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Laser Resurfacing of Silicone-Injected Skin
The "Silicone Flash" Revisited
Warren Zager, MD;
John Huang, MD;
Peter McCue, MD;
David Reiter, MD, DMD
Arch Otolaryngol Head Neck Surg. 2001;127:418-421.
ABSTRACT
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Objective To determine whether prior silicone injection increases the risks associated
with carbon dioxide laser resurfacing.
Design Laboratory determination of the effect of laser energy on liquid silicone;
histologic evaluation of silicone-injected skin after lasing; and histologic
demonstration of silicone deposits in all layers of dermis years after injection
of silicone as filler fluid.
Setting Tertiary care medical center.
Patient-Related Data Histologic examination of freshly excised skin injected with microdroplets
of liquid silicone and subjected to application of carbon dioxide laser energy;
histologic examination of skin excised years after silicone injection.
Interventions High-speed clinical photographic imaging of the effect of laser energy
on silicone fluid; histologic examination of hematoxylin-eosin–stained
sections of skin injected with liquid silicone and subsequently lased.
Main Outcome Measures Response of liquid silicone to application of laser energy; effect of
this response on surrounding normal skin.
Results Exposure of microdroplets of liquid silicone to carbon dioxide laser
energy produced flaring with frank flame. Flaring of dermal silicone caused
collateral skin damage.
Conclusions Prior injection with liquid silicone is a relative contraindication
to cutaneous resurfacing with the carbon dioxide laser. Surgical excision
of silicone-injected skin may be preferable for many patients. A strenuous
needs assessment should be done, alternatives for skin rejuvenation considered,
and comprehensive informed consent obtained from the patient before embarking
on laser resurfacing of silicone-injected skin.
INTRODUCTION
MANY THOUSANDS of patients are undergoing laser resurfacing of facial
skin each year in the United States, according to the statistics currently
available on the World Wide Web sites of cosmetic surgery societies. Demand
is said to be growing dramatically. The expanding patient population presenting
for facial skin rejuvenation must include more and more persons with historical
findings of importance to the facial plastic surgeon. Although carbon dioxide
(CO2) laser skin resurfacing is widely hailed as a safe and effective
treatment modality,1 morbidity is widely reported
as well.2 Furthermore, the patient's medical
history may affect the decision to use laser resurfacing. Weinstein3 documents currently accepted contraindications to
laser resurfacing, including oral retinoid therapy, lack of skin appendages,
and viral diseases, such as hepatitis B, hepatitis C, and human immunodeficiency
virus infection (raising concern about the communicability of plume-borne
viral particles).
A 1986 case report by Becker4 described
"an incandescent flash of yellow-orange flame" on vaporizing silicone deposits
that were being removed from a patient with a ruptured breast implant (Figure 1). Becker indicated his "hope that
photographic documentation will stimulate others to investigate this [observation]
further," but no subsequent report or study has appeared to date. Treating
patients with migration and other complications of prior liquid silicone injection
led us to consider the use of laser resurfacing in such patients. Recall of
Becker's report suggested the following investigation.
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Figure 1. The "silicone flash" (from Becker4).
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MATERIALS AND METHODS
USE OF LIQUID SILICONE AS DERMAL AND SUBDERMAL FILLER
Liquid silicone injection for augmentation of cutaneous wrinkles and
other defects was extremely popular from the 1960s to the 1980s, having been
the ninth most popular cosmetic surgical procedure in the late 1980s according
to the New York Times.5
This article further states that "59,285 injections" of liquid silicone were
made in 1990, although it is impossible to determine the true origin of this
number or what was meant by an injection. A casual Internet search reveals
several suggestions that liquid silicone is still being used as injectable
filler despite both legal disincentives and the emergence of alternatives
for skin rejuvenation. A World Wide Web information site6
contains an inquiry dated August, 17, 1999, from a patient who states that
she had silicone injections around her eyes "less than six months ago." Another
website7 viewed on August 29, 1999, states
that "[p]lastic surgery involves many aspects of body enhancement from silicone
injections to breast implants."
Plastic surgery "bulletin boards" on the Internet contain many inquiries
from patients who had silicone injections in the past and are concerned about
potential implications for current skin rejuvenation therapy.8
There are clearly thousands of patients in the community with dermal and subdermal
silicone deposits. The senior author (D.R.) has surgically removed unsightly
deposits of silicone from several patients over the last 20 years. It is clear
that concern over silicone injections and their impact on subsequent treatment
is warranted.
