Incorrect Methods of PAAG Gel Removal and Their Dangerous Consequences
In the early years following the emergence of PAAG gel complications, due to a lack of awareness about the nature of this substance and its pathophysiological behavior in the body, some treatment interventions aimed at removing PAAG gel were performed incorrectly. These measures not only failed to improve the situation but, in many cases, caused even more serious damage.
Since 2011, Dr. Bayat, with over 14 years of experience as a head and neck surgeon, has dedicated a significant part of his professional activity to studying, reviewing, and treating complications arising from PAAG filler injections. Over the years, with a special focus on the removal of PAAG filler through both open and closed surgical methods, he has gained, without exaggeration, one of the most extensive practical experiences in this field.
Throughout this journey, he has consistently aimed not only to treat patients but also to share his knowledge and experiences honestly and scientifically with colleagues and aesthetic patients. This text has been prepared with the same goal: to be understandable for the general public while also being practical and informative for professional colleagues.
Colleagues who require further consultation or support in managing similar cases can, by introducing themselves through the centre’s staff, benefit from direct guidance and assistance from Dr. Bayat.
Below, we will refer to some of these incorrect methods and their potential risks
Incorrect Methods of PAAG Gel Removal and Their Dangerous Consequences
In the early years following the appearance of PAAG gel complications, due to a lack of understanding of the nature of this substance and its pathophysiological behaviour in the body, some treatment interventions were performed incorrectly. These measures not only failed to improve the condition but, in many cases, caused even more serious damage.
Below, we highlight some of these incorrect methods and their potential risks.
1. Massaging PAAG Gel to Spread It
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2. Using Enzymes to Dissolve PAAG Filler
While many physicians are aware that the enzyme hyaluronidase has no effect on PAAG gel, there have been multiple cases in which this enzyme was injected in an attempt to reduce swelling. Unfortunately, in some of these cases, the injection of hyaluronidase itself led to the onset of infection. It must be clearly emphasized that no enzyme to date has been able to break down PAAG gel, and its use only causes further harm.
Review of Common Methods for PAAG Gel Removal
1. Aspiration (Needle Extraction)
Important Note:
If the cyst wall is ruptured during aspiration, the gel can spread into surrounding areas and form new cysts, increasing both the dispersion and severity of complications. Many patients report that after this procedure, the firmness of the gel is felt not in a single spot but scattered across multiple areas.
This method can only reduce some of the risks associated with PAAG gel when a portion of the gel can be removed without applying pressure. Experience shows that, more often than not, this technique causes more harm than benefit. Except in rare and exceptional cases, I do not recommend using this method.
2. Suction of PAAG Gel (With or Without Ultrasound Guidance)
This method is performed using continuous negative pressure, either in a simple manner or, in some cases, under ultrasound guidance. While the use of ultrasound can provide the physician with better visualization, any pressure applied to the cysts must still be avoided.
Risks of this method: It should be noted that although ultrasound guidance is better than a blind approach, it never provides the three dimensional view and full precision available in open surgery. Suction may remove not only the gel but also natural facial fat tissue, potentially leading to depressions, asymmetry, and facial deformities. Additionally, a false sense of confidence in the physician (due to ultrasound visibility) may result in excessive pressure and further damage.
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3. Removal via Small Skin or Mucosal Incisions
- The cyst is close to the skin or mucosa.
- The cyst is small and palpable.Inflammatory reactions, such as fibrosis or granuloma around the cyst, are minimal, so palpation and access to the cyst are not impeded
- The PAAG cyst is located in areas of the face, such as around the lips or eyes, where access via open surgery is difficult or would require more extensive surgery.
Note:
Even with this method, pressure on the cyst should be avoided, and PAAG filler removal must be performed with minimal trauma to the surrounding health.
4. PAAG Gel Removal via Open Surgery Under Direct Visualization (with Magnification)
This method is recognized as the most effective and safest approach for PAAG gel removal. Using open surgery under a microscope or surgical loupes, it is possible to:
- Completely remove all cyst contents along with the cyst wall.
- Reconstruct damaged areas (using fat grafts or tissue flaps).
- Prevent pressure on the cyst and the spread of gel into healthy tissues.
- Preserve healthy tissues with high precision and minimize damage.
The key to the success of this method lies in the combination of magnification tools (loupes or microscope) and extensive surgical experience in PAAG removal.
Very Important Points in Choosing a PAAG Gel Removal Method.
- Any pressure or manipulation of the cyst and injected areas should be strictly avoided.
- In many cases, refraining from manipulation is safer than performing incorrect treatment interventions.
- For open removal, the use of magnification (loupes or microscope) is essential. Unfortunately, not all surgeons are equipped with these tools or skilled in their use.
- Only certain surgeons with experience in microscopic surgery (such as ENT specialists or vascular surgeons) are capable of properly utilizing magnification.
The primary goal is the surgical removal of cysts containing PAAG. Even surgery has limitations in managing complications such as granulomas and other inflammatory reactions caused by PAAG gel.
How to Assess a Physician’s Ability to Use Magnification
Since the success of open PAAG gel removal depends not only on the surgeon’s experience but also on the proper use of magnification tools, I recommend the following:
For colleagues: ensure that you perform this surgery with high precision using a loupe or microscope.
For patients: consider the following points when selecting your physician:
- Check whether the physician’s office is equipped with a microscope or surgical loupes.
- Review photos or videos of the physician’s surgeries available online, paying attention to the use of magnification tools.
- Consider the physician’s speciality and their experience in precise microscopic surgeries.
Who Can Benefit from Complete PAAG Gel Removal?
- Individuals who have not undergone any previous manipulation of the gel so that the areas affected by PAAG remain limited.
- Patients who have only PAAG gel cysts in the face, with no evidence of other reactions such as granulomas or tissue fibrosis.
These individuals, after complete removal of PAAG gel, can return to normal life just like any other person.
In Practice, for Most Individuals:
The presence of inflammatory reactions such as granulomas, or areas that are inaccessible due to anatomical conditions, often results in some portions of PAAG gel or the cyst wall remaining in the face. Therefore, long term follow up care after gel removal remains essential.
In addition to surgical skills, it is important for the physician to know which issues should not be treated surgically and instead require medical therapy.
Years of experience in managing PAAG filler complications have demonstrated the following facts:
- Preventing PAAG gel complications is far easier than treating them.
- The greatest harm to the face is not caused by PAAG gel itself but by manipulations and incorrect treatments.
- Treatment of PAAG gel complications is often not a single step process, and post treatment care must be considered lifelong.
If you or a loved one are dealing with PAAG filler complications, choosing an experienced physician, the correct treatment method, and avoiding improper manipulations can play a key role in restoring both the health and aesthetic appearance of your face.
Dr. Akbar Bayat
Board Certified Facial Plastic Surgeon (Europe)
