Yichen Shen, Qianqian Pang, Jinghong Xu

Department of Plastic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China

Keywords:Facial filler Liquid silicone Delayed complications Foreign body granulomas

ABSTRACT Liquid silicone injection for cosmetic purposes has a long and notorious history.However,reports of delayed and extensive lesions are rare.Here, we report a case of long-term complications after the use of liquid silicone materials for the correction of facial deformities.In this case, the complications of foreign body granulomas and unique silicone nodules lasting for more than 10 years were reported.Liquid silicone injection can induce delayed adverse reactions, which are difficult to treat.This case presents the successful surgical treatment of a mass injection of liquid silicone.The focus of treatment should be to remove the injected material and degenerated tissue as much as possible while protecting normal tissue and its function.Through open reconstructive surgery with an appropriate incision, postoperative scars can be hidden.Consequently, both functional and aesthetic outcomes can be achieved.

1.Introduction

Owing to the lack of available autologous materials, alloplastic materials have been used in soft tissue augmentation for a considerable time,with impressive growth in the market.1Liquid silicone injection has been used for cosmetic purposes for 60 years and has shown great popularity in Asia for several decades.Since then,serious complications after liquid silicone injection have received much attention from the public and doctors.Complications of liquid silicone injection include infections,hypersusceptibility,vascular embolization,granulomatous reactions,nodule formation,skin discoloration,and filler migration.2Due to the high complication rates and difficulty of the procedure,liquid silicone injection is rarely administered in clinical practice.Instead, safer injection materials, such as hyaluronic acid,are widely used.The author has treated several patients after liquid silicone injection,most of whom experienced significant complications, high risk, and improper treatment in the first operation.However,reports on the surgical repair of such patients are lacking.

This article reports a case of delayed and extensive lesions after liquid silicone injection for the correction of a facial deformity.This rare case involved foreign body granulomas and unique silicone nodules that emerged over a period of 23 years and provides experience with the clinical management and surgical treatment of complications after liquid silicone injection.

2.Case presentation

A 66-year-old female visited our outpatient department with paroxysmal pain,hard skin, stiff facial expressions,and facial filler migration in her right face that began 10 years prior,as well as disfiguring nodules that developed 3 years prior(Fig.1).The patient had a history of liquid silicone injection in her buccal region for the correction of a facial depression deformity after the repair of a transverse facial cleft in another hospital 23 years ago.Some parts of her facial skin gradually presented minor complications attributed to the liquid silicone, including textural changes and a bluish tinge in the skin.These symptoms were occasionally present and were more pronounced during cold weather.The facial filler gradually migrated to other regions,even invading functional structures and eventually causing the presenting symptoms 10 years prior to presentation at our department.The patient underwent magnetic resonance imaging(MRI)(Fig.2),and the results showed that the right zygomatic,temporal, and buccal regions were filled with liquid silicone, and the filler had diffused into the fat interspace of the temporal fossa, with an atrophied masseter muscle, as well as swelling in the surrounding soft tissue.This led to the diagnosis of foreign body granulomas related to liquid silicone injection.

Fig.1. (A)Disfiguring nodules on the buccal region are seen in the preoperative photograph.(B) Postoperative scarring is less noticeable, and an excellent aesthetic outcome is seen in the follow-up photograph after 12 months.

To resolve this, the patient underwent surgery under general anesthesia after providing informed consent.To hide postoperative scars and carry out additional correction of the affected structures, surgical excision was performed through the previous surgical incision for transverse facial cleft surgery.The incision was made from the intertragic incisure to the angulus oris.Widely distributed granuloma tissue and silicone nodule agglomerated gel particles were observed during the operation(Fig.3).Most of the liquid silicone and the surrounding granuloma tissues were removed.Histopathological analysis of the removed material revealed a foreign object combined with fibrocystic tissue with chronic inflammatory cell infiltration.The patient was diagnosed with foreign body granuloma, unique silicone nodules, and facial deformities associated with liquid silicone injection.

After corrective surgery,the patient was satisfied with the procedure.Pain in the affected region was obviously eased,the shape of the patient’s right face improved, and the softness and color of her facial skin were restored over 12 months of follow-up.

3.Discussion

Liquid silicone used to be one of the most common permanent alloplastic materials.Supporters of the product believed that it was noncarcinogenic, had low antigenicity, and did not support bacterial growth.3In many respects, liquid silicone seemed to be an ideal implantable substance.However, despite its relatively inert nature,clinically relevant complications caused by long-term and low-grade inflammation have led to extensive discussion among the public and doctors.4Liquid silicone became popular in Germany, Switzerland, and Japan in the 1940s, and thousands of patients were treated in that decade.5

Fig.3. (A) Silicone and foreign body granuloma tissues were excised.(B) Histological examination shows a foreign object combined with some fibrocystic tissue and chronic inflammatory cell infiltration.

