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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

Bryan.liming@gmail.com

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