Suction-assisted curettage for polyacrylamide hydrogel injection sequelae: a case report with a long-term satisfactory outcome

Introduction

Polyacrylamide hydrogel (PAAG) is a nondegradable synthetic polymer, consisting of 2.5% polyacrylamide, suspended in 97.5% water. Injectable PAAG produced by Ukraine is a jelly-like transparent implant for the treatment of a variety of soft tissue defects and has been successfully used in breast augmentations since 1987. Over the years, it has been subsequently applied in various clinical settings in over 30 countries, including Europe, USA, New Zealand, Canada, Australia, Asia, and South America. However, numerous studies have reported several complications arising from its use (1-6). A detailed and systematic review of cases, comprising of patients who had suffered complications after PAAG injection, was reported in Japan. In their report, PAAG filler complications are often permanent, and difficult, or even impossible to treat (7). In China, due to the numerous complications that had arisen from PAAG’s use, its implementation in breast augmentations has been prohibited by the Chinese State Food and Drug Administration since 2006. Nevertheless, the consequences and long-term complications of PAAG fillers may not become apparent until years or even decades after injection, and they can pose ongoing clinical challenges. Reported adverse effects associated with PAAG injections for breast augmentation include asymmetric breasts, pain, swelling, indurations, lumps, hematoma, inflammation, infection, persistent mastodynia, poor cosmetic results, glandular atrophy, gel migration, granulomatous mastitis, pectoralis major muscle damage, loss of ability to breastfeed, and breast cancer (1-6,8). Animal studies have shown that acrylamide exhibits reproductive and neurotoxicity. Furthermore, its potential to cause gene mutations raises concerns about its genotoxic risk in humans (9). Consequently, many patients with a history of augmentation mammoplasty seek removal of the PAAG filler.

The most effective treatment for PAAG filler complications is surgical removal (10-12). Once complications occur, patients with PAAG fillers can be very difficult to treat. Moreover, it is very unlikely that all PAAG material can be removed, causing secondary complications continually emerge. Removing all the injected material remains a challenge primarily due to the adhesion and indistinct border between the pathological tissue induced by the filler and the surrounding healthy structures, particularly nerves and muscle (13). Preoperatively, it is challenging to accurately detect the border between PAAG granuloma and normal tissue. This difficulty is unavoidable because improper separation during surgery will cause bleeding (14). Therefore, it is necessary to try a new surgical method to improve the material’s clearance rate and reduce surgical complications.

Therefore, the objective of this case report is to describe the application and outcomes of suction-assisted curettage in managing chronic complications from PAAG breast. We present this article in accordance with the CARE reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-25-49/rc).

Case presentation

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 Declaration of Helsinki and its subsequent amendments. Ethics committee approval was not required per the institutional policies. Written informed consent was obtained from the patient for the publication of this study and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

In September 2019, a 65-year-old woman underwent bilateral breast augmentation by PAAG injection at a cosmetic clinic, 20 years ago. As the procedure occurred many years ago, the patient had difficulty recalling details about the injection mammoplasty. The patient presented at our hospital with multiple subcutaneous indurations and asymmetric breasts. The right breast was significantly larger than the left one (Figure 1A). The patient requested surgical removal of the PAAG prosthesis, due to fear and anxiety about breast cancer. As the patient was 65 years old, she refused concomitant breast reconstruction. The patient denied other symptoms such as fever, chills, shortness of breath, acute pain, or nipple discharge. Prior to surgery, magnetic resonance imaging (MRI) and ultrasound were employed to evaluate the extent of PAAG infiltration, as well as the condition and location of the lesions. MRI revealed a substantial accumulation of the injected PAAG within a single compartment of the right breast, with multiple associated nodules observed in the sac and capsule (Figure 1B,1C). Preoperative markings were made on the body surface by the surgeon to indicate the locations of the lesions. Pre-operatively, prophylactic antibiotics were administered before the patient underwent general anaesthesia. A 4-cm subareolar inferior arc incision was then made, and the tissue around the breast were separated inwards along the edge until the external wall of the PAAG-infiltrated sac and capsule were exposed. An incision was made under the sac. A reusable, stainless steel suction cannula with a slightly curved shaft and a smooth, blunt (rounded) end featuring a single oval side aperture was used. This design allowed for safe exploration and effective removal of necrotic tissue without causing iatrogenic damage to the capsule wall or surrounding structures.

