Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e1ee3
CASE REPORT
Silicon emboli syndrome: A Sequela of clandestine
liquid silicone injections. A case report and review
of the literature
Sophie Bartsich, June K. Wu*
Division of Plastic Surgery, Department of Surgery, Columbia University, New York Presbyterian Hospital, New York, NY
10032, USA
Received 15 February 2009; accepted 1 April 2009
KEYWORDS Summary Silicone has long been considered inert, but there is growing evidence that it
Silicone embolism causes an immunologic response. The use of injectible liquid silicone for cosmetic purposes
syndrome; is currently illegal and is associated with significant morbidity. Silicone embolism syndrome
Pulmonary embolus; is a described phenomenon in the pulmonary literature, but it is important that it be equally
Free silicone injection; recognised within the plastic surgery community.
Liquid silicone ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
injection; Elsevier Ltd. All rights reserved.
Free silicone
Silicone has long been considered an inert substance and is surgery events known as ‘pumping parties,’ where patients
a component in many types of implantable medical devices. undergo a series of injections of liquid silicone by unli-
While silicone implants is approved for use in cosmetic censed personnel. The most common injection sites are the
breast augmentation, injectible liquid silicone for aesthetic hips and buttocks, face, breasts, and vagina. There have
surgery has been shown to have significant potential been case reports of pulmonary and neurologic sequelae to
morbidity and is now illegal. Board-certified plastic such procedures, some of which were ultimately fatal. We
surgeons do not routinely practice liquid silicone injections, report on a case of silicone embolism syndrome (SES) in
but there is a growing trend of underground cosmetic a young woman.
Case report
* Corresponding author. Division of Plastic Surgery, Department of
Surgery, New York Presbyterian Hospital, 161 Fort Washington
Avenue, Herbert Irving Pavilion, 6th floor, Room 601, New York, NY A 29-year-old woman with no significant past medical
10032, USA. Tel.: þ1 212 342 3704; fax: þ1 212 305 9626. history presented to the emergency department with
E-mail address: jw92@columbia.edu (J.K. Wu). shortness of breath and chest pain one day after
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2009.04.004
e2 S. Bartsich, J.K. Wu
undergoing an unknown quantity of liquid silicone injec-
tions into her hips and buttocks. The procedure was
performed in a motel room during a pre-arranged session
with a physician visiting from another country. The
patient had undergone three prior sessions, with no
adverse reactions.
In the emergency room, the patient reported dysp-
noea. She was afebrile, normotensive, but tacchycardic to
105, and tachpneic to 26. Her lungs were clear to
auscultation. Chest radiograph and routine laboratory
tests were normal (Figure 1). Her arterial blood gas was
7.30/45/45 with a saturation of 74% on room air. PO2
increased to 61 on 100% FiO2. EKG was unremarkable. She
was admitted to the medical intensive care unit (MICU) for
dyspnoea, and a plastic surgery consultation was
requested.
On physical exam, the patient had numerous small Figure 2 CT scan of chest demonstrating pulmonary nodules,
puncture sites on bilateral hips and buttocks, with no signs significant ground glass opacities, and hypersensitivity
of inflammation or infection. There were patchy areas of pneumonitis.
firmness that were nontender to palpation. In addition, the
patient had bilateral saline breast implants, with no
On hospital day 10 the patient was transferred out of the
evidence of pathology.
ICU. She was discharged home on hospital day 14 with
A lower extremity ultrasound was performed, which was
supplemental oxygen therapy at home.
negative for deep vein thrombus. Chest CT revealed non-
calcified subcentimeter pulmonary nodules and peripheral
ground glass opacity (Figure 2). There was also evidence of Discussion
hypersensitivity pneumonitis.
Based on prior experience, the MICU team made While silicone has long been considered immunologically
a presumptive diagnosis of silicone embolism syndrome. inert, there is evidence of an inflammatory reaction to its
The patient was treated with supportive care, including polymers. The antigen involved in this process has not yet
supplemental oxygen, antibiotics, and IV methylpredniso- been identified, but certain IgG particles have been shown
lone every 6 h. Because of concern for risk of paradoxical to selectively bind to silicone particles.1,2 Histological
cerebral emboli, an echocardiogram was performed which analysis of affected organs reveals granulomas that contain
was normal. vacuoles of silicone, and the number of inflammatory cells
Over the next few days, the patient’s respiratory status is significantly increased in involved tissues. It is unclear
steadily improved. She was successfully weaned to 6 L nasal what the risk factors are for silicone sensitivity, but prior
cannula. The steroid administration was tapered. exposure to liquid silicone may predispose to
hypersensitivity.
Silicone injections are well known to produce significant
local complications, but it is the systemic complications
that carry the highest associated morbidity. SES was first
described in populations of transsexual men who received
serial injections for breast augmentation in the 1970s. Later
reports include young healthy women who seek low cost
enhancement. The majority of adverse events documented
in both groups is pulmonary, and can be categorised as
embolic, congestive, pneumonitis, and diffuse alveolar
damage.3 While the exact mechanism of pulmonary
pathology is unknown, several factors have been impli-
cated, including large volume injections, high-pressure
infiltration, particle migration, and intravascular
injection.4
Patients usually present shortly after their last injection,
typically reporting symptom onset within the first few
hours. Later sequelae may occur within a few days, the
possibility of delayed-onset pneumonitis or local inflam-
mation at injection sites up to years after administration is
possible.5 The most common presenting symptom is hypo-
xaemia (92%), with the majority of patients meeting
Schonfeld criteria for fat embolism syndrome.6 Treatment
is supportive, consisting mainly of supplemental oxygen and
Figure 1 Chest X-ray upon admission within normal limits. steroid therapy.
Silicon emboli syndrome e3
Schmid et al. reported on 32 patients with SES that Funding
they delineated two groups. One group presented with
primarily respiratory symptoms, while the other presented There was no funding for this case report.
with neurologic sequelae. While the overall mortality
associated with SES varies between 24 and 33%, 7 neuro-
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