How to correct disfigurement resulting from soft tissue augmentation of the lips that used too much product.
Lip augmentation with liquid silicone has been well documented and can produce desirable results when performed correctly.1 However, injection of liquid silicone has also been reported to create an unnatural-looking lip that can leave a patient disfigured.2 Deformities can occur by injecting too much product or may be caused by granuloma formation that can occur even years after injection. Various treatment modalities to correct silicone deformities have been utilized. These include local steroid injections, oral steroids, oral antibiotics, imiquimod and surgical excision.3,4 We present two cases of disfigurement of the lips following soft tissue augmentation with too much product that we successfully corrected with surgical revision using the Ellman radiofrequency device.
Patient 1
A 54-year-old HIV-positive Hispanic male presented with concern over the appearance of his lips, which had been injected with an unknown substance approximately 10 year earlier (Figure 1A). He reported having his lips injected only once and denied any associated rash or skin symptoms. His past medical and surgical histories were otherwise negative and he denied taking any medications. Physical examination revealed puffiness of both the upper and lower lips, loss of normal contour and accentuation of the white roll around the vermillion. A biopsy was performed on the lower lip, revealing deposition of lipid-like material throughout the mucosa and dermis consistent with silicone. We surgically excised the excess silicone-filled tissue creating the lip deformity utilizing radiofrequency as discussed below.
Patient 2
A 45-year-old Caucasian female and former model presented for evaluation and correction of her upper lip, which was injected with silicone in Paris nearly 10 years earlier (Figure 1B). She denied any associated rash or skin symptoms. Her past medical and surgical histories were otherwise negative and she took no oral medications. Physical examination revealed puffiness of the upper lip, loss of normal contour and excessive protrusion of her upper lip beyond the lower lip. A biopsy from the upper lip was performed and revealed multiple vacuolated spaces surrounded by foamy histiocytes throughout the dermis and subcutis consistent with a siliconoma. Similarly, we performed surgical excision of excess upper lip tissue using radiofrequency for correction as discussed below.
Materials and Methods
Both patients underwent surgical excision using the Ellman radiofrequency device. This device is an electrosurgical instrument that produces ultra-high frequency radiowaves (3.8-4.0 mega Hertz). Radiowaves enter soft tissue, causing intracellular water to boil, resulting in both cutting and coagulating to varying degrees depending upon the waveform utilized. Radiowave surgery is optimal for soft tissue surgery, as it allows the surgeon to make precise incisions while minimizing surrounding tissue damage and bleeding. The Ellman radiofrequency device has specialized electrodes of varying configurations that are malleable, allowing for multiple cutting angles.5
The patients were positioned sitting upright on the operating table. Areas to be excised were evaluated under tangential lighting. The areas of planned excision were then measured and marked with a surgical pen. Once marked, the lip was secured with a chalazion clamp. Tumescent anesthesia consisting of one part lidocaine with epinephrine (1:100,000) and one part normal saline was injected intraorally as well as along the gingival mucosal border of the intended lip to block the nerve.
Once a regional block was achieved, we made elliptical incisions at the wet-dry junction of the lip using the radiofrequency device on the cutting and coagulation mode (4.0 Hz). We selected a fine tip electrode for these initial incisions. The poles of the ellipse were placed just medial to the oral commissure and the width and depth of the ellipse was dependent upon the deformity of each lip. The elliptical strip of tissue was then excised using a loop-like electrode on cutting and coagulation mode (4.0 Hz). After we removed the desired amount of tissue, we closed the defect with running 6-0 prolene sutures. A bacitracin pressure dressing was then applied. Patients were instructed to continue bacitracin ointment twice daily for one week post-operatively and follow up one week later for suture removal.
