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Part VII
Complications
Chapter 27
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Management ofPatients withASIA
Syndrome inPlastic Surgery
CarlosAlbertoRíos, JaimeAlexanderDomínguez Quiñonez,
CarlosAlejandroLópez Albán, andJhanArturo
Key Points
• History of the use of adjuvant substances for cosmetic procedures.
• Clinical picture and stages of the disease.
• Presurgical risk assessment.
• Use of ineffective techniques for removal of adjuvant material.
• Endoscopic surgery and open surgery with large incisions for material removal.
• Reconstructive surgery.
27.1 Introduction
Iatrogenic allogenosis is a term used to describe iatrogenic body injuries produced
by the injection of a material for the purpose of lling. The injection of adjuvants is
a practice that has a cross-border connotation, and remains its use is maintained in
C. A. Ríos (*)
Centro médico Santuario, Cali, Colombia
e-mail: rios@santuario.com.co
J. A. Domínguez Quiñonez
Evidence-Based Medicine Clinical Research, OnlyEvidence Foundation, Cali, Colombia
C. A. López Albán
Centro para la investigación en salud y rendimiento humano, Cali, Colombia
J. Arturo
Inmugen Corporation, Bogotá, Colombia
Instituto de Virología, Universidad del Bosque, Bogotá, Colombia
Instituto de Medicina Molecular y Regenerativa, Bogotá, Colombia
© Springer Nature Switzerland AG 2023
D. Del Vecchio, H. Durán (eds.), Aesthetic Surgery of the Buttock,
https://doi.org/10.1007/978-3-031-13802-7_27
381
382
C. A. Ríos et al.
different continents. Our experience focuses on Latin America and particularly
Colombia, where many therapists and patients migrate from one country to another
in attempts to solve the problem [1].
Patients who have undergone injections of llers may die immediately, at the
time of injection or in the following hours, due to migration of the biopolymer to
vital organs. Some patients present signs and symptoms during the subsequent
months of injection, which are evidenced by severe inammation, that apparently
occurs due to a combination of the material, your immune reaction to foreign body,
and/or secondary infection, presenting occasionally stulas from the injected substance [2].
Other groups of patients could have delayed symptoms, on average up to 20
years afterward, with signs of systemic inammation that may resemble an autoimmune disease; have been described as the autoimmune/inammatory syndrome
induced by adjuvants (ASIA) or as an inammatory response to a foreign body
[3].The most frequent anatomical site of injection is the gluteal area, followed by
the face, and less frequently the calves, breasts, and genitals [4].
In the last decade, the surgical management of complications derived from the
injection of adjuvants, has been in high demand in the USA and Latin America. In
this chapter we will discuss the complications of substances in the gluteal region,
the symptoms, labs and radiology test, its surgical treatment, and the most frequent
complications, sequels, and reconstructions.
27.2 History
In 1899, Gersuny and Billroht (Vienna, Austria), injected mineral oil (Vaseline) into
the scrotum of a patient castrated for tuberculosis epididymitis [2]. Similarly,
Eckstein introduced the use of subcutaneous parafn injections as a method of
breast enlargement. For a range of years from the time, reports of unwanted effects
begin to appear, in 1912, Hollander reported the complications of parafn injections
into the breasts, referring to them as parafnomas [5].Frederick Strange Kolle in
his book Plastic and Cosmetic Surgery (published in 1911), described the complications of parafn injections into breast tissue, which range from cosmetic defects to
death. The complications included pulmonary embolism, migration, ulceration, stulas, infection, and necrosis.
During the Second World War, Japanese females injected different types of oils
and silicones, especially sex workers, into their breasts; induced by the smaller size
of their mammary glands, typical of Asian women, feature that was not very desirable to Western soldiers. After the 1950s, this practice became popular in the USA
and later in the rest of the world [6]. In the 1960s, the “Cleopatras Needle”
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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383
technique was promoted in Las Vegas; it is estimated that more than 10,000 women
were injected, though there is no clinical record of them [7].
This practice has not stopped, evidenced by countless case reports of complications related to the use of these substances for decades; in the present, frequently
cases of death and sequels from the use of the llers on common people and public
gures are disclosed. Today, the numbers of cases reach different incidences in various parts of the world, to such a high degree that in Cali Colombia it has been
declared a public health problem. Some of the terms that have been reported in
scientic databases are: “parafnomas” and “siliconomas” [4].
