Complications and management of breast enhancement using hyaluronic acid

The emergence of injectable fillers for breast enhancement has offered women several advantages, such as local anesthesia and short recovery times, among others, and the opportunity to more specifically choose breast size. Some fillers, however, have been associated with high complication rates and can be difficult to remove. This article describes the authors’ experience with a commercially available alternative technology that was initially developed for wrinkles and volume restoration, and has been approved for use in breast enhancement in some countries.

The authors report on their experience with using hyaluronic acid of non-animal origin manufactured using commercially available technology (Macrolane, Q-Med AB, Sweden) for breast enhancement in 4000 women treated since 2004 and describe the most common complications and their successful treatment. On average, 30 mL to 40 mL of Macrolane was injected into each breast. Of 274 women who returned to the clinic during 2007, <10% experienced local adverse events (eg, gel dislocation, Macrolane nodules and rare cases of infection). There were no serious systemic events and treatment was well tolerated. To prevent local complications, such as infection, an aseptic injection technique was required and early treatment of adverse events is recommended. While only small volumes of Macrolane were injected, it is comparatively easy and safe to perform breast enhancement of up to one cup size to correct asymmetry between breasts and to create fullness in the upper portion of the breast.

Breast enhancement using injectable fillers offers women the advantage of deciding on their desired size. It is performed under local anesthesia, and does not require hospitalization or have long recovery times. However, the selection of injectable filler is critical because many fillers in the past have been associated with high complication rates (1–4). Furthermore, nonabsorbent materials, such as polyacrylamide hydrogel, are difficult to remove, resulting in deformation of the breasts and scarring. Stabilized hyaluronic acid of non-animal origin manufactured using the patented NASHA™ technology (NASHA gel) has been used for the treatment of wrinkles and augmentation of soft tissue (5,6). NASHA gels (Restylane and Perlane, Q-Med AB, Sweden) are made of hyaluronic acid, which do not release harmful components (such as proteins or viruses) and are, therefore, rarely associated with infectious diseases or allergic reactions (7–10). These products have been approved in the United States but not in Japan. A further formulation of NASHA gel is Macrolane (Q-Med AB, Sweden), which was developed for volume restoration and contouring of body surfaces and has an excellent safety and efficacy profile (11). Until April 2012, the indication for Macrolane also included breast enhancement; however, Macrolane is currently not marketed for this indication due to an ongoing debate over issues with radiological imaging.

The authors report on their experience with Macrolane for breast enhancement in approximately 4000 women since 2004 (originally published in Japanese [12]). Of 4000 women, 395 (9.9%) received multiple injections of Macrolane. During that time, there were three cases of infection and four cases of gel dislocation. Of the 4000 treated women, 274 returned to the clinic in 2007 and were surveyed for additional complications. The present article describes these complications, which were predominantly implant site adverse events, and their subsequent management.