Delayed Hematoma After Silicone Implant Forehead ...of peri-implant hemorrhage complicated by...
Transcript of Delayed Hematoma After Silicone Implant Forehead ...of peri-implant hemorrhage complicated by...
Poster Design & Printing by Genigraphics® - 800.790.4001
Delayed Hematoma After Silicone Implant Forehead Augmentation
Necessitating Implant Removal and Reconstruction
CPT Bryan Liming, MD1; MAJ Joseph Shvidler, MD1
1Madiagn Healthcare System, Department of Otolaryngology, Tacoma, WA
CASE REPORT DISCUSSION
Figure 1. CT showing bony ridges and crescentic
fluid collection over implant.
ABSTRACT
We present the case of a 48
year old Asian female who
presented to our clinic 8 years
after silicone implant forehead
augmentation with complaints
of brow swelling, tenderness
and periorbital edema.
Imaging revealed non rim
enhancing fluid collection and
underlying bony ridges.
Subsequent medical
management included
antibiotics which lead to
resolution of the majority of
symptoms. Patient was then
taken for elective removal of
the implant with subsequent
human acellular tissue matrix
reconstruction. We describe
our decision making process
as well as our intraoperative
maneuvers.
Alloplastic forehead augmentation has been rarely
described in the literature1, and there is an absence of
data on complications. Silicone implants have been used
in applications as varied as duraplasy, orbital floor repair,
malar augmentation and chin augmentation. Delayed
complications have been reported in the literature of these
disciplines.
Silastic dural substitutes have been reported to be
associated with delayed hemorrhagic complications. In
one report of two cases of hematoma formation after
silastic duraplasty2, complications occurred 3 and 9 years
after implantation. On surgical exploration, both patients
had evidence of clot formation between the dural implant
and the fibrous capsule. Another report described a case
of peri-implant hemorrhage complicated by Acinetobacter
infection 32 years after implantation3.
Silicone implants have also been used in the repair of
orbital floor fractures. In a series of 4 patients who
presented in a delayed fashion (1 to 20 years) with
complications of silicone sheet orbital floor repair4., 3
patients had a mass effect from chronic inflammation and
fibrosis while a fourth patient had an abscess. An
additional report describes a periprosthetic hematoma 18
year after repair with silastic requiring orbital exploration
and implant removal5.
While the literature regarding alloplastic forehead implants
is sparse, silastic malar implants are described. One
retrospective review6 of 60 patients over five years
reported a overall complication rate of 16.7% with no
report of hematomas, seromas or bony resorption.
Silicone is a hydrophobic polymer that acquires a layer of
host proteins upon implantation7 . It initiates a foreign body
reaction that then causes development of a fibrous
capsule. It has been hypothesized that the space between
the fibrous capsule and implant is a virtual space that can
fill with hemorrhagic fluid with disruption of the fragile
capillaries in the fibrous capsule8. This could be caused
by repetitive microtrauma to the implant. We believe that
this hemorrhagic process can become secondarily infected
leading to acute exacerbation of symptoms.
•A 48 year old otherwise healthy Asian female with
a history of implant forehead augmentation 8 years
ago presented with 24 hours of forehead pain and
swelling as well as periorbital edema.
•She denied recent trauma, fever, nausea, vomiting.
She reported intermittent chills.
•She endorsed intermittent swelling of the forehead
since implant placement.
•Physical exam revealed bilateral periorbital edema,
right greater than left. Her forehead was
edematous and tender to palpation.
•She was was started on antibiotics and a CT scan
was obtained (Figure 1).
1. Wong, J.K. Forehead augmentation with alloplastic implants. Facial Plast Surg Clinc N
Am. 2010; 18:71-77
2. Fontana et al. Spontaneous haematoma as unsual complication of silastic dural
substitute. Report of 2 cases. Acta Neurochir. 1992; 115:64-66
3. Strom et al. Low-grade infection complicating silastic dural substitute 32 years
postoperatively. Brain Injury. 2011; 25:2: 250-254
4. Warrier et al. Delayed complications of silicaone implants used in orbital fracture
reparis. Orbit. 2008; 27:147-151
5. Ilie et al. Periprosthetic bleeding 18 years post-silicone reconstruction of the orbital floor.
Orbit. 2011; 30:5: 249-251
6. Metzinger et al. Malar augmentation; A 5 year retrospective review of the silastic
midfacial malar implant. Arch Otolaryngol Head Neck Surg 1999; 125: 980-987
7. Sevastionov Vi. Role of protein adsorption in blood biocompatibility of polymers. CRC
Crit Rev Biocompat. 1988;4:109-154
8. Ng TH et al. An unusual complication of silastic dural substitute: Case report.
Neurosugery. 1990; 27:491-493
CONCLUSIONS
REFERENCES
CPT Bryan Liming , MD
Madigan Healthcare System
253-968-1420
CONTACT
•The patient was reexamined 48 hours later and
noted to have some improvement with persistent
edema and tenderness.
•Antibiotics were continued for 10 days with some
improvement.
•She was offered explantation of the implant for
definitive treatment.
•The underlying frontal bone had two corresponding
areas of ridging secondary to bony resportion.
•The superior row was easily accessed and felt to be
potentially cosmetically disfiguring (Figure 5). We
therefore removed these ridges with a 4mm
osteotome.
• To reconstruct the expanded cavity, we used a 6 x
12 x 1.04-2.28mm sheet of human acellular tissue
matrix (Alloderm, Life Cell, NJ) cut the same shape
and size as the explanted implant (Figure 6).
• Aerobic and anaerobic cultures of the hematoma
contents exhibited no growth
• At the 3 month postoperative appointment (Figure
2A), the patient was pleased with her forehead
contour and she denied any pain or discomfort.
Figure 2. Preoperative (A) and 3 months postoperative (B)
profile views of forehead
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Defense
•We used a partial trichophytic incision (Figure 3)
and carried the dissection through the pericranium.
•We encountered a thick fibrous capsule around the
capsule. This contained maroon viscous fluid.
•The fluid was evacuated and the implant was
exposed (Figure 4A).
•The implant was then removed en bloc from the
cavity, it was noted to be a solid piece of silicone
with regular ridging (Figure 4B).
Figure 4: Implant exposed (A) and on back table (B)
We believe that this case is the first reported case of
delayed hematoma complicating an alloplastic forehead
implant. Additionally, the secondary bony resorption and
tissue expansion presented a reconstructive challenge.
These complications must be considered when evaluating
a patient for alloplastic facial augmentation.
In a patient with a history of alloplastic facial augmentation
who presents with pain and swelling, infection, soft tissue
reaction and hematoma must be considered in addition to
other etiologies for facial swelling such as complicated
sinusitis
Figure 5: Underlying bony ridging
Figure 6: Sculpted tissue matrix graft
A
B
Figure 3: Partial tricophytic incision
A
B