Ethnic Skin and Hair: Complications from Illicit Injectables - By Lucy K. Martin, M.D., and Heather Woolery-Lloyd, M.D. N ot long ago, we saw a 31-year-old Colombian female whom, 9 years earlier in Colombia, had received cosmetic injections of an unknown filler substance into the buttocks and lower extremities. When she’d had the substance injected, the procedure had been performed in an office setting by a person she believed to be an esthetician. She received at least five injections during her first and only session. Although she was recommended for follow-up sessions, the patient did not return due to the significant pain she experienced during the initial procedure. During, and immediately following the procedure, the patient developed pain and tenderness in the treated areas. Additionally, approximately 2 years after the procedure, the patient developed progressively indurated and hyperpigmented plaques of the buttocks and lower extremities (see photos). These symptomatic plaques and pain in the treated area persisted to the time she presented to the clinic where we examined her. Imaging studies consisting of a venous Doppler and X-rays of the affected lower extremities were negative. A biopsy of the affected area revealed foreign body granulomas of the deep dermis. Illicit Filler Substances Commonly Used The illicit use of dermal fillers is especially common in Latin American countries. Patients are in search of less expensive cosmetic procedures to enhance beauty. These injections are usually performed by non-physicians in a variety of settings ranging from salons and spas to private homes. The most common illicit filler substances used are industrial silicone and paraffin wax. Our patient likely received paraffin injections, which we concluded after she reportedly saw the injected substance heated in a microwave prior to the procedure. Although most patients believe, just as our patient did, that they are receiving collagen or a medical-grade filler agent, these patients actually receive a variety of unknown filler substances. There have been many reports of foreign body granulomas after injection of unknown filler substances. Our University center has encountered several patients who have lived in or traveled to Latin American countries and received injections with illicit fillers, and the patients present with serious consequences. After almost over 25 years of experience with injectable silicone fluid, practitioners have reported various adverse effects with its use. Often, reports are unclear about whether medical-grade silicone or industrial silicone was used; however, in most cases when a non-physician performed the procedure industrial-grade silicone is more likely to be used. Both local and systemic adverse effects have been described with illicit silicone injections. In these photos, note the hyperpigmented, indurated plaques and scarring of the patient’s ankle and calf. These symptoms are suspected to be caused by paraffin injections that the patient received 9 years earlier. Systemic Complications • Animal studies. Ben–Hur et al was one of the first to report the possible systemic response to injectable silicone in animal studies.1 A different animal study also demonstrated that mice injected with subcutaneous silicone developed silicone deposits in the spleen, liver, adrenal glands, and kidneys. The authors hypothesized that the transport of silicone was made possible by migrating phagocytes.2,3 • Human morbidity and mortality. The literature confirms several serious complications sometimes resulting in death in patients treated with injectable silicone. Ellenbogen et al reported four patients who received silicone injections for cosmetic purposes who later developed various complications including migration granulomatous hepatitis, hypopigmentation and, even death.4 One patient described was a 40-year-old woman who had silicone injections under the breasts, and the procedure was performed by a non-physician. The patient died 10 hours after receiving silicone injections due to severe acute bilateral pulmonary edema secondary to intravascular silicone injection.4 Systemic complications including respiratory distress as well as collagen vascular disease have also been described.5 You can see how the suspected paraffin injections this patient received have adversely affected her thigh and buttocks. Local Complications Local complications have more frequently been described in patients who have received illicit silicone injections. Local changes involving skin color and texture are most frequent. Other changes such as plaques, nodules, induration, ulceration, necrosis, infection, and adenopathy have been described.5 These changes can be observed years after receiving injections. Patients can develop pain, erythema, ecchymosis, pigmentation, and even migration of the injected material to distant locations.6 Achauer reported a serious complication of a patient injected with MDX4-4011 Dow-Corning silicone. The patient had been treated for lipodystrophy as a result of Weber-Christian disease. Eleven years after silicone injections, the patient developed inflammatory lesions of the face, arms, and buttocks.7 Biopsy of affected areas usually reveals foreign-body granulomas. Other fillers known to cause foreign-body granulomas include paraffin. Treatment Treating the complications that result from illicit filler substances is often challenging. Steroids have been used both locally and systemically. Long-term treatment with minocycline (100 mg b.i.d.) has also been reported with favorable outcomes.8 The use of cyclosporine and intralesional interferon alpha has also been reported. Invasive treatments such as liposuction, surgical excision, and debridement have been described in severe cases.9 Baumann et al reported the use of topical imiquimod 5% cream (Aldara) on a patient who received Silicex, a Biopolymere III that contains silicone, in Colombia, South America. The patient clinically presented with indurated 1-cm nodules and edema of the upper and lower lips. Additionally, there were areas of desquamation and ulceration of the lips. The patient later developed facial swelling and submandibular adenopathy. A biopsy confirmed the diagnosis of foreign body granuloma. The patient responded favorably to 2 weeks of topical imiquimod (Aldara) b.i.d. and received treatment for a total of 2 months, with improvement of symptoms.10 An Ongoing Problem The use of illicit injectable materials for cosmetic purposes has been a problem of great concern for some time. Although illicit use of fillers can be encountered in the United States, this problem appears to be especially common in Latin America. Patients present with progressive, tender, indurated nodules of injected areas. The most frequently affected areas on the face are the lips. Frequently affected areas on the body include the calves, thighs and buttocks because patients often seek to augment these areas to achieve a more curvy physique. Clinicians should consider illicit injections as a cause of foreign-body granulomas in patients presenting with nodules on the face and extremities. It is our hope with this case to improve awareness of the serious complications that can be seen with illicit injectable materials. References 1. Ben-Hur N, Ballantyne D: Local and systemic reactions to the injection of liquid silicones (dimethylopolsiloxane) in the experimental animal and their correlation to man. Plast Reconstr Surg 1967; 39:423. 2. Rees TD, Ballantyne D, Seidman I: Visceral response to subcutaneous and intraperitoneal injections of silicone in mice. Plast Reconstr Surg 1967; 39:402. 3. Rees TD, Ballantyne D, Hawthorne T: Silicone fluid research: A follow-up summary. Plast Reconstr Surg 1970; 46:50. 4. Ellenbogen R, Ellenbogen R, Rubin L. Injectable Fluid Silicone Therapy Human Morbidity and Mortality. JAMA 1975; 234(3):308-9. 5. Allevato MA, Pastorale EP, Zamboni M, Kerdel F, Woscoff A. Complications following industrial liquid silicone injection. Int J Dermatol 1996; 35:193-5. 6. Bigata Xavier, Ribera M, Bielsa I, Ferrandiz C. Adverse Granulomatous Reaction After Cosmetic Dermal Silicone Injection. Dermatol Surg 2001; 27:198-200. 7. Achauer BM: A serious complication following medical silicone injection of the face. Plast Reconstr Surg 1983; 251-4. 8. Senet P, Bachelez H, Ollivaud L, Vignon-Pennamnen D, Dubertret L. Minocycline for the treatment of cutaneous silicone granulomas [letter]. Br J Dermatol 1999; 140:985. 9. Rapaport MJ, Vinnik CH, Zarem H. Injectable silicone cause of facial nodules, cellulites, ulceration, and migration. Aesth Plast Surg 1996; 20: 267-76. 10. Baumann LS, Halem ML. Lip Silicone Granulomatous Foreign Body Reaction Treated with Aldara (Imiquimod 5%). Dermatol Surg 2003; 29(4):429-432. Skin & Aging - ISSN: 1096-0120 - Volume 12 - Issue 12_2004 - December 2004 - Pages: 42 - 44