Treatment of Silicone Injection Complications

Fig. 11.1

(a) PA and (b) lateral views of Stage I silicone toxicosis. There are no significant findings on physical exam, but the patient may endorse occasional symptoms, including pain, and diffuse inflammation. Medical management with NSAIDs is the treatment modality of choice in these cases

Stage IIa

Patients present with more frequent pain, in conjunction with clinically evident cellulitis or abscess formation. There may also be several palpable nodules throughout the gluteal region; however no chronic skin changes are present (Fig. 11.2). Alternatively, some patients in this category will present with significant pain but no other physical findings. They may have a history of several emergency room visits for pain control. In these cases, a computed tomography (CT) scan is recommended. Imaging typically shows multiple foreign bodies in the subcutaneous tissue with surrounding inflammation. It is recommended that these patients be treated with a combination of antibiotics, anti-inflammatory agents, and immunomodulators. Alternatively, these patients may benefit from ultrasound-assisted liposuction (UAL) to aid in the removal of the silicone burden [16].

../images/978-3-030-26875-6_11_Chapter/978-3-030-26875-6_11_Fig2_HTML.jpg — Fig. 11.2

(a) PA and (b) lateral views of Stage IIa silicone toxicosis. Several palpable nodules are present throughout the gluteal region; however no chronic skin changes are identified. Patients report frequent pain, in conjunction occasional cellulitis or abscess formation. Treatment may consist of a combination of antibiotics, anti-inflammatory agents, and immunomodulators. These patients are ideal candidates for UAL

Stage IIb

Patients will have progression of their complaints with increasing pain, abscess formation, and worsening skin changes. Commonly, there will be diffuse erythema, palpable masses, and associated contour abnormalities (Fig. 11.3). The skin may be thinning with occasional drainage of serous fluid or oil-like material. Patients will report more frequent emergency room visits in an effort to control symptom progression. Advanced imaging is recommended and shows occasional silicone spheres or biopolymer spheres with strong inflammatory response and surrounding lymphadenopathy. These patients are also candidates for treatment with UAL but they are more challenging, as the UAL will have to occur in a deeper plane due to the degree of skin compromise [16].

../images/978-3-030-26875-6_11_Chapter/978-3-030-26875-6_11_Fig3_HTML.png — Fig. 11.3

(a) PA and (b) lateral views of Stage IIb silicone toxicosis. There is evidence of diffuse erythema, palpable masses, and associated gluteal contour abnormalities. Patients report increasing pain, abscess formation, and worsening skin changes with occasional drainage of serous fluid or oil-like material. These patients are candidates for treatment with UAL in a deeper plane due to the degree of skin compromise [16]

Stage III

These patients are in the most advance stage of silicone toxicosis. They have dramatic visible scarring, with leather-like changes to skin, deep contour abnormalities, and chronic non-healing wounds with possible draining of silicone oil. Most patients will have a history of prior drainage procedures. Palpable tender masses will likely still be present despite prior surgeries (Fig. 11.4). Imaging is not generally needed in these cases, as the only reliable treatment option is surgical resection. In these cases, physicians should try to position scars where they can be concealed by undergarments, as repeat surgeries are often inevitable [16].

../images/978-3-030-26875-6_11_Chapter/978-3-030-26875-6_11_Fig4_HTML.png — Fig. 11.4

(a) PA and (b) lateral views of Stage III silicone toxicosis. Dramatic scarring is present, with leather-like changes to skin, deep contour abnormalities, and chronic non-healing wounds which occasionally drain silicone oil. Palpable tender masses will likely still be present despite prior surgeries. Repeated surgical resection is the only treatment option for these patients

Treatment Options

Medical management should always be attempted in patients with Stage I and IIa silicone toxicosis. NSAIDs are a good starting point for oral treatment regimens but are rarely successful in completely resolving symptoms in even the mildest of cases. Thus, combination treatments are usually employed for a multimodal approach to symptom relief. Intra-lesional steroid injections, systemic steroids, immune-modulators, and antibiotics work well in combination and are useful for temporary improvement in symptoms [1]. Systemic corticosteroids are an excellent option for tempering inflammation, but results are transient and symptoms tend to return once the patient has begun to taper the dose [7, 19]. Minocycline has been most commonly cited as a useful agent for the treatment of silicosis, as it possesses both anti-inflammatory and immunomodulating properties [1]. It is a safe and efficient way to combat the chronic inflammation of siliconomas [1]. Minocycline is typically dosed at 100 mg twice daily, with or without the addition of a tetracycline, and had been reported to provide good results in several clinical reports [12]. The addition of the tetracycline is thought to aid the patient by combating any biofilm on the silicone spheres and augmenting the anti-inflammatory activity of minocycline on the granulomatous immune reaction [12]. If there is concern for a deep infection or progressive cellulitis, patient may need parenteral antibiotics for infection control prior to surgical intervention [3].

