the mammary glands. A yellow, granular jelly-like substance was drawn out by breaking off the fibrous capsules (Fig. 2). The foreign substance was extirpated as much as possible by cannula suction and by applying pressure to the breasts. The surrounding tissues as well as the space emptied of the filler were irrigated a number of times with saline solution. Fig. 2 (A) Preoperative view of polyacrylamide hydrogel (PAAG)-induced lumps in the upper, outer quadrant of the right breast and intermammary area. (B) The injected PAAG shows a yellow, granular, jelly-like appearance. The T2 weighted image of the pre-operational MRI scan revealed that the gel had a bright signal similar to that of water and presented a lobular outline as well as a zebra-stripe appearance with many septa in it. These have been found to be the characteristics of PAAG in MRI findings in previous studies on polyacrylamide hydrogels [1]. The gross findings of the gel removed from the patients body resembled those that have been found in PAAG removal cases in previous studies [1,2]. The breast filler was stained with hematoxylin and eosin (H&E), and we observed homogeneous, atypical, violet substances under a microscope. These characteristics were identical to those found in microscopic findings in the studies of Zhao and Cristesen [1-3] (Fig. 3). Fig. 3 (A) Microscopic findings show atypical dark violet material (H&E, ×40) and (B) a homogenously built polymer gel pool (H&E, ×200). PAAG is a transparent jelly-type material and consists of 2.5% cross-linked polyacrylamide and 97.5% non-pyrogenic water. It is thought that PAAG is a nontoxic, non-allergenic synthetic biomaterial and is relatively safe for implants due to its hydrophilic and non-degradable characteristics [4]. PAAG was first introduced for aesthetic purposes in the Ukraine in the 1980s and was widely utilized in the old Soviet Union and Eastern Europe. In 1997, PAAG was approved by the Chinese Food and Drug Administration and it has been a popular injection option for local hospitals and private cosmetic clinics in China for correcting facial depressions, lip enhancement, and breast augmentation [4]. However, the safety and benefits of PAAG have also been controversial in China, and as the number of reports on late complications of PAAG have increased, it now rarely used in university hospitals. Many complications from PAAG injections for aesthetic purposes have been reported thus far [4,5] including breast induration, lump formation, hematoma, inflammation, infection, mastalgia, and lactation. Among these complications, breast induration or lump formation are the most common complications, especially in patients with insufficient breast subcutaneous tissues [1,4,5]. In most cases, removal of PAAG from the breasts led to immediate improvement of the symptoms. In this case, it was difficult for the authors to remove the gel completely, even with cannula suction, saline irrigation, and manual physical pressure on the breasts. The PAAG was spread over the breast tissues and some even reached deep into the pectoralis major muscle. Qaio et al. [5] reported that patients still had residual PAAG in breast tissues after blind suction, and that repeated blind suctions could injure the surrounding normal breast tissues. Therefore, it is helpful to perform an open surgery through periareolar and inframammary incisions for effective removal, and it is necessary to mention the possibility of incomplete removal to patients prior to the surgery. The MRI scan was helpful for revealing and treating the complication in this case. PAAG can be easily distinguished on an MRI image from the signals of mammary glands, fat tissue, and muscles. An MRI scan is useful in demonstrating the distribution of injected PAAG and associated lesions as well as planning the treatment for complications of PAAG injection. According to other reports on similar cases [2], patho-histological examinations have revealed macrophages, giant cells, and lymphocytes in the tissues surrounding the injected PAAG, with foreign body reaction findings. This indicates that the PAAG in breasts affects surrounding tissues and may cause serious foreign body reactions. However, our case report has its limitations in that it does not include a pathological report about the surrounding tissues. Nonetheless, the remarkable thing about this case is that the patient visited the hospital ten years after the PAAG injection with only the appearance of breast lumps and without any other symptoms such as tenderness, induration, or changes in appearance. Under circumstances where various injection fillers for aesthetic purposes are widely used clinically, this case is clinically remarkable.

A study on the measurement of wrist motion range using the iPhone 4 gyroscope application.

IntroductionMeasuring the range of motion (ROM) of the wrist is an important physical examination conducted in the Department of Hand Surgery for the purpose of evaluation, diagnosis, prognosis, and treatment of patients. The most common method for performing this task is by using a universal goniometer. Materials and MethodsThis study was performed using 52 healthy participants to compare wrist ROM measurement using a universal goniometer and the iPhone 4 Gyroscope application. Participants did not have previous wrist illnesses and their measured values for wrist motion were compared in each direction. ResultsNormal values for wrist ROM are 73 degrees of flexion, 71 degrees of extension, 19 degrees of radial deviation, 33 degrees of ulnar deviation, 140 degrees of supination, and 60 degrees of pronation.The average measurement values obtained using the goniometer were 74.2 (5.1) degrees for flexion, 71.1 (4.9) degrees for extension, 19.7 (3.0) degrees for radial deviation, 34.0 (3.7) degrees for ulnar deviation, 140.8 (5.6) degrees for supination, and 61.1 (4.7) degrees for pronation. The average measurement values obtained using the iPhone 4 Gyroscope application were 73.7 (5.5) degrees for flexion, 70.8 (5.1) degrees for extension, 19.5 (3.0) degrees for radial deviation, 33.7 (3.9) degrees for ulnar deviation, 140.4 (5.7) degrees for supination, and 60.8 (4.9) degrees for pronation. The differences between the measurement values by the Gyroscope application and average value were 0.7 degrees for flexion, −0.2 degrees for extension, 0.5 degrees for radial deviation, 0.7 degrees for ulnar deviation, 0.4 degrees for supination, and 0.8 degrees for pronation. The differences in average value were not statistically significant. ConclusionsThe authors introduced a new method of measuring the range of wrist motion using the iPhone 4 Gyroscope application that is simpler to use and can be performed by the patient outside a clinical setting.

