聚丙烯酰胺水凝胶隆乳术后 16 年 乳房罕见畸形一例报告

2019-09-19 董政 王彦进 陈振雨 中国美容整形外科杂志

患者女性,42 岁, 16 年前于某整形美容医院行“双侧乳 房 PAHG 注射隆乳术”,双侧乳房注射量共 350 ml;手术顺 利,术后无明显并发症, 自觉乳房外形满意。6 年前无诱因下 发现双侧乳房增大变形,未做任何处理。

聚丙烯酰胺水凝胶(polyacrylamide hydrogel, PAHG)又称奥美定, 是一种不可吸收的软组织填充物。在我国, 奥美定作 为置入物用于临床已近 20 年,其作为注射隆乳的填充物,置 入后不能被完全去除,而且分解后具有毒性,其并发症远高 于其他置入物[1]。2018 年 7 月,青岛大学附属医院整形美容中 心收治 1 例奥美定注射隆乳术后双侧乳房不对称增大患者, 现报道如下。

1 病例资料

患者女性,42 岁, 16 年前于某整形美容医院行“双侧乳 房 PAHG 注射隆乳术”,双侧乳房注射量共 350 ml;手术顺 利,术后无明显并发症, 自觉乳房外形满意。6 年前无诱因下 发现双侧乳房增大变形,未做任何处理。7 d 前发现双侧乳房 不对称,右侧明显大于左侧, 无瘙痒、胀痛、 红肿等症状。查体 可见双侧乳房明显不对称,右侧乳房明显大于左侧,双侧乳 房表面张力高,伴血管曲张;站立时双侧乳头下垂至第 7 肋 平面,触诊无压痛;乳头间距 28.0 cm,右侧距正中线的距离 为 16.0 cm,左侧为 12.0 cm;双侧乳头距乳房下皱襞的距离 为:右侧 14.0 cm,左侧 16.0 cm;双侧乳房皮肤无破溃、橘皮 样变及红肿硬结;双侧乳头大小对称,无内陷,挤压乳头无溢 液(图 1)。乳腺 B 超示:双乳腺体深面见假体组织回声,外上 象限为著,右侧较厚处约 7.4 cm,透声欠佳,可见片絮状高回 声,左侧较厚处约 5.0 cm, 内透声欠佳; 双侧乳腺腺体无明显增 厚, 回声增强, 分布不均匀, 左乳外下象限见 0.7 cm×0.3 cm低 回声结节,形态规则,边界清,右乳未见具体结节。左乳低回 声结节(BI- RADS3 类)。双侧乳腺 MR 平扫 + 单脏器薄层扫 描示:右侧乳房较左侧大,双侧乳腺少量纤维腺体组织覆盖 于假体周围;双侧乳腺内见椭圆形假体样信号,右侧假体明 显大于左侧,左侧假体下部呈“葫芦样”形态改变,双侧假体 边缘尚光整,双乳腺体层内见多发条片状长 T2 信号影;双侧 腋下见多发结节样长 T2 信号影;双侧乳头未见明显下陷,皮 肤及血管未见明显异常。双侧乳腺 MR 动态增强扫描 + 单脏 器薄层扫描示:左乳内下象限后带(7:00- 8:00 位置)及右乳下象限(6:00 位置)见团片状强化信号影,左侧明显,动态 增强扫描早中期轻度强化,晚期强化明显,左侧最大范 围 25 mm×10 mm;双侧腋下见多发结节样短 T1 强化信号 影(图 2)。初步诊断为:PAHG注射隆乳术后。于全身麻醉下行 双侧乳房切开清创引流术。于双侧乳房下皱襞设计约 6 .0 cm 切口,切开皮肤至皮下组织,钝性分离至右侧可见淡黄色包 膜,剪刀切开包膜,负压吸引出约 1 650 ml 淡黄色液体和黑 褐色液体(图 3),稍黏稠,0.05%稀碘伏冲洗。同法行左侧乳 房填充物抽吸术,吸出约 500 ml 淡黄色液体,左侧较右侧黏 稠,0.05%稀碘伏冲洗。双侧各取少量包膜组织送组织病理, 抽吸出 25 ml 淡黄色液体送细胞病理。手指伸入包膜腔内,可 触及腔内组织,较正常乳腺组织粗糙。深入充分分离各个囊 腔,并用特制刮匙搔刮,清除囊腔内水凝胶。在保证局部乳腺 腺体形态及功能的前提下,尽可能去除肉眼可见的 PAHG 组 织,直至肉眼不能发现 PAHG 成分或变性液化的组织。双氧 水及大量生理盐水多次冲洗囊腔,直到冲洗液呈现清亮状 态。最后用庆大霉素稀释液灌洗。腔内放置负压引流,术后在 充分引流的基础上,以双氧水、生理盐水反复冲洗,并酌情应 用庆大霉素稀释液灌洗,引导残腔逐渐封闭。手术顺利,出血 量约 50 ml, 未予输血。术毕加压包扎后返回病房。术后病理 示:左侧填充物为无定形蓝染填充物,包膜均为增生纤维结 缔组织,慢性炎症并异物巨细胞反应,内见无定形蓝染填充 物。术后恢复良好,术后 1 周拔管。