Results
Patient 1 underwent excision of excess silicone in the upper and lower lips and tolerated the procedure very well (Figure 2, left). He returned 3 days post-operatively complaining of moderate swelling and pain of the lower lip. Erythema and mild swelling were noted on examination and he was started on clindamycin 300 mg orally twice daily for 14 days as a precaution. He returned 4 days later for suture removal and his symptoms had resolved. At that time, the upper and lower lips were healing successfully, and there was no evidence of asymmetry. At his 9-month follow up, the patient was very pleased with the results. See Figure 4-A (right).
Patient 2 underwent excision and repair of the upper lip (Figure 3, left). She also tolerated the procedure well. She had no immediate complications and her sutures were removed 7 days post-operatively. She returned 6 weeks later with concern for one area of scar tissue that was slightly raised, involving the left mucocutaneous border. Recommendations at that time were daily massage, with instructions to follow up in 6 weeks. Six weeks later, her examination was unchanged and the scar was injected with 0.2 cc of kenalog 10mg/mL. Within a few weeks, she reported flattening of the scar. At her 9-month follow up, the scar was barely perceptible and the patient was delighted with her results (Figure 4-B, right).
Discussion
Liquid silicone is a permanent injectable polymer that has been used for tissue augmentation for many years. Silicone is deposited as droplets in the extracellular matrix. Initially, a transient acute inflammatory reaction may occur, followed by the development of fibrosis. Injection of liquid silicone has been linked to several side effects, including pain, bruising, erythema, induration, excessive tissue elevation and migration of material injected to distant locations, resulting in deformity and granuloma formation.6 Granulomas from silicone have been reported to occur several decades after injection. The pathogenesis of silicone granuloma formation is not known.2
The treatment of silicone granulomas, as well as over-injection of silicone, especially involving the lips, is difficult. Often, if medical managements such as oral steroids or steroid injections are ineffective, surgical intervention is warranted.
Moor and colleagues recently reported successful wedge-shaped excision with Z-plasty repair in 59 patients with lip deformities due to over-injection of silicone oil. A series of wedge-like incisions were made to reproduce a normal lip line, and at least 2 Z-plasties for all incision lines were used to prevent scar contracture. Results were impressive, with 90% of patients expressing satisfaction at the 3-month follow-up period.7
Our 2 patients presented with lip deformities from over-injection of liquid silicone and underwent surgical excision using radiofrequency. We selected the Ellman device because it is has several advantages when used on soft tissues such as the lips. It allows the surgeon to make precise incisions while simultaneously cauterizing tissue. Surrounding soft tissue damage is also minimized.
We found using radiofrequency to be very efficacious and ideal for this surgical procedure. Most importantly, our patients acquired superb symmetry of the lips and were extremely satisfied with their final results. Because of the precision of the Ellman radiofrequency device and its optimal cosmetic results, we recommend its use for the correction of silicone deformities in the lip.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Kirkland is a dermatology fellow at Affiliated Dermatologists in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists in Morristown, NJ. She is a Mohs surgeon, a cosmetic laser surgeon and a dermatologist at Affiliated Dermatologists.
Disclosure: The authors disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article
References
1. Fulton JE Jr, Porumb S, Caruso JC, Shitabata PK. Lip augmentation with liquid silicone. Dermatol Surg. 2005;31(11 Pt 2):1577-1585; discussion 1586.
2. Waller JM, Wu JJ, Murase JE, Dyson SW. An indurated, enlarged lower lip. Clin Exp Dermatol. 2008;33(6):799-800. doi: 10.1111/j.1365-2230.2007.02562.x.
3. Arin MJ, Bäte J, Krieg T, Hunzelmann N. Silicone granuloma of the face treated with minocycline. J Am Acad Dermatol. 2005;52(2 Suppl 1):53-56.
4. Baumann LS, Halem ML. Lip silicone granulomatous foreign body reaction treated with aldara (imiquimod 5%). Dermatol Surg. 2003;29(4):429-432.