It is important to note that, once injected, silicone permanently resides in the tissues and surgery may be the only way to definitively treat chronic symptoms. However, traditional options for surgical resection, including en bloc excision, dermolipectomy, or suction-assisted lipectomy (SAL), can be technically difficult and have disfiguring results [10, 16]. While surgery is unquestionably indicated for patients with Stage III changes who may have deep tissue abscesses, fistulas, and fasciitis, alternatives should be considered in most other cases [3]. Standard liposuction has been suggested as an alternative to surgical excision, but it is difficult to pass a standard liposuction cannula through the inflamed tissues in a controlled fashion, and there is risk of injury to adjacent, non-affected areas with this technique [13, 16, 19]. UAL, however, performs better when faced with dense fibrotic tissues and, thus, is a good option for select cases of silicone toxicosis [16].

Specifically, patients with Stage IIa and IIb silicone toxicosis are the best candidates for UAL. UAL is a safe and effective method of removing silicone infested tissue while avoiding extensive surgical mutilation and results in minimal bleeding and less pain than traditional surgical excision or SAL [7]. Additionally, UAL of the gluteal region can be combined with SAL of the abdomen and flanks to allow for immediate intramuscular fat grafting for buttock augmentation, if desired by the patient [7]. Lipofilling can be particularly useful for patients with expected large volumes of toxin removal to prevent deflated or irregular contours following UAL [16].

Patient Selection

Candidates for UAL often have severe symptoms related to their silicone toxicosis but opt to delay their medical care in an effort to prevent the embarrassment and fear associated with admitting to receiving illicit injections [6]. It is important for physicians to thoroughly question patients with atypical symptoms when there is a concern for toxicosis, as silicone can mimic other inflammatory conditions or even malignancy and an incorrect diagnosis could result in a thoroughly mismanaged patient [6]. Patients will usually have a history of gluteal augmentation injections from a friend or acquaintance [16]. The substance is typically unknown to the patient, though they might believe it to be silicone [16]. Since patients who receive silicone injections usually place a great deal of importance on their appearance, even moderate degrees of silicone-related skin changes can cause psychological embarrassment with withdrawal behaviors [2, 6]. Furthermore, there is usually a concern that surgical excision is the only treatment option, and the fear of permanent scarring and further deformity may cause patients to refuse treatment [6]. In these cases, UAL is just one of several alternate treatment options that should be considered [6]. However, before deciding to proceed with UAL, it is important for the physician to rule out severe and atypical infections or open wounds in the gluteal region which should be treated prior to any liposuction procedures [7, 19].

Preoperative Evaluation and Imaging

Patient Expectations

During the preoperative consultation, it is important for the physician to set realistic expectations for the patient [16]. Informed consent must be obtained and there should be discussions regarding cost, likely outcomes, limitations of correction, and other issues that may arise when treating a complicated problem like silicone toxicosis [12]. Patients need to be aware that it can be hard to predict results of UAL because there is usually limited information regarding the technique used during the original injections, as well as the amount and composition of the material injected [4, 19]. Photographic documentation is imperative so that any preexisting contour irregularities are noted in the medical record [12]. Most importantly, patients need to understand that it is difficult or impossible to remove all of the foreign material and affected tissue [13, 16, 20]. There is no cure [16]. The realistic goal should be to decrease the patient’s pain while optimizing their function and form [16].

Imaging

Preoperative CT imaging of the abdomen and pelvis is used to evaluate the severity of the toxicosis and the depth of silicone deposits [7, 16]. Imaging studies are obtained with the patient in a prone position in order to avoid pressure on the gluteal region [16]. On CT silicone collections can be well-circumscribed or diffuse areas and will appear hyper-dense with occasional accompanying calcifications (Fig. 11.5) [10, 14, 16]. The goal of the study is to determine the level at which the silicone was injected [10]. Although most silicone is placed in the subcutaneous plane, any intramuscular silicone should be noted as it will not be amenable to removal with UAS due to concern for excessive bleeding [7, 16].