Complications after silicone injection therapy in aesthetic plastic surgery

Calcinosis Universalis Secondary to Silicone Injections in a Patient With HIV and Chronic Kidney Disease: A Case Report of Silicone-Induced Hypercalcemia

Medical literature has long reported evidence of complications associated with cosmetic procedures, including silicone injections. Recent years have seen an increase in case reports involving hypercalcemia resulting from these injections. A common current hypothesis for the development of hypercalcemia associated with silicone injections is granulomatous inflammation against a foreign body.  This report aimed to describe the case of a 44-year-old African American male with human immunodeficiency virus (HIV) and chronic kidney disease (CKD) who presented to our hospital and was diagnosed with calcinosis universalis secondary to a history of silicone injections, as well as to present a literature review of silicone-induced hypercalcemia. This was a case report (n=1) from a large academic medical center for which the patient, who first presented in May 2023, had two inpatient admissions and two outpatient visits before being lost to follow-up. Relevant images, laboratory results, and treatments were included.  The patient's history was significant for HIV, hypertension, CKD, recurrent nephrolithiasis, and tobacco use disorder. Physical examination was positive for flank pain while labs were significant for Na 137 mmol/L, K 2.7 mmol/L, blood urea nitrogen (BUN) 28 mg/dL, creatinine 3.72 mg/dL, calcium 13.4 mg/dL, hemoglobin 9.3 g/dL, white blood cell count 6,700 u/L and platelet count 105,000 u/L. Renal ultrasound revealed bilateral nephrolithiasis and left-sided hydronephrosis. Computerized tomography (CT) upon admission showed hyperlucid deposits in the bilateral gluteal area. Initial management included intravenous (IV) fluids and one dose of IV pamidronate, which resulted in reduced calcium levels during the admission. Subsequent management included outpatient follow-up with endocrinology during which denosumab was prescribed. This case had similar findings to other reports in the literature detailing silicone-induced hypercalcemia, which also reported abnormal imaging or nephrolithiasis, low-normal parathyroid hormone (PTH), normal 25-hydroxyvitamin D, and elevated 1,25-dihydroxyvitamin D. Silicone injection-induced hypercalcemia should be considered as a differential diagnosis in patients presenting with otherwise unexplained elevated serum calcium and a history of past cosmetic procedures. If suspected, the use of imaging techniques (e.g. positron emission tomography (PET) scans or MRI) may help ascertain the diagnosis. Further research is needed to determine the most appropriate therapies for complex patients such as those with immunodeficiency or renal disease.

Liquid silicone embolism syndrome (SES) in lungs and liver - A case report

Silicone embolism syndrome (SES) is a well known complication after injection of silicone gel as well as liquid silicone. Rarely, men use physiologic salt solution or liquid silicone injected into the subcutaneous tissue of the scrotum, the penis, the upper genital or the inguinal region. Those men, who call themselves "siliconers", want to get a larger penis and scrotum, also visible when wearing clothes. Injections of liquid silicone in the mentioned regions can lead to liquid silicone embolism in the lungs and also the liver, sometimes eventually leading to death via right heart failure as in the present case. Autopsy revealed "frog spawn"-like vacuoles in the subcutaneous tissue of the genital region and liquid silicone embolism in lungs and liver. Additionally, toxicological analyses revealed different liquid silicones. Smaller oligomers were transported into lung and liver, larger ones showed local enrichment at the injection site. The seized Polydimethylsiloxane (PDMS) could not be detected in abdominal fat, blood or urine, potentially due to low perfusion of fat tissue, the aqueous character of blood and urine or the time span between last injection and death.

A case of recurrent leg necrotic ulcers secondary to silicone migration in a transgender patient: radiographic, ultrasound and MRI findings

Injection of massive quantities of liquid silicone into body parts for cosmetic purposes is a popular practice among the transgender population. Although a myriad of short-term complications associated with this procedure have been described, few reports of chronic and persistent ailments exist. We present the case of a male-to-female transgender with recurrent necrotic leg ulcers associated with migration of the silicone material injected in the buttocks 25 years ago. We review the imaging findings as well as the clinical and pathological aspects of this presentation, with an emphasis on the necessity of a high degree of suspicion for silicone-associated complications in a transgender patient presenting with leg wounds. We highlight the importance of the characteristic sonographic snowstorm artefact generated by free silicone material in soft tissues in the diagnosis of this entity.