Figure 1 The timeline summarizing the key events of the patient’s history. (A) Pre-operative breasts exhibiting asymmetry and deformity. (B) T1-weighted MRI scan and (C) T2-weighted MRI scan of preoperative MRI findings of both breasts, showing structural disorder and displacement, with a large quantity of PAAG within a single compartment. Numerous PAAG-induced nodules can be seen in the sac and capsule of the right breast. (D) Surgically removed PAAG material appearing as viscous yellow liquid and the dark red brittle particles among pathological tissue. (E) Postoperative appearance of the breasts. The images were published with the patient’s consent. MRI, magnetic resonance imaging; PAAG, polyacrylamide hydrogel.

The right breast was found to contain a small amount of watery, yellowish liquid and a substantial amount of dark red, brittle PAAG particles (Figure 1D), indicating that the PAAG fillers had infiltrated the surrounding tissue. Conversely, the left breast contained more viscous, yellowish PAAG liquid particles with only a few dark red, brittle particles confirming that the PAAG did not invade the surrounding tissue. Observations during the procedure demonstrated that the physicochemical properties of PAAG changed after implantation, resulting in degeneration of the breast tissue.

Subsequently, the lobular sacs were then gently irrigated alternately with approximately 37 ℃ normal saline and diluted hydrogen peroxide solution with a 50 mL injector without pressure until the fluid became translucent and no visible PAAG particles were found. Chronic stimulation of PAAG caused the formation of fibrous tissue (15,16). A scalpel and an electrocoagulator were used to remove the PAAG-infiltrated parts of the superficial sac wall and lesions that were easy to detach.

A sample of these lesions was sent for intraoperative frozen-section histopathological examination, which confirmed benign findings. Based on this confirmation, we proceeded with suction-assisted curettage to thoroughly clear the remaining material. For the deep layer of breast tissue, the papillary and granular lesions along with the polypropylene gel attached to the sac wall were removed by means of suction-assisted curettage until the surface of the inner sac wall was smooth. The remaining small parts of necrotic and degenerated tissue was carefully removed using blunt dissection under direct visualization. As the open lumen was clearly visible, hemostasis was achieved using electrocautery. After removal of the injected material was completed, the incision was sutured to reconstruct the breast anatomy. From incision to suture, the entire surgical operation took approximately 2.5 hours, with an estimated blood loss of 50 milliliters. Subsequently, Jackson-Pratt drains were placed in the submammary region, and an elastic pressure dressing was applied. The patient then received antibiotics.

Postoperative histopathological examination of the breast nodules stained with hematoxylin and eosin and observed under a light microscope exhibited the following features: numerous purple-blue foreign bodies formed acellular structures accompanied by a large number of multinucleated giant cells and lymphocytes. Drainage volume gradually decreased, and the negative pressure drainage device was removed 48 hours later. Antibiotics were discontinued on the fifth postoperative day. Removal of the PAAG-injected material was deemed complete without residual lesions. Postoperatively, the bilateral breasts were symmetrical (Figure 1E), without obvious swelling or subcutaneous nodules. At the 1-month follow-up, Reexamination using B-mode ultrasound indicated that no hematoma or lacuna was found leading to a satisfactory result for the patient. The patient tolerated the surgical procedure well. Throughout the postoperative course and during all follow-up visits, no adverse or unanticipated events were recorded.

Intraoperative ‘complete removal’ was assessed macroscopically. Long-term follow-up ultrasound imaging 4 years postoperatively (June 2023) identified a minimal, avascular residual area (∼8.0 cm × 0.5 cm), most consistent with stable microscopic adherent particles or fibrotic scar. The patient remains asymptomatic, indicating successful control of the disease process. The patient expressed satisfaction with the final cosmetic outcome and the relief of symptoms. A graphical timeline of the case evolution is presented in Figure 1.

Discussion

Key findings

This study presents a surgical technique for removing PAAG breast fillers via a periareolar incision combined with suction-assisted curettage and gentle irrigation. In this single case, the technique achieved satisfactory clearance of PAAG and necrotic tissue, and was characterised by a favourable operative duration and well-concealed postoperative scarring. Short-term follow-up at 1 month revealed no complications such as infection or hematoma, and long-term stability was observed over a 4-year period. Interestingly, the procedure revealed that PAAG had stimulated markedly different local reactions within the same individual, producing a watery fluid in the right breast and a viscous yellow fluid in the left, highlighting the complexity and heterogeneity of PAAG’s biological and physicochemical behaviour in vivo.