The literature on silicone fluid injection contains many references
to the intended subcutaneous placement of the material. Authors such as Ashley
et al9 documented their investigations into
the use of silicone fluid, and clinicians such as Rees et al10
described using silicone fluid as a "fat substitute." It is not clear why
this was thought to be the preferred deposition depth, however, as migration
seemed to occur when the material was placed in the subcutaneous fat but not
when it was placed in the dermis. Figure 2 shows histologic sections from a patient whose lumpy and unsightly
deposits of silicone fluid were placed between 6 and 9 years prior to excision,
revealing silicone deposited throughout as well as deep to the dermis. Interestingly,
this was reported as "fatty degeneration of the dermis" by one pathologist
who was unaware of the clinical history. Furthermore, it is not logical to
believe that one can repeatedly pass a needle filled with silicone fluid through
the skin without depositing at least a trace in all levels through which the
needle passes. As a result, we believe that most patients who underwent injection
of liquid silicone have deposits at all levels within as well as beneath the
dermis, as demonstrated in this and other patients of the senior author.
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Figure 2. Intact facial skin 5 years after
liquid silicone injection. Numerous vacuoles are present within the papillary
and reticular dermis (arrows). The vacuoles vary in size and shape and show
an accompanying mild lymphocytic infiltrate (hematoxylin-eosin, original magnification
x200).
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SELECTED FACTS ON THE PHYSICS OF LASER SKIN RESURFACING
Choi et al11 demonstrated that temperatures
higher than 100°C were measured during CO2 laser irradiation
of skin. Pulse stacking can lead to peak temperatures approaching 400°C
and to tissue charring with as few as 3 stacked pulses. Thus, thermal injury
in lased skin is not surprising. Multiple studies have documented the increased
depth of penetration produced by overlapping laser pulses. Many others have
documented scarring and hypertrophic scarring from CO2 laser irradiation
of skin.
LABORATORY INVESTIGATION
Microdroplets of medical grade silicone fluid were placed on various
surfaces with a 30-gauge needle on a 1-mL syringe and struck with single 5-W
pulses from a CO2 laser (Sharplan Lasers Inc, Vernon Hills, Ill).
High-speed digital photography was used to capture the resultant effect.
Informed consent was obtained for the use of freshly excised skin patches
from amputation stump revision surgery. The skin was transported directly
from the operating room to the laboratory. Microdroplets of medical grade
liquid silicone were injected through the skin into the subcutaneous plane,
as has been advocated in the past for facial defects. The skin samples were
then lased with the CO2 laser set at 5 W, as for skin resurfacing.
A single pass was made over each area.
The skin specimens were immediately placed in formalin for transfer
to the pathology laboratory. Routine histologic examination was performed
using light microscopy on the specimens after fixation, paraffin embedding,
sectioning, and staining with hematoxylin-eosin.
RESULTS
Figure 3 shows a representative
flame resulting from exposure of a microdroplet (0.02 mL) of silicone fluid
to a single 5-W pulse of CO2 laser energy. Note the dramatic flame,
which is reminiscent of Becker's silicone flash on a smaller scale. This particular
image shows lasing of a silicone droplet placed on a water-soaked tongue blade.
Silicone droplets approach a spherical shape similar to their appearance in
the histologic sections shown later when placed on a water-soaked surface.
No damage of the underlying material was observed, and similar results were
obtained on a variety of other surfaces. A tongue blade was chosen because
it held the water better than ceramic and other nonporous surfaces.
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Figure 3. Flame from a lased microdroplet
of liquid silicone.
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A representative histologic section of silicone-injected skin that was
then lased with the CO2 laser set at 5 W is shown in Figure 4. Note the thermal damage surrounding the silicone fluid
droplet (Figure 4B, arrowheads).
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Figure 4. A, Thermally damaged skin with
photocoagulation of the epidermis, which has separated from the papillary
dermis (arrows). There is superficial coagulative necrosis of papillary dermis,
with only scattered basal cells remaining. B, Thermally damaged silicone-injected
skin, with vaporization of epidermis and coagulative necrosis of papillary
dermis, reticular dermis, and subcutis. Note collapsed silicone vacuoles (arrowheads)
(hematoxylin-eosin, original magnification x 100).