In the long and notorious history of liquid silicone use,there has been an increase in the number of reports about the adverse consequences of its injection.A PubMed search using the terms “l(fā)iquid silicone”,“complication”, and “case” revealed seven case reports.Detailed information on these cases is summarized in Table 1.In summary,three cases presented a patient with a granulomatous reaction after liquid silicone injection,6–8while two cases reported silicone embolism syndrome.9,10In addition, Antonelli et al.11reported a case of buttock and thigh augmentation with liquid-silicone-induced genital lymphedema.Another case described a young man who developed autoimmune syndrome induced by adjuvants, calcinosis cutis, and chronic kidney disease after multiple liquid silicone injections during sex reassignment surgery.12Based on a study of 54 patients, Rapaport et al.13summarized the common causes of typical complications as poorly trained medical staff,adulterated or contaminated materials, mass injections, and a shallow injection level.In our case, the patient experienced periodic painful inflammation and a delayed granulomatous reaction that spread all over the face and developed into disfiguring silicone nodules.These changes were caused by the migration of silicone fluid and skin fibroblastic reactions inducing surrounding fibrotic capsules over a prolonged period.

Table 1Previous cases of liquid silicone injection.

Liquid silicone, as a dermal filler, can induce adverse reactions that are very difficult to treat.Granuloma is a specific form of inflammation that develops into foreign body granuloma when the body identifies exogenous (foreign) materials.14Foreign body granulomas are noninfectious granulomas that are commonly characterized histologically by inflammatory cells, such as multinucleated giant cells.15In our case,foreign body granulomas induced by liquid silicone injection were located in the dermis and subcutaneous tissue,which gradually hardened and turned into disfiguring silicone nodules due to fibrosis.Therefore,the patient sought treatment for both symptom relief and aesthetic reasons.Small-volume injections can be treated with topical cryotherapy or intralesional corticosteroid injection.16However, surgical excision is the treatment of choice for large doses.We eventually opted for surgery through the previous incision because high-dose injections induced the deformity of the entire right face and filler migration into the deep tissue.

Fig.2. In the preoperative facial magnetic resonance imagining (MRI), a liquid silicone mass is observed (A) on the right buccal region and (B) on the right zygomatic region.

However, there are still numerous problems that need to be solved urgently.Currently,the administration authorizes only a few designated clinicians.to use injectable silicone under strict protocol conditions,such as vitreoretinal surgery.17Nevertheless,in Asia and Europe,many cases of complications remain from illicit mass injections of liquid silicone by unlicensed practitioners.18In addition, off-label injections of FDA-approved products are not illegal in certain cases in the USA.19There are still huge challenges pertaining to clinical treatment because the clinical manifestations are sometimes complex and atypical.The formulation of personalized treatment strategies and surgical plans for each patient are urgently needed.

Here, we present the case of a patient with a long-term (23 years)exacerbation of foreign body granuloma and disfiguring silicone nodules on whom reliable surgery was performed.This case also has limitations,such as inevitable small residues, possible iatrogenic dissemination during the operation, and insufficient correction of secondary facial deformities.We focused on removing the injected material and degenerated tissue as much as possible while protecting normal tissues and their function.Postoperative scars were successfully hidden by performing open reconstructive surgery with an appropriate incision.

4.Conclusion

Silicone injections can be harmful, triggering several complications,even after long periods.Based on this case, we suggest that small nodules caused by small-volume injections should be treated with a hormonal injection, while nodules caused by large-volume injections should be treated with open surgery.In addition, liquid silicone injections will cause permanent foreign body reactions; therefore, close long-term follow-up is always needed, even after treatment.Open surgery performed through an appropriate incision should be designed according to specific circumstances and performed only by experienced surgeons.

Ethics declarations

Ethics approval and consent to participate

The need for ethical approval was waived as it is a case report.The patient provided written informed consent prior to study enrolment.

Consent for publication

The patient provided written informed consent to publish the data presented in this study.

Competing interests

The authors declare that they have no competing interests.

Authors’contributions

Shen Y: Methodology, Investigation, Writing-Original draft, Visualization.Pang Q: Formal analysis, Writing-Reviewing and editing.Xu J:Conceptualization,Supervision.