Medial epicanthoplasty without a vertical scar.

BackgroundThe epicanthal fold (Mongolian fold) in Asians reduces the aesthetic results of eyelid surgery, and thus, medial epicanthoplasty is commonly performed in combination with a double fold operation or blepharoptosis correction. Epicanthoplasty is one of the most popular cosmetic operations conducted in Asia, but scarring is a common problem. MethodsFrom December of 2006 to July of 2011, we treated 60 cases using our epicanthoplasty method, which was designed to reduce scarring. A double fold operation and blepharoptosis correction was performed along with epicanthoplasty in 54 cases and an epicanthoplasty without a double fold operation in the remaining 6 cases. Follow-up periods ranged from 6 months to 4 years and 10 months. Previously, we used an elliptical excision epicanthoplasty method, which was simple and practical. However, the elliptical excision method leaves a vertical scar on the nasal side of the upper and lower eyelids. To avoid this scar, we placed an additional incision parallel with the ciliary margin of the lower and/or upper eyelids. The results of epicanthoplasty were evaluated by asking the patients and the surgeon involved to allocate visual analog scale scores. ResultsWith the exception of 1 case of hypertrophic scarring and 4 cases of undercorrection, patients were satisfied with their results. Mean patient and surgeon visual analog scale scores were 4.6 and 4.2, respectively. The advantages of the described procedure are its simplicity and the minimal scarring caused in the epicanthal area. ConclusionsThis method could become an effective means of removing the Asian epicanthal fold and minimizing vertical scars.

Strategies for Simultaneous Double Eyelid Blepharoplasty in Asian Patients With Congenital Blepharoptosis

BackgroundMost patients with blepharoptosis prefer to undergo a double eyelid operation and a ptosis repair simultaneously to achieve the optimal cosmetic and functional result. However, it is difficult to achieve symmetry in patients with blepharoptosis.MethodsSurgery was performed on the levator aponeurosis or frontalis muscle to correct blepharoptosis while double eyelid surgery was simultaneously performed to correct blephroptosis in 264 patients over the past 15 years. This report describes 39 representative cases of unilateral congenital blepharoptosis and 30 representative cases of bilateral congenital blepharoptosis. In cases of unilateral ptosis with good or fair levator function, a levator resection or plication was performed, and the position of the lid margin was adjusted to 1 to 2 mm below the upper limbus. Cases of severe unilateral blepharoptosis were corrected by frontalis muscle flap, orbicularis oculi muscle flap, or frontalis myofacial flap, and the height of the double eyelid was created to be 1 to 2 mm less than the height on the normal side. The position of the lid margin was adjusted to the level of the superior limbus, and the height of the lid crease of the ptotic eye was determined to be according to that on the nonptotic side. For bilateral ptosis patients with equal levator function, the height of the double eyelid was designed symmetrically. Bilateral blepharoptosis patients with unequal levator muscle function should have the double eyelids on both sides created the same as in normal cases, and they must be grafted in proportion to the severity of the blepharoptosis. If the results are unpredictable, the two-stage operation should be performed.ResultsOnly 30% of the eyelids in this study were perfectly symmetric after the blepharoptosis operation, with 70% asymmetric. These 70% showed good symmetry immediately after surgery, but asymmetry occurred 6 months after the operation.ConclusionIn blepharoptosis surgery, different techniques for double eyelids must be applied according to the method of ptosis correction used. Usually, the height of the double eyelid on the ptotic side should be a little less than the normal double eyelid height on the nonptotic side. However, it is difficult to achieve symmetric double eyelids in blepharoptosis patients.

Comparison of Blepharoptosis Correction Using Müller-aponeurosis Composite Flap Advancement and Frontalis Muscle Transfer.

Background: Treatments for severe blepharoptosis are well documented and include the most common operations for restoring upper eyelid ptosis, which are levator surgery and frontal muscle transfers; however, the choice of treatment is still controversial. There are different approaches to the restoration of upper eyelid ptosis, and the choice will be based on ptosis severity and the surgeon’s skill and experience. Methods: Two hundred and fourteen patients presenting with a levator function of between 2 and 4 mm received ptosis correction between 1991 and 2010 at our clinic. Of these, 71 patients underwent Müller aponeurosis composite flap advancement for correction of 89 eyelids, and frontalis muscle transfer was performed on 143 patients (217 eyelids). Postoperative results were evaluated with an average follow-up period of 23 months. Results: The preoperative average for marginal reflex distance (MRD1) in the Müller aponeurosis composite flap advancement group was 1.25 mm, and in the frontal muscle transfer group, it was 0.59 mm. The area of corneal exposure (ACE) was 57.2% in the Müller aponeurosis composite flap advancement group and 53.6% in the frontal muscle transfer group. The postoperative average distance was not significantly different for the 2 techniques. In the Müller aponeurosis composite flap advancement group, MRD1 was 2.7 mm and ACE was improved to 73.5%. In the frontal muscle transfer group, MRD1 was 2.3 mm and ACE was 71.2%. Undercorrection and eyelid asymmetry were the most frequently observed postoperative complications for both techniques. Conclusions: In our study, we confirmed that Müller aponeurosis composite flap advancement and the frontalis transfer technique are both effective in the correction of severe blepharoptosis; our results showed no significant differences between the 2 techniques.