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Direct Migration of Liquid Silicone Oil to the Mediastinum
CLINICAL COMMUNICATION TO THE EDITOR
Direct Migration of Liquid Silicone Oil to the Mediastinum To the Editor: We report a previously healthy 45-year-old Latin woman who presented to our institution with progressive chest tightness and shortness of breath of 1-month duration. Six weeks previously, she received 250 mL of liquid silicone oil in each breast by a general practitioner. Immediately after the procedure, she noticed an increase in her breast size. She was performing breast massage several times per day as instructed by her physician to improve her breast augmentation. Ten days later, she started to have chest tightness, shortness of breath, and intermittent fevers together with progressive reduction in her breast size to their original size. She had no skin rashes or arthralgia. During the initial evaluation, the patient was afebrile and hemodynamically stable. There was no local tenderness over the anterior chest area and no evidence of skin lesions or subcutaneous nodules. Her lung auscultation and the rest of her physical examination results were normal. Her white blood cell count was 8300/mm3 with a normal differential, and she had an oxygen saturation of 98% on room air. A computed tomography of her chest with intravenous contrast (Figure 1) showed accumulation of material with a density of fat in the anterior mediastinum and a small left-sided pleural effusion with no evidence of parenchymal lung involvement or mediastinal lymphadenopathy. Pleural fluid analysis showed no white blood cells, and the cultures were negative. On the basis of the radiologic finding, the absence of clinical or laboratory evidence of infection, and the temporal relationship of her clinical picture with the recent breast augmentation procedure, the diagnosis of direct migration of liquid silicone oil was suspected. The patient was treated symptomatically with ibuprofen with partial resolution of her symptoms. On subsequent clinic visits, she remained asymptomatic, and a repeated computed tomography scan 2 months later showed no change in the radiologic abnormalities.
DISCUSSION Liquid silicone oil injection has been used extensively in the past for different cosmetic purposes. This practice started to decline in the mid-1970s because of accumulative case reports of several complications associated with this agent. The more serious complications associated with liquid silicone injections, such as silicone migration and formation of inflammatory granulomas, are usually related to the injection of a large volume of impure liquid silicone by inexperienced health care personnel.1,2 Recently, pulmonary silicone embolism and pneumonitis have also been reported.3,4 Liquid silicone oil usually travels along the path of least resistance, tracking along tissue planes. This is more likely to happen when liquid silicone is injected in large boluses, which will prevent proper encapsulation and allow for distant migration.5 To our knowledge, this is the first case in the literature with direct migration of liquid silicone oil from the breast to the mediastinum. Although direct instillation of the silicone oil into the mediastinum during the initial procedure might have occurred, the temporal relationship of symptom development and the initial change in the patient’s breast size argue against this possibility. Two explanations may account for this picture. First, the initial injection may have created a small tract in the chest wall through which the liquid silicone oil slowly leaked into the mediastinum. Alternatively, the liquid silicone oil may have been placed too deep below the pectoralis muscle, and the repetitive applied pressure by chest massages forced the agent through the loose connective tissue between the intercostal spaces into the mediastinum. Saleh Alazemi, MD Maritza M. Suarez, MD Horst J. Baier, MD Department of Medicine University of Miami Miller School of Medicine Miami, Fla
Saleh Alazemi, MD Horst J. Baier, MD Horst J. Baier has financial disclosure to GlaxoSmithKline, Pfizer, and Boehringer Ingelheim. Requests for reprints should be addressed to Saleh Alazemi, MD, University of Miami, Miller School of Medicine, Division of Pulmonary and Critical Care Medicine, PO Box 016960 (R-47), Miami, FL 33101. E-mail address: [email protected]
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
Pulmonary and Critical Care Division University of Miami Miller School of Medicine Miami, Fla
doi:10.1016/j.amjmed.2007.06.034
e4
The American Journal of Medicine, Vol 121, No 2, February 2008
Figure 1 Computed tomography of the chest with intravenous contrast. A and B, Accumulation of liquid silicone oil in the mediastinum at the level of the carina. C and D, Lower cut level showing associated small pleural effusion.
References 1. Narins RS, Beer K. Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006;118(3 Suppl):77S-84S. 2. Duffy DM. The silicone conundrum: a battle of anecdotes. Dermatol Surg. 2002;28:590-594.
3. Gurvits GE. Silicone pneumonitis after a cosmetic augmentation procedure. N Engl J Med. 2006;354:211-212. 4. Schmid A, Tzur A, Leshko L, Krieger BP. Silicone embolism syndrome: a case report, review of the literature, and comparison with fat embolism syndrome. Chest. 2005;127:2276-2281. 5. Prather CL, Jones DH. Liquid injectable silicone for soft tissue augmentation. Dermatol Ther. 2006;19:159-168.