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COMMENT
Becker5 observed and described flaming
of liquid silicone when it was contacted by the energy beam from a CO2 laser. We confirmed that this also happens when silicone microdroplets
in the dermis are lased. We have demonstrated histologically that silicone
fluid contaminates the full thickness of soft tissue through which the needle
passes, despite an intent not to inject until the tip reaches the subdermal
fat. We have demonstrated thermal injury in the skin around intradermal silicone
deposits. As a result, we are convinced that the potential for scarring is
real when lasing skin previously injected with liquid silicone, despite the
intended injection deeper than the laser penetrates. Temperatures in skin
exposed to a single pass of a CO2 laser reach 100°C, and can
reach in excess of 400°C after 3 passes. These temperatures are sufficient
to cause full-thickness burns and resultant scarring. The addition of an open
flame from lased silicone deposits is highly likely to cause scarring.
On the basis of our observations, we believe that prior injection with
liquid silicone is a relative contraindication to CO2 laser resurfacing.
From Becker, we know that larger deposits of liquid silicone produce a dramatic
flame. Therefore, visibly lumpy silicone deposits should be treated by direct
excision of the skin island containing them. Whenever possible, direct excision
of silicone-containing skin is preferred over any attempt to resurface the
area, in our opinion.
CONCLUSIONS
Prior injection with liquid silicone is a relative contraindication
to skin resurfacing with a CO2 laser. Unsightly deposits of liquid
silicone should be treated by direct excision of the skin island harboring
them. Punch excision and grafting would be appropriate to manage isolated
deposits before lasing. Alternatives to laser resurfacing should be considered
strongly. Should both the facial plastic surgeon and the patient choose CO2 laser resurfacing for treatment, comprehensive informed consent must
be obtained. The laser should be used in single-pass mode, with great care
taken to avoid overlapping pulses. Multiple treatment sessions with minimal
penetration are preferable to deeper lasing in a single treatment episode.
The use of lasers with less depth of penetration than first-generation CO2 units should be considered. Further work needs to be done to determine
if a particular type or class of laser minimizes the risk of thermal injury
and scarring when used on silicone-injected skin.
AUTHOR INFORMATION
Accepted for publication September 8, 2000.
Presented at the Annual Meeting of the American Academy of Facial Plastic
and Reconstructive Surgery, New Orleans, La, September 23, 1999.
From the Departments of Otolaryngology–Head and Neck Surgery
(Drs Zager, Huang, and Reiter) and Pathology and Laboratory Medicine (Dr McCue),
Jefferson Medical College, Philadelphia, Pa.
Corresponding author and reprints: David Reiter, MD, DMD, Department
of Otolaryngology–Head and Neck Surgery, Jefferson Medical College,
925 Chestnut St, Philadelphia, PA 19107 (e-mail: david.reiter{at}mail.tju.edu).
REFERENCES
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1. Alster TS, Garg S. Treatment of facial rhytids with a high energy pulsed carbon dioxide
laser. Plast Reconstr Surg. 1996;98:791-794.
ISI
| PUBMED
2. Rendon-Pellarano MI, Lentini J, Eaglstein WE, et al. Laser resurfacing: usual and unusual complications. Dermatol Surg. 1999;25:360-366.
PUBMED
3. Weinstein C. Erbium laser resurfacing: current concepts. Plast Reconstr Surg. 1999;103:602-616.
ISI
| PUBMED
4. Becker DW. Laser silicone flash. Plast Reconstr Surg. 1988;81:600.
PUBMED
5. Doctors continuing to inject silicone despite FDA warnings agency says. New York Times. February 2, 1992;sect 1:1.
6. The Plastic Surgery Information Forum. Laser eyelift. Available at: http://www.webplastics.com. Accessed September
11, 1999.
7. Internet Care Directory. Plastic surgeon. Available at: http://www.caredirectory.com. Accessed January
16, 2001.
8. The Plastic Surgery Information Forum. Facelift. Available at: http://www.webplastics.com. Accessed September
11, 1999.
9. Ashley FL, Braley S, Rees TD, Goulian D, Ballantyne DL Jr. The present status of silicone in soft tissue augmentation. Plast Reconstr Surg. 1967;39:411.
PUBMED
10. Rees TD, Jobe RP, Ballantyne DL Jr. Inorganic Implants. In: Converse JM, ed. Reconstructive Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1977:394-401.
11. Choi B, Barton JK, Chan EK, Welsh AJ. Imaging of the irradiation of skin with a clinical CO2 laser
system: implications for laser skin resurfacing. Lasers Surg Med. 1998;23:185-193.
PUBMED
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