In fillers for soft-tissue augmentation, not only safety and efficacy but also possible removal is of concern. The necessity for extensive surgery to remove some fillers deters many surgeons from their use.1 We report on the easy removal of polyacrylamide hydrogel, marketed as Aquamid. Several long-term studies proving its safety and efficacy have been published.2 Few reports are found about complications, yet some cases required removal.3 Experience with removal of the gel has not yet been described. Aquamid is considered to be inert, but gel accumulations, especially on the lip, occur sporadically. This complication can be seen shortly after injection, but also after several years. The following two cases represent examples of the surgical removal of Aquamid.
Patient 1 was a 42-year-old woman who presented with asymmetry on the upper lip following previous trauma and scarring. She underwent treatment with 2 ml of Aquamid. After 3 months, she presented with overcorrection and several small lumps in the upper lip. Because of the scarred tissue, the application had been too superficial and manual modulation after application was insufficient. Removal of the excess gel was possible by direct excision using local anesthesia.
Patient 2 is a 34-year-old woman who sought consultation for lack of projection of the upper lip. She received 4 ml of Aquamid to the upper and lower lips and was satisfied with the result. After 6 years, she developed asymmetry and bulging in the upper lip. This was possibly related to a rhinoplasty procedure performed several months before. In this patient, easy and complete removal of the lump could be achieved by needle aspiration (Fig. 1) and manual expression through a small stab incision using local anesthesia (Fig. 2).
In conclusion, we find that removal of Aquamid is possible but should be performed under surgical precautions. In case of erroneously superficial application, the material can be excised directly; otherwise, manual expression and/or needle aspiration is possible. Visible scars can almost always be avoided.
Most undesired results with fillers can be attributed to incorrect application4; nevertheless, even if all precautions are taken, removal may be desired. An altered body image or changes in facial architecture with aging or caused by additional surgery or subcutaneous tissue dystrophy associated with weight changes can necessitate filler removal even after several years. Easy removal is safest when there is no tissue ingrowth and no significant capsule formation that needs to be removed surgically. Permanent fillers are either hydrophilic, hydrophobic, or combination products. Hydrophilic fillers, such as Aquamid, seem to induce the least capsule formation and tissue ingrowth, probably because the water exchange allows reduction of a biofilm.5 Because necessity of removal cannot be ruled out for any permanent filler, polyacrylamide hydrogel seems to be a good option, as it has been in successful clinical use for more than 16 years and allows for correction even after a long time.
Timm P. Wolter, M.D.
Norbert Pallua, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery, Hand Surgery, Burn Center
University Hospital of the RWTH
The authors have no financial interest in any of the products mentioned in this article.
1.Wolfram D, Tzankov A, Piza-Katzer H. Surgery for foreign body reactions due to injectable fillers. Aesthetic Plast Surg
2.von Buelow S, Pallua N. Efficacy and safety of polyacrylamide hydrogel for facial soft-tissue augmentation in a 2-year follow-up: A prospective multicenter study for evaluation of safety and aesthetic results in 101 patients. Plast Reconstr Surg
3.Kalantar-Hormozi A, Mozafari N, Rasti M. Adverse effects after use of polyacrylamide gel as a facial soft tissue filler. Aesthet Surg J
4.Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg
. 2008;34(Suppl 1): S92–S99.
5.Christensen L, Breiting V, Janssen M, Vuust J, Hogdall E. Adverse reactions to injectable soft tissue permanent fillers. Aesthetic Plast Surg
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