Strengths and limitations

The strengths of this technique include: (I) the periareolar incision, centred within the surgical field, not only avoids the conspicuous scar associated with an inframammary fold incision but also improves intraoperative exposure, allowing for a certain degree of direct visualisation during the procedure; (II) compared to traditional blind extrusion or en-bloc surgical excision, suction‑assisted curettage offers precision and convenience, contributing to well efficient clearance; (III) the use of gentle irrigation aims to minimise iatrogenic tissue trauma; (IV) after intraoperative rapid pathological confirmation of benign disease, prioritising the removal of gel, liquefied necrotic tissue, and the main pathological focus via suction‑assisted curettage, rather than attempting complete dissection of the densely adherent fibrous capsule, that allows for a balanced trade‑off among thoroughness, operative time, and surgical trauma. This study has several limitations. Primarily, as a single case report, its findings have limited generalizability. Secondly, its retrospective design, coupled with the loss of early postoperative ultrasound images (due to a hospital system upgrade), restricts a fuller imaging assessment of the immediate outcome. Third, although the 4-year follow-up provides encouraging data on stability, even longer-term monitoring would help confirm the durability of the result. Finally, the technique’s success relied significantly on surgical experience and judgement, and its reproducibility needs to be evaluated in future prospective studies with larger cohorts.

Comparison with similar research

Conventional surgical methods for PAAG removal, such as those employing an inframammary incision with manual extrusion and pressurised irrigation, are relatively straightforward but carry drawbacks, including visible scarring, a largely blind approach that may predispose to PAAG displacement (17). While surgical excision is widely acknowledged in the literature as the definitive treatment for PAAG complications, the specific technical approach varies (11,12,18). The suction-assisted curettage technique described here, adapted from gynaecological surgery (19), has been less frequently documented for PAAG removal. This approach provides enhanced visualization and utilizes mechanically assisted evacuation, features that may offer greater operative convenience and contribute to controlled tissue handling and operative time in this context, representing a technical adaptation within this specific clinical context.

Explanations of findings

As a non‑degradable foreign material, PAAG provokes a chronic foreignbody reaction, which underlies the formation of fibrous capsules, tissue adhesions, and various complications, the pathological finding of an irregular, densely adhered fibrous capsule is typical of chronic PAAG sequelae (7,15). The design of our surgical protocol was guided by this pathophysiological understanding, with the central aim of removing the foreign material (PAAG and associated necrotic tissue) to eliminate the source of inflammatory stimulation. The marked difference in the characteristics of the reactive material observed between the two breasts intraoperatively underscores the complexity of the interaction between PAAG and host tissues, an interaction likely modulated by factors such as the injection plane and the local microenvironment. The deliberate choice not to pursue complete, forceful dissection of the capsule where it was densely adherent to the pectoralis major muscle was a risk-benefit decision, which was aimed at avoiding the prolonged anaesthesia, increased trauma, and higher hematoma risk associated with aggressive dissection, particularly after malignancy was ruled out by frozen section.

Implications and actions needed

This case report presents a potential surgical removal technique for individuals with symptoms or concerns related to PAAG injections, as well as recipients of similar cosmetic fillers. The approach specifically addresses considerations such as aesthetic scarring, procedural feasibility, and intraoperative safety. However, given the documented health risks associated with PAAG, including chronic inflammation, local tissue morbidity, and reports, though debated, of possible carcinogenic potential (19,20), it remains crucial to enhance long‑term monitoring and education for those who have undergone such injections. Moving forward, the following actions are recommended: The use of intraoperative ultrasound or other real-time imaging modalities could potentially be integrated in the future to provide additional guidance and further optimize the precision of tissue resection, especially in cases with more complex infiltration. Conduct prospective, multicenter clinical studies with larger cohorts to systematically evaluate the safety, efficacy, and reproducibility of this technique and its modifications. Establish a long-term follow-up system for PAAG-related complications to better delineate its long-term health impacts. Strengthen regulatory oversight and patient education to prevent the continued use of unauthorised or non-standardised injectable materials, and to promote standardised management for individuals who have already received these injections.

Conclusions

The present case demonstrates that suction-assisted curettage can be effectively used to address PAAG filler complications, achieving a good clinical outcome with long-term stability. Our preliminary experience suggests that this technique may represent a viable and tissue-preserving surgical option worthy of further evaluation in similar clinical scenarios.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-25-49/rc

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-25-49/prf

Funding: This work was supported by the Xiamen Medical and Health Guiding Projects (No. 3502Z20244ZD1152) and College Students’ Innovation and Entrepreneurship Training Program (No. 202412631055).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-25-49/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 Declaration of Helsinki and its subsequent amendments. Ethics committee approval was not required per the institutional policies. Written informed consent was obtained from the patient for the publication of this study 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/.