图 1 PAHG 隆乳术 16 年乳房畸形 a. 左侧位 b. 正位 c. 右侧位 
图 2 双侧乳腺 MR 动态增强扫描 + 单脏器薄层扫描 图 3 术中右侧引流液形态

2 讨论

1997 年 PAHG开始用于整形手术。PAHG 具有水溶性、 亲水性和相对惰性、无毒性特性[2],但其降解后的单体丙烯酰 胺具有毒性,与人体水分结合后可沿周围组织游走、浸润,对 局部组织产生毒性作用[3-4],刺激周围组织产生持续炎症,并 有致癌的可能[5-6]。临床应用后因发现有诸多并发症,2006 年 4 月,国家食品药品监督管理局停止使用, 但很多不正规的医 疗美容医院或门诊仍在使用过期、伪劣填充物。 该病例为 PAHG 隆乳术后并发双侧乳房不对称肿大的 原因:⑴PAHG 注射后填充物在组织中分散与周围组织混 合,被淋巴细胞、巨噬细胞等炎症细胞包裹形成慢性肉芽肿 和纤维性病变。术后病理示:左、右侧包膜均为增生的纤维结 缔组织,呈慢性炎症并异物巨细胞反应,内见无定形蓝染填 充物[7]。考虑为 PAHG注射后周围组织出现炎症反应,因吸收 炎性渗出物而导致双侧乳房增大变形。⑵PAHG 吸收水分 后,成为细菌等其他物质最佳的培养基,可能导致细菌等物质繁殖而引起感染。所以术中应尽可能清除填充物,彻底破 坏腔性分隔。术中右侧引流液较左侧稀且呈黑褐色,引流量 达 1 650 ml。考虑是右侧感染后出现的脂肪液化。⑶PAHG注 射后引起机体免疫反应。⑷PAHG注射隆乳术后引起的相关 并发症以及乳腺组织紊乱, 与材料自身的特性有关。 PAHG注射早期乳房是柔软的,但在术后 7~90 d 可表现 为单发或多发的结节。发生硬结的原因可能是注射过程中由 于乳房后间隙内压力不断上升,使 PAHG 扩散至皮下或乳腺 组织,因周围组织相对致密而形成结节;也可能是由于注射 物被周围炎性组织包裹形成。这些硬结在外观上与乳腺癌 类似,与周围组织粘连很难彻底清除。PAHG 奥美定具有良 好的组织相容性和稳定性,不引起毒性,进入人体后,可分 解成具有毒性的单体,毒害神经系统[4]。由于人体不能吸收 PAHG, 因而可能会对软组织造成损害,注射后会出现游走变 形,甚至还会出现感染及癌变等严重的并发症。关于乳腺癌 的发生与注射 PAHG的相关性需要进一步研究[8]。患者术后 须定期查体,尽早发现病变与异常状态,便于及时处理。

参考文献略。

原始出处:

董政,王彦进,陈振雨,聚丙烯酰胺水凝胶隆乳术后 16 年 乳房罕见畸形一例报告[J],中国美容整形外科杂志,2019,30(8):510-513.

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    2019-09-21 tastas
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    2019-09-21 wushaoling
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    2019-09-21 syscxl