27.3 Clinical Presentation
In two studies conducted in Cali to evidence the adjuvants as a public health problem, the natural history of the disease is described [4]. The application of adjuvants
can produce complications in three main moments: (1) Immediately after its application (death). (2) Short or medium time (signs of local irritation or inammation).
(3) Late symptoms that can appear after many years and, in some cases, apparently
do not produce visible side effects.
The appearance of the symptoms is usually conditioned by the type of substance
used, the dosage, the site of application, and the injection deepness. The symptoms
can appear in an insidious, even confusing way, and many patients do not remember
exactly the event in which the modeling was applied or do not associate the initial
symptoms with the application of the adjuvant, usually the symptoms are considered as local and trivial events on the skin, at other times, despite medical intervention, these clinical manifestations are interpreted as emotional problems and/or
stress (Fig.27.1). At present, it is consistently observed that the signs and symptoms
of the ASIA syndrome manifest as already known pathologies of immunological/
rheumatological origin, or a mixture of them, for example the overlap of Sjögren’s
syndrome/systemic lupus erythematosus- SLE.Among the diseases and symptoms
that we can mention are: Fibromyalgia syndrome, arthritis or arthralgia, myalgia,
myositis, muscle weakness, fatigue or chronic fatigue syndrome, sleep disorders,
memory loss, dry eyes and mouth, sjögren syndrome, stiffness morning sickness,
cognitive impairment, sicca syndrome, nonspecic neurological manifestations,
dysesthesias, paresthesias, lymphadenopathy, silicone lymphadenopathy, fever,
angioedema, skin nodules, ulcers, stulas, foreign body granuloma. These clinical
expressions, in the presence of prostheses or biopolymer injection of any type,
whether commercial or unknown, could be grouped bibliographically as part of the
term siliconosis [8]. As will be seen later, with or without the presence of
autoantibodies.
384
OTHER ILLNESS SIGNS AND SYMPTOMS INCREASE
C. A. Ríos et al.
Fig. 27.1 Most frequent
symptoms according to the
time stages of the
disease [9]
TIMES
IMMEDIATE
MEDIATE
LATE
SIGNS & SIMPTONS SECUNDARY TO FOREIGN BODY INYECTION
DEATH
INJECTED MATERIAL EXUDATE
SECRETION ASSOCIATED WITH INFECTION
EDEMA
ERYTHEMA
TISSUE NECROSIS
VOLUME INCREASE
CANNOT SIT KNEELING
TROPHIC CHANGES IN SKIN
HYPER PIGMENTATION
SICK
HERDEING OF THE AREA
BURNING PAIN
PERMANENT AND / OR CONSTANT PAIN
MODERATE INTENSITY PAIN
HYPERESTHES
PAIN RELATED TO OTHER BODY SEGMENTS
INTOLERANCE TO SITTING OR PRONE
TISSUE NECROSIS
DEFORMITY
DEPRESSION
INSOMNIA
MEMORY LOSS
VISUAL ACUITY LOSS
SELF ESTEEM
27.3.1 Immediate Presentation
REACTIONS
Death by application of biopolymers, may occur suddenly during the initial hours of
the application of the adjuvant. It is attributable to the migration of the of the applied
substance to different parts of the anatomy, and it is related to the injection of large
volumes of synthetic biomaterial. Several autopsies have shown evidence of modeling material in the Vena Cava, cardiac valves, the white substance in the brain, brain
stem, cerebellum, renal mesangium, etc., all associated with hemorrhage and
inammatory inltration [2].
27.3.2 Intermediate Presentation
The initial symptom is usually a skin disorder (redness), at the site of application of
the adjuvants or in the surrounding area. When presented in an intermediate form
(from days to 6months), there is usually an exudation of synthetic material that has
been injected, through the wounds created by the inltration needle (Fig.27.2),
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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Fig. 27.2 Exudation of
biopolymers through the
wounds created by the
inltration needle
385
sometimes the exudation is purulent, typical of a localized infection, and associated
to signs of inammation: warmth, redness, and sometimes necrosis of the tissue,
which can be extensive, compromising supercial and deep tissues.