Introduction to Fillers

BACKGROUND

Over the last few years, injectable soft-tissue fillers have become an integral part of cosmetic therapy, with a wide array of products designed to fill lines and folds and revolumize the face.

METHODS

This review describes cosmetic fillers currently approved by the Food and Drug Administration and discusses new agents under investigation for use in the United States.

RESULTS

Because of product refinements over the last few years-greater ease of use and longevity, the flexibility of multiple formulations within one line of products, and the ability to reverse poor clinical outcomes-practitioners have gravitated toward the use of biodegradable agents that stimulate neocollagenesis for sustained aesthetic improvements lasting up to a year or more with minimal side effects. Permanent implants provide long-lasting results but are associated with greater potential risk of complications and require the skilled hand of the experienced injector.

CONCLUSIONS

A variety of biodegradable and nonbiodegradable filling agents are available or under investigation in the United States. Choice of product depends on injector preference and the area to be filled. Although permanent agents offer significant clinical benefits, modern biodegradable fillers are durable and often reversible in the event of adverse effects.

Silicone implants and lymphoma: The role of inflammation

The risk of hematological malignancies is mainly determined by genetic background, age, sex, race and ethnicity, geographic location, exposure to certain chemicals and radiation; along with the more recently proposed immune factors such as chronic inflammation, immunodeficiencies, autoimmunity, and infections. Paradigmatic examples include the development of lymphoma in Sjögren's syndrome and Hashimoto thyroiditis, gastric MALT lymphoma in Helicobacter pylori infection, or lymphomas associated with infections by Epstein-Barr virus, human herpes virus 8 (HHV 8) and leukemia/lymphoma virus 1 (HTLV-1). A growing number of reports indicates an increased risk of lymphoma, particularly of the anaplastic large cell (ALCL) type. The implants, specifically those used in the past, elicit chronic stimulation of the immune system against the prosthetic material. This is particularly the case in genetically susceptible hosts. We suggest that polyclonal activation may result in monoclonality in those at risk hosts, ultimately leading to lymphoma. We suggest that patients with an inflammatory response against silicone implants be monitored carefully.

Respiratory Disease following Illicit Injection of Silicone: A Case Report

Unregulated, pseudomedical procedures risk serious sequelae even when otherwise safe compounds are used. Silicone is commonly used legally in cosmetic procedures owing to its durability, resistance to heat and aging, and low immunogenicity. However, inappropriate or illegal silicone injection can pose severe local and systemic complications including serious pulmonary compromise. We describe the case of a 30-year-old female who presented with hemoptysis and progressive shortness of breath following illicit silicone injections to the gluteal fat and was found to have new, diffuse, bilateral, ground-glass opacities on contrast-enhanced pulmonary computed tomography. Transbronchial biopsy elucidated that this was a lipoid pneumonia-type injury secondary to silicone infiltration.

Complications from injectable materials used for breast augmentation

Fewer surgical procedures have a history as fascinating and as terrifying as breast augmentation. Initial efforts at augmentation involved injection of substances such as paraffin or oil into the breast tissue, or the implantation of substances including ivory or glass balls, or rubber. More recent efforts have included the injection of liquid silicone or polyacrylamide hydrogel. The current paper reviews four distinct eras of breast augmentation, and provides the current status of these injection materials. A case report is presented on a woman whose breasts were injected with polyacrylamide hydrogel in Iran. The current status of this group of materials is also presented. During the past 110 years, history has repeated itself during each of the four eras of injection.

The history of injectable silicone fluids for soft-tissue augmentation

BACKGROUND

The debate over the legitimacy of silicone as a safe tool for soft-tissue augmentation has spanned well over half a century. Proponents concede that injections of questionable purity and/or of massive quantities have produced unfavorable outcomes. They assert that in experienced hands with "injectable-grade" silicone, there are very few problems. Despite these claims, the literature is replete with disastrous outcomes following silicone fluid injection, often many years after the initial treatment.

METHODS

An extensive review of the English-language literature was conducted using MEDLINE.

RESULTS

A comprehensive review of injectable silicones was completed, revealing the origins, misuses, early clinical trials, and support for and against the injection of silicone fluids for the augmentation of soft tissues.