Direct Migration of Liquid Silicone Oil to the Mediastinum To the Editor: We report a previously healthy 45-year-old Latin woman who presented to our institution with progressive chest tightness and shortness of breath of 1-month duration. Six weeks previously, she received 250 mL of liquid silicone oil in each breast by a general practitioner. Immediately after the procedure, she noticed an increase in her breast size. She was performing breast massage several times per day as instructed by her physician to improve her breast augmentation. Ten days later, she started to have chest tightness, shortness of breath, and intermittent fevers together with progressive reduction in her breast size to their original size. She had no skin rashes or arthralgia. During the initial evaluation, the patient was afebrile and hemodynamically stable. There was no local tenderness over the anterior chest area and no evidence of skin lesions or subcutaneous nodules. Her lung auscultation and the rest of her physical examination results were normal. Her white blood cell count was 8300/mm3 with a normal differential, and she had an oxygen saturation of 98% on room air. A computed tomography of her chest with intravenous contrast (Figure 1) showed accumulation of material with a density of fat in the anterior mediastinum and a small left-sided pleural effusion with no evidence of parenchymal lung involvement or mediastinal lymphadenopathy. Pleural fluid analysis showed no white blood cells, and the cultures were negative. On the basis of the radiologic finding, the absence of clinical or laboratory evidence of infection, and the temporal relationship of her clinical picture with the recent breast augmentation procedure, the diagnosis of direct migration of liquid silicone oil was suspected. The patient was treated symptomatically with ibuprofen with partial resolution of her symptoms. On subsequent clinic visits, she remained asymptomatic, and a repeated computed tomography scan 2 months later showed no change in the radiologic abnormalities.
DISCUSSION Liquid silicone oil injection has been used extensively in the past for different cosmetic purposes. This practice started to decline in the mid-1970s because of accumulative case reports of several complications associated with this agent. The more serious complications associated with liquid silicone injections, such as silicone migration and formation of inflammatory granulomas, are usually related to the injection of a large volume of impure liquid silicone by inexperienced health care personnel.1,2 Recently, pulmonary silicone embolism and pneumonitis have also been reported.3,4 Liquid silicone oil usually travels along the path of least resistance, tracking along tissue planes. This is more likely to happen when liquid silicone is injected in large boluses, which will prevent proper encapsulation and allow for distant migration.5 To our knowledge, this is the first case in the literature with direct migration of liquid silicone oil from the breast to the mediastinum. Although direct instillation of the silicone oil into the mediastinum during the initial procedure might have occurred, the temporal relationship of symptom development and the initial change in the patient’s breast size argue against this possibility. Two explanations may account for this picture. First, the initial injection may have created a small tract in the chest wall through which the liquid silicone oil slowly leaked into the mediastinum. Alternatively, the liquid silicone oil may have been placed too deep below the pectoralis muscle, and the repetitive applied pressure by chest massages forced the agent through the loose connective tissue between the intercostal spaces into the mediastinum. Saleh Alazemi, MD Maritza M. Suarez, MD Horst J. Baier, MD Department of Medicine University of Miami Miller School of Medicine Miami, Fla
Saleh Alazemi, MD Horst J. Baier, MD Horst J. Baier has financial disclosure to GlaxoSmithKline, Pfizer, and Boehringer Ingelheim. Requests for reprints should be addressed to Saleh Alazemi, MD, University of Miami, Miller School of Medicine, Division of Pulmonary and Critical Care Medicine, PO Box 016960 (R-47), Miami, FL 33101. E-mail address: [email protected]
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
Pulmonary and Critical Care Division University of Miami Miller School of Medicine Miami, Fla
doi:10.1016/j.amjmed.2007.06.034
e4
The American Journal of Medicine, Vol 121, No 2, February 2008
Figure 1 Computed tomography of the chest with intravenous contrast. A and B, Accumulation of liquid silicone oil in the mediastinum at the level of the carina. C and D, Lower cut level showing associated small pleural effusion.
References 1. Narins RS, Beer K. Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006;118(3 Suppl):77S-84S. 2. Duffy DM. The silicone conundrum: a battle of anecdotes. Dermatol Surg. 2002;28:590-594.
3. Gurvits GE. Silicone pneumonitis after a cosmetic augmentation procedure. N Engl J Med. 2006;354:211-212. 4. Schmid A, Tzur A, Leshko L, Krieger BP. Silicone embolism syndrome: a case report, review of the literature, and comparison with fat embolism syndrome. Chest. 2005;127:2276-2281. 5. Prather CL, Jones DH. Liquid injectable silicone for soft tissue augmentation. Dermatol Ther. 2006;19:159-168.