5. Niamtu J 3rd. Radiowave surgery versus CO laser for upper blepharoplasty incision: Which modality produces the most aesthetic incision? Dermatol Surg. 2008;34(7):912-921. doi: 10.1111/j.1524-4725.2008.34177.x
6. Bigatà X, Ribera M, Bielsa I, Ferrándiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg. 2001;27(2):198-200.
7. Moor EV, Olshinka A, Ad-El D. Surgical technique for remodeling lip deformities due to overinjection of silicone oil. Dermatol Surg. 2012;38(7 Pt 1):1049-1053.
How to correct disfigurement resulting from soft tissue augmentation of the lips that used too much product.
Lip augmentation with liquid silicone has been well documented and can produce desirable results when performed correctly.1 However, injection of liquid silicone has also been reported to create an unnatural-looking lip that can leave a patient disfigured.2 Deformities can occur by injecting too much product or may be caused by granuloma formation that can occur even years after injection. Various treatment modalities to correct silicone deformities have been utilized. These include local steroid injections, oral steroids, oral antibiotics, imiquimod and surgical excision.3,4 We present two cases of disfigurement of the lips following soft tissue augmentation with too much product that we successfully corrected with surgical revision using the Ellman radiofrequency device.
Patient 1
A 54-year-old HIV-positive Hispanic male presented with concern over the appearance of his lips, which had been injected with an unknown substance approximately 10 year earlier (Figure 1A). He reported having his lips injected only once and denied any associated rash or skin symptoms. His past medical and surgical histories were otherwise negative and he denied taking any medications. Physical examination revealed puffiness of both the upper and lower lips, loss of normal contour and accentuation of the white roll around the vermillion. A biopsy was performed on the lower lip, revealing deposition of lipid-like material throughout the mucosa and dermis consistent with silicone. We surgically excised the excess silicone-filled tissue creating the lip deformity utilizing radiofrequency as discussed below.
Patient 2
A 45-year-old Caucasian female and former model presented for evaluation and correction of her upper lip, which was injected with silicone in Paris nearly 10 years earlier (Figure 1B). She denied any associated rash or skin symptoms. Her past medical and surgical histories were otherwise negative and she took no oral medications. Physical examination revealed puffiness of the upper lip, loss of normal contour and excessive protrusion of her upper lip beyond the lower lip. A biopsy from the upper lip was performed and revealed multiple vacuolated spaces surrounded by foamy histiocytes throughout the dermis and subcutis consistent with a siliconoma. Similarly, we performed surgical excision of excess upper lip tissue using radiofrequency for correction as discussed below.
Materials and Methods
Both patients underwent surgical excision using the Ellman radiofrequency device. This device is an electrosurgical instrument that produces ultra-high frequency radiowaves (3.8-4.0 mega Hertz). Radiowaves enter soft tissue, causing intracellular water to boil, resulting in both cutting and coagulating to varying degrees depending upon the waveform utilized. Radiowave surgery is optimal for soft tissue surgery, as it allows the surgeon to make precise incisions while minimizing surrounding tissue damage and bleeding. The Ellman radiofrequency device has specialized electrodes of varying configurations that are malleable, allowing for multiple cutting angles.5
The patients were positioned sitting upright on the operating table. Areas to be excised were evaluated under tangential lighting. The areas of planned excision were then measured and marked with a surgical pen. Once marked, the lip was secured with a chalazion clamp. Tumescent anesthesia consisting of one part lidocaine with epinephrine (1:100,000) and one part normal saline was injected intraorally as well as along the gingival mucosal border of the intended lip to block the nerve.
Once a regional block was achieved, we made elliptical incisions at the wet-dry junction of the lip using the radiofrequency device on the cutting and coagulation mode (4.0 Hz). We selected a fine tip electrode for these initial incisions. The poles of the ellipse were placed just medial to the oral commissure and the width and depth of the ellipse was dependent upon the deformity of each lip. The elliptical strip of tissue was then excised using a loop-like electrode on cutting and coagulation mode (4.0 Hz). After we removed the desired amount of tissue, we closed the defect with running 6-0 prolene sutures. A bacitracin pressure dressing was then applied. Patients were instructed to continue bacitracin ointment twice daily for one week post-operatively and follow up one week later for suture removal.