27.3.3 Late Presentation
Late symptoms appear 5–7 years after the injection of the material, with an average of 20 years, there are reports of symptoms arising up to 40 years after the
application. The rst late sign is usually local skin irritation, similar to cellulitis,
or a pustule, in addition to hyperpigmentation, erythema around the lesion, and
hyperesthesia, with or without skin induration. However, the occurrence of
symptoms may alternate in time for months or even years with asymptomatic
periods.
The pain is described as a permanent burning type, from low to moderate intensity, but constant. The insidious onset of the pain becomes more and more consistent
and could evolve into unmanageable chronic pain, not because of its intensity but
because of its persistence. Intolerance to prone or sitting positions is common, so
patients constantly try to assume different positions to lessen the pain and avoid the
discomfort. Hypersensitivity is frankly a hyperesthesia. Pain can be referred to other
areas of the body, the arms, the legs, or to the back. It is similar to the signs and
symptoms of bromyalgia or is often accompanied by it. Pain at different points of
the body is associated with physical exhaustion, sleep disorders, and nonrepairing sleep.
386
Fig. 27.3 Necrosis of the
tissue and loss of skin
integrity caused by
biopolymers
C. A. Ríos et al.
In the most complicated cases, there is tissue necrosis, with loss of skin
integrity and exposure of deep tissue (Fig.27.3). The lesion is usually bilateral.
The polymer seems to move to the palpation giving the sensation of
having“bubbles”.
The concomitant inammatory processes are presumably related to the frequency of the symptoms generated by the adjuvants, which may aggravate other
preexisting pathologies. There is a remarkable decrease in the quality of life of
patients, showing depression, irritability, insomnia, non-refreshing sleep, loss of
memory, reducedvisual acuity, among others. There is low self-esteem, condence
collapses in them to show their body for fear of being judged, even suicide attempts
have been reported [10–14].
In a cohort evaluated by the work team (753 patients), just one reported no
symptoms. Nonetheless, there were cases who reported up to 24 simultaneous
symptoms, the average ranging from 10 to 19 symptoms. The highest frequency
was found in 16 simultaneous symptoms corresponding to 8.5% of the total
patients (Fig.27.4).This might be the reason for the loss of the patient’squality of
life and confusion with other clinical pictures, as well as for the magnitude of the
problem.
27.3.4 Drugs
The pain response to painkillers is far from being optimal. Pain and inammation
do not respond adequately to NSAIDs, steroids, cytostatic agents, or other analgesics,however, it has been shown that the administration of antibiotics, in certain
cases, decreases the signs and symptoms, for which there is presumed to be an
underlying infectious process, in the form of biolm.
TELAGIECTACIES / VASCULAR SPIDERS
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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NECK NODES
FEVER
BLEACHING
ULCERATIONS
PAPULE
INFECTIONS
PRURITUS
NODES
EDEMA
ERYTHEMA
SKIN ATROPHY
PUS SECRETION
INFLAMMATION
SKIN STIFFNESS
TISSUE NECROSIS
SUBSTANCE MIGRATION
PICKING UP FABRICS
TISSUE DEGENERATION
DRAINAGE OF INJECTED SUBSTANCE
387
SIGNS AND SYMPTOMS SECONDARY TO BIOPOLYMEROS INJECTIONS
90,0%
80,0%
70,0%
100,0%
60,0%
50,0%
40,0%
30,0%
20,0%
10,0%
0,0%
BLUE COLORING
REDNESS
HYPERIGMENTATION
ASYMMETRY
DEFORMITY
DIARRHEA
VISUAL ACUITY LOSS
HEADACHE
DRY EYES
IRRITABLE BOWEL
DRY MOUTH
INSOMNIA
MEMORY LOSS
JOINT PAIN
MUSCLE PAIN
UNSPECIFIC PAIN
MOOD CHANGES
TINGLING AND CRAMPS
TEMPERATURE INCREASE
INJECTED PLACE VOLUME INCREASE
OBSTRUCTION BREATHING
MOBILITY LOSS AND / OR SENSITIVITY
DEPRESSION AND ANXIETY
Fig. 27.4 Frequency of symptoms presented in autoimmune/inammatory syndrome induced by adjuvants
388
C. A. Ríos et al.
The improvement of local and systemic symptoms of the disease, is only relevant
when a large proportion of the adjuvants has been surgically removed from the
body. As long as there is the presence of biopolymer residues, there will always be
the possibility of symptom recurrence [4].