CONCLUSIONS

A better understanding of the history of injectable silicone fluids for soft-tissue augmentation can give insight into the pitfalls and complications surrounding its use. There has been an evolution in the technique and type of products used for soft-tissue augmentation. In its current use, silicone oil for permanent soft-tissue augmentation could be a very powerful tool. There is some literature that supports the use of a small amount of purified, high-viscosity silicone oil; however, there has not been a single longitudinal study to date with appropriate follow-up data. The unanswered question remains: Are the risks worth the potential benefits of silicone oil as a permanent filler?

Biocompatibility of Agarose Gel as a Dermal Filler: Histologic Evaluation of Subcutaneous Implants

BACKGROUND

The search for safe and effective tissue fillers has been an ongoing effort in plastic and cosmetic surgery over recent decades. Biocompatibility is a prerequisite for any substance to be used as an implant material, and potential biomaterials need to be characterized by histologic evaluation of tissue responses. Collagen is a well-known tissue filler. Agarose gel is widely used in bioengineering. Both products are considered biocompatible. The purpose of this study was to evaluate the bioactivity of agarose gel as a dermal filler compared with collagen.

METHODS

Tissue responses to agarose gel and collagen were evaluated in a rat in vivo model (n = 96). Four groups were evaluated: group 1 (n = 24), rats with agarose gel implants; group 2 (n = 24), rats with collagen implants; group 3, a placebo group (n = 24); and group 4, a control group (n = 24). Responses and biocompatibility were assessed by histopathologic and histomorphometric evaluation at 1 week to 8 months after implantation.

RESULTS

Agarose gel showed marked bioactivity and biodegradation, although the implants integrated well into tissues: newly formed collagen bands were observed inside the implants and no granulomas were detected. Collagen implants showed low cell infiltration and a significant loss of product over time.

CONCLUSIONS

Agarose gel is a biocompatible product that can be considered for use as a tissue filler. Further investigation is required to assess its long-term efficacy and safety.

Calcium Hydroxylapatite Gel (Radiesse) Injection for the Correction of Postrhinoplasty Contour Deficiencies and Asymmetries

OBJECTIVES

To describe our technique for the injection of calcium hydroxylapatite gel (Radiesse) to treat postrhinoplasty contour defects and to evaluate the agent's efficacy, duration of action, required dosage, complication rates, and patient satisfaction. Slight defects or asymmetries are not uncommon, even after well-executed rhinoplasty surgery in the most expert of hands. These contour deformities have been treated with filler agents in the past, but with mixed results. Calcium hydroxylapatite gel was recently introduced as a filler agent in facial plastic surgery, but its use has not yet been described in the correction of postrhinoplasty nasal contour defects.

DESIGN

A prospective before-and-after trial conducted in a private-practice facial cosmetic surgery office. Eligible patients had postrhinoplasty contour irregularities or asymmetry. Postrhinoplasty irregularities at the nasal dorsum or tip underwent subcutaneous injection with calcium hydroxylapatite. Main outcome measures included number of treatments, posttreatment injection pain score, required dose and complications, natural feel, patient satisfaction, and length of follow-up. Digital photographs were evaluated by blinded observers.

RESULTS

Thirteen patients were followed up prospectively for a mean of 2.5 months. The mean injection pain score was 1.9 (scale, 0-5); the mean dose, 0.19 mL. Patient satisfaction was good to excellent in 11 (85%) of 13 cases. Photographic improvement was seen in 15 (88%) of 17 treatment sites.

CONCLUSIONS

Calcium hydroxylapatite gel has been shown in this study to improve postrhinoplasty nasal symmetry and smooth the curves and lines that constitute the contour of the nose. The longevity of nasal augmentation by calcium hydroxylapatite remains unsettled; long-term safety is also unknown. Long-term studies of safety and efficacy are indicated.

Treatment of acne scars with liquid silicone injections: 30-year perspective

BACKGROUND

This article addresses the use of liquid injectable silicone as both an immediate and long-lasting treatment for broad-based, depressed acne scars. The only filler substance that maintains precision and permanence in improving and/or correcting these types of acne scar defects is medical-grade liquid silicone.

OBJECTIVE

We describe five patients with a history of acne scarring who showed improvements from injections of liquid silicone at the initial treatment session and lasting over a 10-, 15-, and 30-year follow-up period.

METHODS

Monthly liquid silicone injections using a technique known as the microdroplet, multiple-injection approach.

