INTRODUCTION: For over fifty years, injectable silicone has been used for soft-tissue enhancement. Unfortunately, the history of silicone injections has been riddled with a lack of standardization of composition and guidelines on volume of injectate, lack of follow up, recommended dosing intervals, and use by unskilled or unlicensed practitioners. Although it is thought to be ideal for implantation because of its noncarcinogenic and minimally antigenic properties, it is known to cause major complications.
CASE PRESENTATION: The patient is a 41 year-old transgender female with a past history of HIV, MRSA Endocarditis, Hepatitis B, and Renal Vein Thrombosis. Her surgical history was notable for bilateral breast implants ten years prior and social history was significant for occasional cocaine use. The patient was noncompliant with her medications. She presented to the emergency room complaining of fever, headaches, and generalized malaise for three days. On physical exam her vital signs were blood pressure 93/60, pulse 112, oxygen saturation on room air 96%, and temperature 103. She was a well-appearing female, no apparent distress, lungs were clear to auscultation and the rest of physical exam was unremarkable. Labs revealed a normal white blood cell count and serum chemistry was remarkable for an LDH of 561 (WNL). Chest radiograph was unchanged from two weeks prior at which time no infiltrates were seen. She was admitted, blood cultures drawn, and antibiotics started. Day two of hospitalization, she developed shortness of breath, became hypotensive, and was intubated and transferred to the intensive care unit. Chest CT scan revealed multiple small nodular opacities mostly in the midlung zones and more confluent opacities on in the left lung. Bronchoscopy on day four was unrevealing and all cultures were negative. On day seven, she underwent an open lung biopsy, which revealed lung tissue with intravascular lipoid emboli consistent with silicone oil and nonspecific interstitial pneumonitis. The specimen was sent for scanning electron microscopy with x-ray diffraction, and silicone was demonstrated in the intravascular vacuoles. Upon further questioning the patient's partner, it was discovered that the patient had been injecting silicone in her lips, breasts, hips and buttocks.
DISCUSSIONS: Typically, “black-market” silicone is impure and injected in large volumes as compared to medical grade silicone. Complications from silicone injection may occur soon after injection or may occur years later. Minor complications include textural skin changes and small nodule formation. More serious complications include severe edema, localized discoloration of the area, migration, pneumonitis, cellulitis and ulcerations. Pulmonary complications are caused by vascular spread and are manifested as acute or latent pneumonitis, pulmonary edema, adult respiratory distress syndrome, diffuse alveolar hemorrhage, or pulmonary embolism. Pulmonary function tests often reveal a restrictive pattern. Evidence of silicone in cells by a trans-bronchial biopsy, or BAL with atomic absorption and infrared spectrometry serves as a diagnostic tool. BAL may be characterized by increased cellularity, or alveolar macrophages with large pleomorphic cytoplasmic inclusions seen on electron microscopy. Once diagnosed, antibiotics, systemic corticosteroids, NSAID's, and local resection can all play a role in treatment.
CONCLUSION: There is little information on whether the adverse events associated with silicone are a result of an aberrant host response in a susceptible individual, an infection with an unusual response or a normal host response to contamination. The key to its successful use will lie in understanding technique for administration, using US Food and Drug approved product, and treatment of complications. Patients with silicone injections should be followed carefully and warned of the potential life threatening complications that can occur.
DISCLOSURE: Lopa Patel, No Financial Disclosure Information; No Product/Research Disclosure Information