Cosmetic Injection

Shih-chang (Ming) Wang, FRANZCR

Terminology

Abbreviations

Polyacrylamide gel (PAAG)

Definitions

Injection of oil, gel, or autologous fat into breast for cosmetic augmentation
- Any cosmetic injection may result in foreign body granulomatous reaction or secondary infection
- Typically performed in smaller clinics and beauty parlors
Paraffin from early 20th century, silicone since 1960s
- Widespread once, now illegal in USA; still used in some parts of world (e.g., Asia, Mexico)
PAAG since late 1990s
- Jelly-like transparent gel: 95-97.5% water and 2.5-5 % polyacrylamide, typical volume 150-200 mL
- Used for gel electrophoresis, ophthalmic operations, drug treatment, food packaging, water purification
- Used in plastic and aesthetic surgery since early 1990s (e.g., faciomaxillary reconstruction)
- Used for breast augmentation since 1997

Anatomy-Based Imaging Issues

Overview

Appears as discrete blobs or confluent collections depending on injection technique, location
Intraparenchymal or retroglandular; may be periglandular

Imaging Recommendations

T1W, T2W images, fat suppression
Contrast-enhanced MR if inflammation or infection suspected clinically

MR Features

Signal Characteristics

T1W image
- Paraffin, silicone, PAAG: Mildly hypointense
  - Signal may be increased in secondary infection
- Injected fat: High-signal mass(es)
T2W image
- Paraffin, silicone, PAAG: Hyperintense heterogeneous collections
- Injected fat: High- or intermediate-signal mass(es)
T2W FS image, STIR
- Paraffin, silicone, PAAG: Hyperintense
- Injected fat may have normal or abnormal fat signal and thus variable degrees of suppression
- Inflammation may appear hyperintense
- Necrotic fat injections may show high signal fluid-filled cysts, especially if single large injection
T1W C+ image
- Granulomas show variable enhancement
- Rim enhancement around collections especially if inflammatory changes
Enhancement kinetics
- Slow, with prolonged delayed enhancement
- Resonant frequencies differ for each injected material

Differential Diagnosis

Other Fluid Collections

Silicone implant
Seroma or lymphocele
Abscess/infection

Clinical Considerations

Presentation

Usually focal or diffuse lumps, hardening, deformity
Inflammation or frank infection, especially with PAAG, fat injections
Discomfort or pain
Silicone mastitis may have draining sinuses, ulceration, deformity

Demographics

Predominantly Asian patients, also Eastern European
Also reported in male transsexuals

Implications and Management

Prognosis

Long-term adverse consequences unknown
No known association with breast cancer or collagen vascular disease

Management

Infection and scarring may require local surgical removal or mastectomy in extreme cases
May impair ability to perform routine breast cancer screening

Selected References

1. Hyakusoku H et al: Complications after autologous fat injection to the breast. Plast Reconstr Surg. 123(1):360-70; discussion 371-2, 2009

2. Lui CY et al: Evaluation of MRI findings after polyacrylamide gel injection for breast augmentation. AJR Am J Roentgenol. 191(3):677-88, 2008

3. Teo SY et al: Radiologic features of polyacrylamide gel mammoplasty. AJR Am J Roentgenol. 191(3):W89-95, 2008

4. Erguvan-Dogan B et al: Direct injection of paraffin into the breast: mammographic, sonographic, and MRI features of early complications. AJR Am J Roentgenol. 186(3):888-94, 2006

5. Qiao Q et al: Management for postoperative complications of breast augmentation by injected polyacrylamide hydrogel. Aesthetic Plast Surg. 29(3):156-61; discussion 162, 2005

6. Christensen LH et al: Long-term effects of polyacrylamide hydrogel on human breast tissue. Plast Reconstr Surg. 111(6):1883-90, 2003

7. Cheung YC et al: Lumpy silicone-injected breasts: enhanced MRI and microscopic correlation. Clin Imaging. 26(6):397-404, 2002

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