References

1. Feng XL, Yi CX, Peng C, et al. Analysis and treatment of complications induced by polyacrylamide hydrogel injection. Zhonghua Zheng Xing Wai Ke Za Zhi 2003;19:331-3.
2. Xiaoling F, Yi C, Zhang Y, et al. Analysis of the complications induced by polyacrylamide hydrogel injection. Plast Reconstr Surg 2004;114:261-2. [Crossref] [PubMed]
3. Liu Y, Cen Y, Xu XW, et al. Analysis of complications induced by polyacrylamide hydrogel injection for augmentation mammaplasty. Zhonghua Zheng Xing Wai Ke Za Zhi 2005;21:464-6.
4. Yao H, Su G, Hou H, et al. Complications of Polyacrylamide Hydrogel Facial Injection: Clinical Studies and Literature Review. Aesthetic Plast Surg 2025;49:1833-41. [Crossref] [PubMed]
5. Legonkova OA, Sultanova NO, Stafford VV, et al. Long-Term Biodegradation of Polyacrylamide Gel Residues in Mammary Glands: Physico-Chemical Analysis, Chromatographic Detection, and Implications for Chronic Inflammation. Molecules 2024;29:3247. [Crossref] [PubMed]
6. Zou H, Mo R, Wang S, et al. Analysis of breast follow-up results in patients after polyacrylamide hydrogel (PAAG) or silicone prosthesis removal. J Plast Reconstr Aesthet Surg 2023;77:219-27. [Crossref] [PubMed]
7. Ono S, Ogawa R, Hyakusoku H. Complications after polyacrylamide hydrogel injection for soft-tissue augmentation. Plast Reconstr Surg 2010;126:1349-57. [Crossref] [PubMed]
8. Xie L, Wan H, Shao S, et al. Granulomatous mastitis and pectoralis major muscle defect following polyacrylamide hydrogel injection: a case report and literature review. AME Case Rep 2024;8:46. [Crossref] [PubMed]
9. Xu C, Cao M, Bao B, et al. Tissue degeneration 7 years after breast augmentation with injected polyacrylamide hydrogel (PAAG). Aesthetic Plast Surg 2012;36:160-2. [Crossref] [PubMed]
10. Jin R, Luo X, Wang X, et al. Complications and Treatment Strategy After Breast Augmentation by Polyacrylamide Hydrogel Injection: Summary of 10-Year Clinical Experience. Aesthetic Plast Surg 2018;42:402-9. [Crossref] [PubMed]
11. Qiu H, Liang Q, Zhou X, et al. Multiple bilateral breast hematomas as a complication of polyacrylamide hydrogel injection for breast augmentation: A case report. JPRAS Open 2025;46:117-22. [Crossref] [PubMed]
12. Tang P, Ng SL. Delayed complications from polyacrylamide gel breast fillers: a case report. J Surg Case Rep 2024;2024:rjae095. [Crossref] [PubMed]
13. Qian B, Xiong L, Guo K, et al. Comprehensive management of breast augmentation with polyacrylamide hydrogel injection based on 15 years of experience: a report on 325 cases. Ann Transl Med 2020;8:475. [Crossref] [PubMed]
14. Deloge C, Bernelin M, Andreoletti JB. Augmentation mammaplasty using injected polyacrylamide hydrogel: Report of a recent case and literature review. Ann Chir Plast Esthet 2024;69:166-72. [Crossref] [PubMed]
15. Shen H, Lv Y, Xu JH, et al. Complications after polyacrylamide hydrogel injection for facial soft-tissue augmentation in China: twenty-four cases and their surgical management. Plast Reconstr Surg 2012;130:340e-8e. [Crossref] [PubMed]
16. Chen G, Wang Y, Huang JL. Breast cancer following polyacrylamide hydrogel injection for breast augmentation: A case report. Mol Clin Oncol 2016;4:433-5. [Crossref] [PubMed]
17. Zhu XG, Shi QL, Deng XL, et al. Clinical effect and influencing factors of focused ultrasound ablation surgery combined with suction curettage for the treatment of mass-type cesarean scar pregnancy. Zhonghua Fu Chan Ke Za Zhi 2022;57:253-8. [Crossref] [PubMed]
18. Leng B, Ren J, Yang Z, et al. Breast Reconstruction with Silicone Prosthesis Immediately Following Polyacrylamide Gel Removal. J Coll Physicians Surg Pak 2019;29:1092-5. [Crossref] [PubMed]
19. Li T, Gui Y, Cui X, et al. Lumboabdominal migration of injected polyacrylamide hydrogel following breast augmentation: a case report and literature review. Gland Surg 2024;13:1863-72. [Crossref] [PubMed]
20. Zhao Y, Yuan NA, Li K, et al. Bilateral breast cancer following augmentation mammaplasty with polyacrylamide hydrogel injection: A case report. Oncol Lett 2015;9:2687-93. [Crossref] [PubMed]