Results
Patient 1 underwent excision of excess silicone in the upper and lower lips and tolerated the procedure very well (Figure 2, left). He returned 3 days post-operatively complaining of moderate swelling and pain of the lower lip. Erythema and mild swelling were noted on examination and he was started on clindamycin 300 mg orally twice daily for 14 days as a precaution. He returned 4 days later for suture removal and his symptoms had resolved. At that time, the upper and lower lips were healing successfully, and there was no evidence of asymmetry. At his 9-month follow up, the patient was very pleased with the results. See Figure 4-A (right).
Patient 2 underwent excision and repair of the upper lip (Figure 3, left). She also tolerated the procedure well. She had no immediate complications and her sutures were removed 7 days post-operatively. She returned 6 weeks later with concern for one area of scar tissue that was slightly raised, involving the left mucocutaneous border. Recommendations at that time were daily massage, with instructions to follow up in 6 weeks. Six weeks later, her examination was unchanged and the scar was injected with 0.2 cc of kenalog 10mg/mL. Within a few weeks, she reported flattening of the scar. At her 9-month follow up, the scar was barely perceptible and the patient was delighted with her results (Figure 4-B, right).
Discussion
Liquid silicone is a permanent injectable polymer that has been used for tissue augmentation for many years. Silicone is deposited as droplets in the extracellular matrix. Initially, a transient acute inflammatory reaction may occur, followed by the development of fibrosis. Injection of liquid silicone has been linked to several side effects, including pain, bruising, erythema, induration, excessive tissue elevation and migration of material injected to distant locations, resulting in deformity and granuloma formation.6 Granulomas from silicone have been reported to occur several decades after injection. The pathogenesis of silicone granuloma formation is not known.2
The treatment of silicone granulomas, as well as over-injection of silicone, especially involving the lips, is difficult. Often, if medical managements such as oral steroids or steroid injections are ineffective, surgical intervention is warranted.
Moor and colleagues recently reported successful wedge-shaped excision with Z-plasty repair in 59 patients with lip deformities due to over-injection of silicone oil. A series of wedge-like incisions were made to reproduce a normal lip line, and at least 2 Z-plasties for all incision lines were used to prevent scar contracture. Results were impressive, with 90% of patients expressing satisfaction at the 3-month follow-up period.7
Our 2 patients presented with lip deformities from over-injection of liquid silicone and underwent surgical excision using radiofrequency. We selected the Ellman device because it is has several advantages when used on soft tissues such as the lips. It allows the surgeon to make precise incisions while simultaneously cauterizing tissue. Surrounding soft tissue damage is also minimized.
We found using radiofrequency to be very efficacious and ideal for this surgical procedure. Most importantly, our patients acquired superb symmetry of the lips and were extremely satisfied with their final results. Because of the precision of the Ellman radiofrequency device and its optimal cosmetic results, we recommend its use for the correction of silicone deformities in the lip.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Kirkland is a dermatology fellow at Affiliated Dermatologists in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists in Morristown, NJ. She is a Mohs surgeon, a cosmetic laser surgeon and a dermatologist at Affiliated Dermatologists.
Disclosure: The authors disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article
References
1. Fulton JE Jr, Porumb S, Caruso JC, Shitabata PK. Lip augmentation with liquid silicone. Dermatol Surg. 2005;31(11 Pt 2):1577-1585; discussion 1586.
2. Waller JM, Wu JJ, Murase JE, Dyson SW. An indurated, enlarged lower lip. Clin Exp Dermatol. 2008;33(6):799-800. doi: 10.1111/j.1365-2230.2007.02562.x.
