MA. Encarnacion R. Legaspi-Vicerra, MD, FPDS and Lawrence Marshall Field, MD, FIACS
MA. Encarnacion R. Legaspi-Vicerra, MD, FPDS is Medical Director, Total Skin Care Center; Visiting Consultant, St. Luke’s Medical Center, Global City, Philippines. Lawrence Marshall Field, MD, FIACS is International Traveling Chair of Dermatologic Surgery (ISDS)
A 57-year-old Filipino woman had paraffin materials placed in her nose, chin, and cheeks approximately 15 years prior to consultation. Progressive enlargement of the chin had occurred, simulating a witch’s chin deformity, with a lesser degree of the distal nose and columellar area. Restoration of a relatively normal chin contour was accomplished by using tumescent bi-level anesthesia, mobilizing the protuberant tissues, hemi-ressecting the excess skin, and sculpting the subjacent tissue to an appropriate degree. The nose was then entered at the columellar junction with the upper lip, an open rhinotomy was accomplished, the supra-cartilaginous fibrous tissue was serially ressected to reform the profile, the cartilage was replaced to narrow the nasal configuration, and the nose structure was then replaced. Cosmetic improvement was significant. (J Clin Aesthetic Dermatol. 2010;3(6):54–58.)
Contour defects of the face or skin, such as scars from acne, accidents, or reconstructive and cosmetic problems, may be treated by soft-tissue correction. Facial augmentation has been performed by using various materials, including organic substances, such as ivory, liquid paraffin, autologous fat, and coral. Inorganic substances, such as liquid silicone gel, injectable bovine collagen, and gelatin matrix implants, have likewise been used.
Paraffinoma is defined as a tumefaction, usually a granuloma, caused by the prosthetic or therapeutic injection of paraffin. Parrafin oil, discovered in 1830, is a purified hydrocarbon from petroleum that has been used in the past as an augmentation material in various parts of the human body for restoration of body defects or aesthetic body contouring. Paraffin injection was regarded as a simple and effective method of improving body contour. It was widely used in breast augmentation until the long-term complication of paraffinoma was recognized.
This procedure requires an undetermined number of repeated injections, which may lead to migration of foreign materials and host immune response. Paraffinoma in the breast can present as a painless breast mass; a destructive ulcer simulating breast carcinoma; a painful, hard mass clinically resembling cancer; or a hard mass with ulceration or sinus formation, usually associated with lymphadenopathy.[3–6] This makes it difficult to correctly diagnose and provide suitable treatment.
Some practitioners, especially nonsurgeons and nonphysicians, use liquid injectable materials, such as liquid silicone or paraffin, to perform noselift and chin augmentation procedures. Klein et al reported scalp paraffinomas, which occurred 35 to 42 years after injection of paraffin for treatment of baldness. These procedures are considered unacceptable in dermatology, dermatological surgery, and cosmetic surgery because of the unstable nature of these materials. These injectable substances migrate to other parts of the face and tumor-like lesions develop after several months or even years. These tumors are known as siliconoma when liquid silicone is used or paraffinoma when paraffin is used.
These tumors are very difficult to remove, even in the hands of a competent surgeon. The injected material eventually mixes with the tissue, which leads to disfigurement of the face. Long-term follow up is advised to determine the possibility of malignant degeneration after the use of these injectable substances.
On the other hand, unabsorbable fatty material used for nasal packing may provoke an inflammatory reaction (variously termed as oleogranuloma, lipogranuloma, paraffinoma, oil granuloma, sclerosing lipogranulomatosis, and myospherulosis). A computed tomography (CT) scan excludes other causes for the deformity. Surgical excision of the tissue is indicated with an appropriate warning of possible recurrence.
On CT scan of the face, paraffinoma appears as an ill-defined infiltration in the buccal fat pad and the subcutaneous fat with multiple punctate calcifications (Figure 1). When calcifications associated with soft tissue infiltration are incidentally noticed on CT, particularly bilaterally, the diagnosis of foreign body granulomas secondary to cosmetic cheek augmentation is highly possible and an appropriate review of the medical history is highly recommended.