RESULTS

This article documents the safety, effectiveness, and precision of silicone in addition to highlighting the fact that its permanence is what distinguishes it from other filler materials.

CONCLUSION

As a precise and permanent filling substance used for soft tissue augmentation, liquid injectable silicone can improve and/or eliminate depressed, broad-based acne scars through a technique known as the microdroplet, multiple-injection

Salvage of Silicone-Treated Facial Deformities Using Autogenous Free Tissue Transfer

BACKGROUND

Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma.

METHODS

Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented.

RESULTS

In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent).

CONCLUSIONS

We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment.

Adverse reactions to injectable soft tissue permanent fillers

BACKGROUND

Synthetic injectable facial fillers with a permanent effect are widely atoxic and nonimmunogenic, but they differ with respect to composition and in chemical and biologic characteristics. Yet, they all act as foreign bodies in the tissues eliciting a host response that try to remove the gel. Inflammatory nodules may develop at the sites of injection-for some fillers, many years later, for others, not. Why is that?

METHODS

Biopsies were contributed by various plastic surgeons from Europe and Australia after requests were made at international congresses and workshops. The study was based on (a) 5 biopsies from unreactive tissue obtained at different times after injection of polyacrylamide hydrogel (Aquamid); (b) 28 biopsies from intermediate or late inflammatory nodules after injection of polyacrylamide hydrogel (Aquamid) (20 cases), a hyaluronic acid-polyhydroxyethylmethacrylate/ethylmethacrylate gel (Dermalive) (2 cases), and a gel consisting of polylactic acid in mannitol/carbomethoxycellulose (New-Fill) (6 cases); and (c) a review of the literature on adverse reactions after injection with permanent fillers.

RESULTS

Clinically unreactive tissues after injection with Aquamid showed modest or no host reaction. Inflammatory nodules showed an increased foreign body reaction and a bacterial infection after injection with Aquamid, and a combination of moderate foreign body reaction, fibrosis, and in some cases also bacterial infection after injection with Dermalive and New-Fill. According to the literature, inflammatory nodules occur no later than 1 year after injection with polyacrylamide hydrogel, but up to 6 years after injection of combination gels (Artecol), and up to 28 years after injection of silicone gel.

CONCLUSIONS

Inflammatory nodules are likely to be caused by a low-grade infection maintained within a biogfilm surrounding the hydrophobic silicone gel and the combination gels. Aquamid gel may prevent formation of a biofilm through its high water-binding capacity, explaining why late inflammatory nodules are not seen after injection of this polyacrylamide hydrogel product.

Effects of monopolar radiofrequency treatment over soft-tissue fillers in an animal model: Part 1

BACKGROUND AND OBJECTIVES

Monopolar radiofrequency (RF) treatment is used by physicians to tighten and contour the skin of their patients. In many cases, patients have received prior treatment with other aesthetic modalities such as soft-tissue augmentation or they may wish to receive these treatment modalities simultaneously. Together, soft-tissue augmentation and monopolar RF treatment have the potential to restore tissue volume and improve facial laxity. To date, no published studies have documented the effects of RF treatment directly over soft-tissue fillers.

STUDY DESIGN/MATERIALS AND METHODS

We examined the tissue interactions of monopolar RF heating with five commonly injected fillers in a juvenile pig model. This is the first part of a two-part study. In this study, the interaction of monopolar RF and filler substances was examined over a period of 4 months. The five soft-tissue fillers examined were cross-linked human collagen (Cosmoplast), hyaluronic acid (Restylane), calcium hydroxylapatite (Radiesse), polylactic acid (Sculptra), and liquid injectable silicone (Silikon 1000).

RESULTS

There was no apparent increase in the risk of local burns and no observable effect of RF treatment on filler persistence in the tissue. With monopolar RF treatment, an increase in fibroplasia and collagen deposition surrounding Restylane, Radiesse, and Sculptra was observed. When scored in a blinded fashion, the increase in collagen deposition was statistically significant for Radiesse.

CONCLUSIONS

In this animal study, RF treatment had no observed adverse effect on filler collagen responses or persistence. Filler presence did not increase the risk of undesirable thermal effects with monopolar RF treatment. Further clinical studies are required to evaluate the effect of monopolar RF treatment over dermal fillers with respect to aesthetic outcome.