3. Arin MJ, Bäte J, Krieg T, Hunzelmann N. Silicone granuloma of the face treated with minocycline. J Am Acad Dermatol. 2005;52(2 Suppl 1):53-56.
4. Baumann LS, Halem ML. Lip silicone granulomatous foreign body reaction treated with aldara (imiquimod 5%). Dermatol Surg. 2003;29(4):429-432.
5. Niamtu J 3rd. Radiowave surgery versus CO laser for upper blepharoplasty incision: Which modality produces the most aesthetic incision? Dermatol Surg. 2008;34(7):912-921. doi: 10.1111/j.1524-4725.2008.34177.x
6. Bigatà X, Ribera M, Bielsa I, Ferrándiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg. 2001;27(2):198-200.
7. Moor EV, Olshinka A, Ad-El D. Surgical technique for remodeling lip deformities due to overinjection of silicone oil. Dermatol Surg. 2012;38(7 Pt 1):1049-1053.
How to correct disfigurement resulting from soft tissue augmentation of the lips that used too much product.
Lip augmentation with liquid silicone has been well documented and can produce desirable results when performed correctly.1 However, injection of liquid silicone has also been reported to create an unnatural-looking lip that can leave a patient disfigured.2 Deformities can occur by injecting too much product or may be caused by granuloma formation that can occur even years after injection. Various treatment modalities to correct silicone deformities have been utilized. These include local steroid injections, oral steroids, oral antibiotics, imiquimod and surgical excision.3,4 We present two cases of disfigurement of the lips following soft tissue augmentation with too much product that we successfully corrected with surgical revision using the Ellman radiofrequency device.
Patient 1
A 54-year-old HIV-positive Hispanic male presented with concern over the appearance of his lips, which had been injected with an unknown substance approximately 10 year earlier (Figure 1A). He reported having his lips injected only once and denied any associated rash or skin symptoms. His past medical and surgical histories were otherwise negative and he denied taking any medications. Physical examination revealed puffiness of both the upper and lower lips, loss of normal contour and accentuation of the white roll around the vermillion. A biopsy was performed on the lower lip, revealing deposition of lipid-like material throughout the mucosa and dermis consistent with silicone. We surgically excised the excess silicone-filled tissue creating the lip deformity utilizing radiofrequency as discussed below.
Patient 2
A 45-year-old Caucasian female and former model presented for evaluation and correction of her upper lip, which was injected with silicone in Paris nearly 10 years earlier (Figure 1B). She denied any associated rash or skin symptoms. Her past medical and surgical histories were otherwise negative and she took no oral medications. Physical examination revealed puffiness of the upper lip, loss of normal contour and excessive protrusion of her upper lip beyond the lower lip. A biopsy from the upper lip was performed and revealed multiple vacuolated spaces surrounded by foamy histiocytes throughout the dermis and subcutis consistent with a siliconoma. Similarly, we performed surgical excision of excess upper lip tissue using radiofrequency for correction as discussed below.
Materials and Methods
Both patients underwent surgical excision using the Ellman radiofrequency device. This device is an electrosurgical instrument that produces ultra-high frequency radiowaves (3.8-4.0 mega Hertz). Radiowaves enter soft tissue, causing intracellular water to boil, resulting in both cutting and coagulating to varying degrees depending upon the waveform utilized. Radiowave surgery is optimal for soft tissue surgery, as it allows the surgeon to make precise incisions while minimizing surrounding tissue damage and bleeding. The Ellman radiofrequency device has specialized electrodes of varying configurations that are malleable, allowing for multiple cutting angles.5
The patients were positioned sitting upright on the operating table. Areas to be excised were evaluated under tangential lighting. The areas of planned excision were then measured and marked with a surgical pen. Once marked, the lip was secured with a chalazion clamp. Tumescent anesthesia consisting of one part lidocaine with epinephrine (1:100,000) and one part normal saline was injected intraorally as well as along the gingival mucosal border of the intended lip to block the nerve.