27.4 Diagnostic
The diagnosis should be based on the clinical history; patients with adjuvant disease
present a constellation of well-dened symptoms, and although sometimes the initial diagnosis can be misleading, the symptoms are invariably associated with the
inltration of a “foreign” substance. The diagnosis of ASIA syndrome is clinical
and is made when two major criteria or one major and two minor criteria are present
in the clinical picture (Table27.1).
In the timing of the phenomenon, we can distinguish three moments, application of the modelers, diagnosis of the condition, and patients who have already
submitted to the removal of biopolymers [4]. Science must concentrate on efforts
to improving the technologies for the diagnosis and management of the effects of
adjuvants.The crucial goals to be achieved are: cost/effectiveness in retirement,
guaranteeing an optimal result based on evidence; cost/utility, which implies that
what is done as an intervention must improve the quality of life of those affected;
and cost/benet, which implies the best technology at the lowest possible
cost [15].
Table 27.1 Diagnostic criteria for ASIA syndrome
Major criteria
1. Exposition to an external agent (silicone, hyaluronic acid, polymethylmethacrylate, etc.)
prior to the onset of symptoms
2. The appearance of typical clinical signs and symptoms:
• Arthralgias and/or arthritis
• Chronic fatigue
• Sleep disturbances or non-refreshing sleep
• Myalgias or muscle weakness
• Neurological manifestations (associated with demyelination)
• Cognitive impairment or memory loss
• Xerostomia
• Fever
• Biopsy with pathognomonic ndings of granulomas in the involved organs
• The elimination of the external agent induces the improvement of the clinical picture
Minor criteria
1. Development of antibodies directed to the adjuvant
2. Development of any other autoimmune diseases
3. Presence of specic HLAs (HLA DRB1, HLA DQB1)
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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389
27.5 Assessment ofPerioperative Risk
Several aspects have to be considered in the surgical evaluation of patients with
systemic inammatory diseases. The evaluation of the perioperative risk is important during the elaboration of the surgical plan, in order to stratify the risk of adverse
events as well as to estimate the perioperative morbidity and mortality of the
patients.
This information may be useful to support decision making by medical staff and
patients, regarding appropriate surgical and nonsurgical treatment during the perioperative period as well as to identify new potential complication, guide the use of
anesthesia during surgery, optimize interventions, and guide preoperative practices
focusing on the healing process. The standardization of methods allows us to guarantee valid and reproducible results that can facilitate clinical decision-making [16].
27.6 Labs
The lab work on patients with adjuvants disease is usually negative for systemic
inammatory diseases, autoimmune diseases, or infectious conditions. In ASIA
syndrome the diagnostic aids are considered as a minor criterion for diagnosis.
Blood count,liver function tests, and inammatory markers (such as ESR and
C-reactive protein), appear in normal ranges, even in patients with serious clinical
conditions. Complement C3 and C4 consumption as well as rheumatoid factor and
antinuclear antibodies are normal in most cases [7, 11, 17, 18]. Along with the
National Institute of Health of Colombia (INS—Instituto Nacional de Salud), we
are researching the potential relationship between the symptomatology caused by
adjuvants,and their association with infectious processes in the form of biolm.
27.7 Radiological Imaging
Different techniques could be performed to assess the extension, deepness, and the
migration of the adjuvants. With ultrasound, the structure of the tissue is damaged
by the hardness of the material and images with artifacts, with acoustic shadowing
phenomena, and with snowstorms pattern are reported without evidence of deep
tissue alterations [7].
Using the Gallium 67 Scan, a higher absorption of the tracer was found on the
silicone injection sites on the buttocks and hips regions. The scan could show areas
of inammation, demonstrating migration to areas unimaginable by plastic surgeons (aorta, mediastinum, lung, spleen, etc.) [18–22] (Fig.27.5).
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