Ultrasound-assisted liposuction for the removal of siliconomas

In the past, the traditional methods of removing siliconomas have been excision of the affected tissues or suction of the injected silicone. Unfortunately siliconomas are often found in exposed areas, where it is undesirable to leave visible scars, and suction is technically difficult and often unsuccessful because the affected tissues are so hard. Because we have used ultrasound-assisted liposuction for other procedures since 1984, it seemed logical to find out whether this technique would be useful to remove siliconomas. We have used it in three such patients, ranging in age from 36 to 84 years. Our mean follow up is 38 months (range 18 months-4 years). We have found that it results in improvement in all patients. The only problem was a minor burn at the entrance port in one patient.

Injectable silicone: cause of facial nodules, cellulitis, ulceration, and migration

Fifty-four patients with problems following "medical grade" silicone injections into the face and legs were seen from 1974 until 1995. Complications consisted of chronic cellulitis, nodules, foreign body reactions, and movement of material to near and distant parts of the body. These difficulties usually demonstrated themselves many years after injection. It is suggested that problems occur despite good technique, good material, and small amounts injected. Because the side effects are unpredictable and often uncorrectable, further studies must be performed to insure silicone's safety.

Silicone granuloma in acral skin in a patient with silicone-gel breast implants and systemic sclerosis

A 68-year-old white woman was referred to us by her rheumatologist for possible participation in a clinical study of photopheresis for scleroderma. In February 1993, she noticed edema of her distal phalanges, Raynaud's phenomenon in both hands, flu-like symptoms, fatigue, intermittent diarrhea, abdominal pain, tearing in both eyes, dyspnea on exertion, dysphagia, and odynophagia. Bilateral silicone-gel breast implants had been placed 12 years before; 2 months before her present evaluation, they were removed and found to be ruptured. Physical examination revealed edema, limited to the fingers and hands bilaterally, and slight induration of the skin on the dorsum of both hands and distal forearms. The remainder of the physical examination was normal. According to our study protocol, a skin biopsy specimen from the dorsum of the right hand was taken, but all other laboratory investigations were refused. Histopathologic examination revealed multiple clear spaces of varying sizes in the dermis and multinucleated macrophages containing small refractile particles, characteristic of silicone granuloma (Figs. 1 and 2); however, the specimen showed no evidence of scleroderma. X-ray energy dispersive analysis by scanning electron-microscopy confirmed the presence of elemental silicon in the small refractile particles. The patient did not receive any treatment after her diagnosis and shortly thereafter, she was lost to follow-up.

Dermal and subdermal tissue filling with fetal connective tissue and cartilage, collagen, and silicone: experimental study in the pig compared with clinical results. A new technique of dermis mini-autograft injections

The early reaction to the injection of silicone, collagen, and lyophilized heterologous fetal connective and cartilage tissues into the limiting zone deep dermis-superficial subcutaneous tissue was histologically examined in the pig and compared with clinical results. The inflammatory reaction to lyophilized heterologous fetal tissue is considerably more intense than that to collagen and silicone and lasts for several weeks. Therefore, it is not recommended for soft tissue filling in the face. Admitting an inferior antigenicity of fetal tissues, the authors suggest that enzymatically denaturalized collagen should be manufactured from heterologous fetal connective tissue, to be then further tested. The reaction of tissue to silicone and collagen is minimal. Silicone is preferred for dermal injections since in clinical experience it remains in the site of injection much longer. For subdermal injections, however, collagen is preferred. Based on experience with over 600 patients since 1958, the first author continues using liquid silicone. The lack of complications is probably a result of the fact that only small amounts (milliliters) of silicone were used in wrinkles or small depressions in the dermal layer and that from the beginning injection into the subcutaneous tissue was avoided. Since 1988 a new technique for the treatment of wrinkles and skin depressions with injections of dermal miniautografts has been used with satisfactory results.

The history of injectable biomaterials and the biology of collagen

The authors discuss the history and use of injections of paraffin, silicone, and collagen for soft-tissue contouring. The structure and uses of collagen are described with particular reference to Zyderm Collagen Implant, a highly purified bovine collagen.

Substances for soft tissue augmentation: collagen and silicone

Zyderm injectable collagen and silicone are both used for soft tissue augmentation. Neither is perfect. Critical factors associated with their use include lesion selection and injection technique. Both may have immediate and delayed adverse reactions.