Once a regional block was achieved, we made elliptical incisions at the wet-dry junction of the lip using the radiofrequency device on the cutting and coagulation mode (4.0 Hz). We selected a fine tip electrode for these initial incisions. The poles of the ellipse were placed just medial to the oral commissure and the width and depth of the ellipse was dependent upon the deformity of each lip. The elliptical strip of tissue was then excised using a loop-like electrode on cutting and coagulation mode (4.0 Hz). After we removed the desired amount of tissue, we closed the defect with running 6-0 prolene sutures. A bacitracin pressure dressing was then applied. Patients were instructed to continue bacitracin ointment twice daily for one week post-operatively and follow up one week later for suture removal.
Results
Patient 1 underwent excision of excess silicone in the upper and lower lips and tolerated the procedure very well (Figure 2, left). He returned 3 days post-operatively complaining of moderate swelling and pain of the lower lip. Erythema and mild swelling were noted on examination and he was started on clindamycin 300 mg orally twice daily for 14 days as a precaution. He returned 4 days later for suture removal and his symptoms had resolved. At that time, the upper and lower lips were healing successfully, and there was no evidence of asymmetry. At his 9-month follow up, the patient was very pleased with the results. See Figure 4-A (right).
Patient 2 underwent excision and repair of the upper lip (Figure 3, left). She also tolerated the procedure well. She had no immediate complications and her sutures were removed 7 days post-operatively. She returned 6 weeks later with concern for one area of scar tissue that was slightly raised, involving the left mucocutaneous border. Recommendations at that time were daily massage, with instructions to follow up in 6 weeks. Six weeks later, her examination was unchanged and the scar was injected with 0.2 cc of kenalog 10mg/mL. Within a few weeks, she reported flattening of the scar. At her 9-month follow up, the scar was barely perceptible and the patient was delighted with her results (Figure 4-B, right).
Discussion
Liquid silicone is a permanent injectable polymer that has been used for tissue augmentation for many years. Silicone is deposited as droplets in the extracellular matrix. Initially, a transient acute inflammatory reaction may occur, followed by the development of fibrosis. Injection of liquid silicone has been linked to several side effects, including pain, bruising, erythema, induration, excessive tissue elevation and migration of material injected to distant locations, resulting in deformity and granuloma formation.6 Granulomas from silicone have been reported to occur several decades after injection. The pathogenesis of silicone granuloma formation is not known.2
The treatment of silicone granulomas, as well as over-injection of silicone, especially involving the lips, is difficult. Often, if medical managements such as oral steroids or steroid injections are ineffective, surgical intervention is warranted.
Moor and colleagues recently reported successful wedge-shaped excision with Z-plasty repair in 59 patients with lip deformities due to over-injection of silicone oil. A series of wedge-like incisions were made to reproduce a normal lip line, and at least 2 Z-plasties for all incision lines were used to prevent scar contracture. Results were impressive, with 90% of patients expressing satisfaction at the 3-month follow-up period.7
Our 2 patients presented with lip deformities from over-injection of liquid silicone and underwent surgical excision using radiofrequency. We selected the Ellman device because it is has several advantages when used on soft tissues such as the lips. It allows the surgeon to make precise incisions while simultaneously cauterizing tissue. Surrounding soft tissue damage is also minimized.
We found using radiofrequency to be very efficacious and ideal for this surgical procedure. Most importantly, our patients acquired superb symmetry of the lips and were extremely satisfied with their final results. Because of the precision of the Ellman radiofrequency device and its optimal cosmetic results, we recommend its use for the correction of silicone deformities in the lip.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Kirkland is a dermatology fellow at Affiliated Dermatologists in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists in Morristown, NJ. She is a Mohs surgeon, a cosmetic laser surgeon and a dermatologist at Affiliated Dermatologists.