The authors report the case of a 57-year-old Filipino woman who had paraffin materials placed in her nose, chin, and cheeks 15 years prior to consultation (Figure 2, Figure 3, Figure 4, Figure 5). The purpose of the injections was to improve the aesthetic appearance of the face, more particularly to enhance her nose, chin, and lips. Repeated injections of an undetermined amount were administered over a period of five years. Three years prior to consultation, additional injections of undetermined quantity were made to the upper eyelid, chin, and columellar area. The patient was initially satisfied with her “improved appearance”; however, two years prior to consultation, the patient noted undesirable changes in her face. Progressive enlargement of the chin had occurred, simulating a witch’s chin deformity, with a lesser degree of deformity of the distal nose and columellar area.
Clinical findings. The patient presented with nodules in her nose, chin, and cheeks. Lesions were nonerythematous, ill-defined nodules and were firm to the touch with deep palpation. No feeling of pain, uneasiness, or discomfort was noted. No relevant past medical history was revealed. No history of asthma, allergic reactions to food or medication, or autoimmune diseases was noted. History of present illness began 15 years prior to consultation. The aim of the surgical intervention was to restore the disfigured appearance of the nose and chin to a cosmetically acceptable level.
Restoration of a relatively normal chin contour was accomplished by using tumescent bi-level anesthesia, mobilizing the protuberant tissues, hemi-ressecting the excess skin, and sculpting the subjacent tissue to an appropriate degree. The nose was then entered at the columellar junction with the upper lip, an open rhinotomy was accomplished, the supra-cartilaginous fibrous tissue was serially ressected to reform the profile, the cartilage was replaced to narrow the nasal configuration, and the nose structure was then replaced. Cosmetic improvement was significant.
Histopathological findings. The histopathological findings of paraffinoma have been described in several articles.[4,8–10] The histological features include chronic granulomatous inflammation with foreign body multinucleated giant cells and numerous vacuolated spaces containing paraffin oil and/or calcification, resulting in the so-called “Swiss cheese” appearance, as demonstrated in this study.
Interstitial infiltration by plasma cells and fibroblastic reaction are consistently present. In this case study, an elliptical skin segment of the chin measuring 0.8×0.6cm for biopsy was obtained. The findings on routine histology show adipocytes of varying sizes and aggregations of vacuoles with foamy centers in the subcutaneous fat.
Dermatopathological diagnosis was paraffinoma.
The histological findings in paraffinoma are often not straightforward and may not totally exclude a malignant lesion. Liquid paraffin infiltrates soft tissues and causes a foreign body reaction characterized histologically by chronic granulomatous inflammation with infiltration by lymphocytes, plasma cells, lipid-containing foamy cells, and cystic spaces containing paraffin oil and calcification. The presence of numerous vacuolated spaces with surrounding foreign body multinucleated giant cell reaction is suggestive of reaction to an exogenous cause. However, histologically it may be difficult to distinguish between a subcutaneous paraffinoma and well-differentiated liposarcoma. Hence it is important to obtain a relevant clinical history in interpreting histopathological results.
The clinical features of paraffin oil injection consist of 1) acute inflammatory phase (1–6 months after injection) and 2) latent phase (during which the substance is tolerated). After a variable time-interval, late reactions appear. The paraffin oil is resistant to the action of lysosymal enzymes of tissues and macrophages, which leads to chronic granulomatous inflammation. This is parallel to other foreign body reactions. The foreign body reaction to paraffin oil results in the formation of fibrous tissue, which helps walling of the mineral oil and separates it into small globules. This reaction may lead to skin induration, necroses, and disfiguring subcutaneous nodules. The granulomatous tissue may further undergo suppuration and fistulae formation, giving rise to discharging sinuses. Mineral oil spreads and infiltrates soft tissues; therefore, an area larger than the original oil injection area is often affected.
Histopathology of paraffinoma reveals chronic granulomatous inflammation with foreign body giant cells and cystic spaces containing paraffin oil and calcification giving the so-called “Swiss cheese” microscopic appearance.
The term paraffinoma describes the tumours caused by granulomatous reaction to paraffin (mineral oil) or other lipophilic substances introduced in the subcutis. Tumors are also sometimes designated according to the injected substance as oleomas or siliconomas when oil or silicon, respectively, is injected.