Disclosure: The authors disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article
References
1. Fulton JE Jr, Porumb S, Caruso JC, Shitabata PK. Lip augmentation with liquid silicone. Dermatol Surg. 2005;31(11 Pt 2):1577-1585; discussion 1586.
2. Waller JM, Wu JJ, Murase JE, Dyson SW. An indurated, enlarged lower lip. Clin Exp Dermatol. 2008;33(6):799-800. doi: 10.1111/j.1365-2230.2007.02562.x.
3. Arin MJ, Bäte J, Krieg T, Hunzelmann N. Silicone granuloma of the face treated with minocycline. J Am Acad Dermatol. 2005;52(2 Suppl 1):53-56.
4. Baumann LS, Halem ML. Lip silicone granulomatous foreign body reaction treated with aldara (imiquimod 5%). Dermatol Surg. 2003;29(4):429-432.
5. Niamtu J 3rd. Radiowave surgery versus CO laser for upper blepharoplasty incision: Which modality produces the most aesthetic incision? Dermatol Surg. 2008;34(7):912-921. doi: 10.1111/j.1524-4725.2008.34177.x
6. Bigatà X, Ribera M, Bielsa I, Ferrándiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg. 2001;27(2):198-200.
7. Moor EV, Olshinka A, Ad-El D. Surgical technique for remodeling lip deformities due to overinjection of silicone oil. Dermatol Surg. 2012;38(7 Pt 1):1049-1053.
A 54-year-old HIV-positive Hispanic male presented with concern over the appearance of his lips, which had been injected with an unknown substance approximately 10 year earlier (Figure 1A). He reported having his lips injected only once and denied any associated rash or skin symptoms. His past medical and surgical histories were otherwise negative and he denied taking any medications. Physical examination revealed puffiness of both the upper and lower lips, loss of normal contour and accentuation of the white roll around the vermillion. A biopsy was performed on the lower lip, revealing deposition of lipid-like material throughout the mucosa and dermis consistent with silicone. We surgically excised the excess silicone-filled tissue creating the lip deformity utilizing radiofrequency as discussed below.
A 45-year-old Caucasian female and former model presented for evaluation and correction of her upper lip, which was injected with silicone in Paris nearly 10 years earlier (Figure 1B). She denied any associated rash or skin symptoms. Her past medical and surgical histories were otherwise negative and she took no oral medications. Physical examination revealed puffiness of the upper lip, loss of normal contour and excessive protrusion of her upper lip beyond the lower lip. A biopsy from the upper lip was performed and revealed multiple vacuolated spaces surrounded by foamy histiocytes throughout the dermis and subcutis consistent with a siliconoma. Similarly, we performed surgical excision of excess upper lip tissue using radiofrequency for correction as discussed below. 
Patient 1 underwent excision of excess silicone in the upper and lower lips and tolerated the procedure very well (Figure 2, left). He returned 3 days post-operatively complaining of moderate swelling and pain of the lower lip. Erythema and mild swelling were noted on examination and he was started on clindamycin 300 mg orally twice daily for 14 days as a precaution. He returned 4 days later for suture removal and his symptoms had resolved. At that time, the upper and lower lips were healing successfully, and there was no evidence of asymmetry. At his 9-month follow up, the patient was very pleased with the results. See Figure 4-A (right).
Patient 2 underwent excision and repair of the upper lip (Figure 3, left). She also tolerated the procedure well. She had no immediate complications and her sutures were removed 7 days post-operatively. She returned 6 weeks later with concern for one area of scar tissue that was slightly raised, involving the left mucocutaneous border. Recommendations at that time were daily massage, with instructions to follow up in 6 weeks. Six weeks later, her examination was unchanged and the scar was injected with 0.2 cc of kenalog 10mg/mL. Within a few weeks, she reported flattening of the scar. At her 9-month follow up, the scar was barely perceptible and the patient was delighted with her results (Figure 4-B, right). 