In general, it is advisable to perform excisional surgery to remove as much of the injected material or affected area as possible.[3,5,8] In some cases, conservative treatment may be the only option because of very deep and widespread distribution of the paraffin oil. In another case, a bodybuilder, developed skin and muscle necroses forming multiple ulcers after paraffin oil injections into his muscles for muscle augmentation. The ulcers healed after conservative treatment with a compression bandage.
Foreign body granuloma occurs when inoculated or implanted, exogenous materials that are foreign to the dermis or subcutaneous tissue persist and have the capacity to induce a foreign body granulomatous reaction.
The injection of oily substances, such as paraffin, petrolatum, vegetable oil, mineral oil, lanolin, sesame oil, camphor oil, impure silicone, and beeswax, which were used in the past to repair cosmetic defects or as vehicles for repository therapy or are presently used erroneously, subsequently produce a foreign body reaction.
In the 19th century, Eckstein used paraffin as an alternative to petrolatum because the melting temperature was too high (65 degrees) to soften after the injection. The technique involved the injection of a substance that is semi-liquid when heated, then solidifies when it gets colder. It remains stable and inert in the human body. It was used for the cure of palatal and urinary fistulae and hernia, but mainly for cosmetic indications: filling facial wrinkles and cheeks, treating baldness, augmenting the breast and penis, and treating nasal defects. Although serious complications were reported, it remained popular for the first 20 years of the 20th century.
Liquefied paraffin wax or beeswax injection was widely practiced up to the 1970s in Asian countries, particularly by back-street practitioners. This method is no longer performed due to the serious local complications of formation of paraffinoma, inflammatory reactions, tissue necrosis, and sinus tract formation. Systemic complications, including pulmonary and cerebral embolism, have been reported.
It is not possible to predict the kind of reaction that will be triggered as a response to a foreign body or exogenous substance; however, there are reports in the medical literature on the clinical latency and clinical presentation of such reactions. According to a series study by Cabral et al, the average latency before onset is six years. There are sclerodermatous skin changes with or without hyperpigmentation, hardening of the tissue with subcutaneous lumps or nodules, deformation, and ulceration.
Paraffin granulomas are still rarely seen because of the long latency period between implantation and onset of clinical symptoms. The hallmark of paraffin granuloma is the so-called “Swiss cheese” pattern in the deeper dermis and subcutis. Multiple, round, sharply circumscribed vacuoles of varying size are surrounded by a granulomatous reaction with multinucleated giant cells. Typically, the vacuoles are empty on high magnification.
The treatment of paraffinomas is regionalized. The treatment of choice for the facial area is the intralesional administration of corticosteroids. Allopurinol is used for larger lesions. Intralesional injection of long-lasting crystalline corticosteroids has usually been the treatment of choice, which may require up to 24 weeks. However, this treatment bares the risk of disfiguration by skin atrophy with telangiectasias and scarring. Recently, patients have successfully been treated with minocycline, cyclosporine, and allopurinol. Severe granulomas occasionally require surgical excision. With this patient, restoration of a relatively normal chin contour was accomplished by using tumescent bi-level anesthesia, mobilizing the protuberant tissues, hemi-ressecting the excess skin, and sculpting the subjacent tissue to an appropriate degree. The chin was debulked to remove the tumor-like lesion. The nose was then entered at the columellar junction with the upper lip, an open rhinotomy was accomplished, and the supra-cartilaginous fibrous tissue was serially ressected to reform the profile. The cartilage was replaced to narrow the nasal configuration, and the nose structure was also replaced.[11,16,17]
The diagnosis of paraffinomas may be difficult to determine without histopathological results. Because of the ubiquitous presentation of paraffinoma, the attending clinician should rely primarily on attaining a good history of present illness to determine the probable diagnosis of the lesions. It is prudent for physicians to consider paraffinoma, siliconoma, or foreign body granuloma in examining patients with nodules in the nose, chin, and lip areas. In this age of patients seeking beauty through easily attainable and inexpensive treatment options performed by nonphysicians or cosmetologists, physicians should raise their index of suspicion of a possible foreign body granuloma so that these problems may be addressed as soon as possible and not progress to possible carcinomas. If aesthetic intercession is denied or not attainable by the patient, the physician may suggest performing a diagnostic skin biopsy. The distinctive histopathological findings of uniformly spaced round cystic structures enclosing nonbirefringent particles must, however, alert dermatopathologists to make the diagnosis of paraffinoma.
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