Cosmetic Medicine Case Report
Complications After Self-Injection of Hyaluronic Acid and Phosphatidylcholine for Aesthetic Purposes
Aesthetic Surgery Journal 30(3) 442–447 © 2010 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X10374088 www.aestheticsurgeryjournal.com
Shimpei Ono, MD, PhD; and Hiko Hyakusoku, MD, PhD
Abstract Various types of dermal fillers have been developed for soft tissue augmentation, including hyaluronic acid products, which have been approved by regulatory agencies in Europe, the United States, and elsewhere. Phosphatidylcholine (PPC) injection has attracted attention for its application in the treatment of cellulite, weight loss, and skin rejuvenation. Because the public can now buy PPC and similar products from various online pharmacy websites without the involvement of a clinician, there is potential for misuse. The authors discuss two cases of complications experienced by patients after selfinjection of hyaluronic acid and PPC for aesthetic purposes. Keywords self-injection, hyaluronic acid, phosphatidylcholine, complication, filler
Various types of dermal fillers have been developed for soft tissue augmentation in the management of the aging face worldwide.1 Hyaluronic acid (HA) products, primarily employed for the treatment of wrinkles and trough augmen tation, have been approved by regulatory agencies in Europe, the United States, and elsewhere. Phosphatidyl choline (PPC) has also attracted attention in recent years as a treatment for cellulite, weight loss, and skin rejuvenation.2 Injectable PPC (along with similar products) is now availa ble to the public through various online pharmacy websites without the approval of a clinician, potentially leading to misuse of these treatments. In this report, we discuss two cases of complications experienced by patients after selfinjection of HA and PPC for aesthetic purposes.
Case Presentations The first patient was a 36-year-old woman who experi enced swelling after self-injecting HA. She did not have a history of any psychiatric disease. Ten months prior to hospital admission, she purchased an HA product on the Internet, which she self-administered into her nasolabial folds in an attempt to look younger. She obtained informa tion about how to purchase and self-inject HA from vari ous websites and message boards on the Internet. She later reported that in the hours immediately following injection, her entire face began to swell, but she did not seek medical assistance at that time. Several months
postinjection, she was still suffering from prolonged swell ing and induration around the injection site (Figure 1), and she was admitted to our hospital after referral from a private clinic. The second patient was a 21-year-old female university student, also without a history of any psychiatric disease. Six months before admission, she purchased a PPC prod uct on the Internet and self-injected it into her buttock and thigh in an attempt to remove excess subcutaneous fat. Similar to the first case, she also obtained information about how to purchase and self-inject PPC online. Within a few days postinjection, her entire buttock and thigh area began to swell and redden. She also suffered from pan niculitis of the buttock and thigh, followed by dermal necrosis at the injection sites. After receiving treatment for the panniculitis and skin ulcer, she was admitted to our hospital for treatment of the scars and postinflammatory hyperpigmentation (Figure 2a and 2b).
From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan. Corresponding Author: Shimpei Ono, MD, PhD, Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan. E-mail:
[email protected]
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Figure 1. Clinical image after self-injection of HA.
Discussion A review of the literature on self-injection of dermal fillers was conducted through PubMed and with Japanese search software (Ichushi, Ver. 4). We found that several research ers have previously reported similar cases of individuals self-injecting various substances in an attempt to improve their appearance. In 2004, the case of a 45-year-old woman with a history of depression who self-injected bovine fat in liquid form into her face was reported.3 She claimed influence from a television program. Other materi als reported as having been self-injected include olive oil,4 automobile transmission fluid,5 mineral oil,6 sweet almond oil,7 sesame seed oil,8 and vegetable oil.9 In addition, there have been some reports of fat embolus caused by selfinjection.7,9 In the Japanese literature, four case reports (a total of 10 cases) of self-injection of Vaseline and/or sili cone into the penis have been published. In addition, there has been one report of a man who attempted breast aug mentation via self-injected vegetable oil. Most patients discussed in previous case reports have had a history of psychosexual problems and have engaged in frequent, repeated self-injections. It is extremely unu sual for an individual without any history of psychological illness to self-inject for rejuvenation purposes. To our knowledge, this is the first report in the literature of selfinjection of aesthetic products.
Information About Self-Injection on the Internet Through the Google Internet search engine, we conducted a general search with the terms hyaluronic acid self-injection,
which resulted in nearly 60,000 hits. Similarly, a search for mesotherapy self-injection resulted in over 10,000 hits and lipolysis self-injection had over 7500 hits. The public can easily obtain HA and PPC products, as well as injection syringes and needles, from a number of Internet sites. Some of these sites suggest repeating self-injection every week— sometimes every day. Various websites and message boards also contain instructions for self-injection. The information from these sites and the patients’ descriptions of selfinjection are summarized below. Most individuals appear to self-inject these materials without anesthesia, after the product is cooled with a refrigerant. Some of them apply a topical anesthetic pur chased on the Internet; some apply an external hemor rhoid ointment for anesthesia; others use the same needle repeatedly and keep surplus materials in the refrigerator for two to three months (and sometimes more). According to these patients, they can inject the materials just as well as a physician, at a reduced cost. They are fearful about government restrictions on purchasing these products. Injection intervals range from nearly every day to two and three times per year for HA and every two to three months for PPC. The HA product Hyalos (Maruho, Japan) (at a cost of about 6000 Japanese yen, or about $65) is often purchased for the first trial of self-injections. The popular HA products commonly found in aesthetic clinics can be bought for about 30,000 Japanese yen. It is possible to buy Lipostabil (Sanofi-Aventis, Bridgewater, New Jersey), a PPC-based product for lipolysis injection, for 2000 to 3000 Japanese yen per ampoule. All of these prod ucts can be easily purchased online through personal import agencies and individual clinics. Many sites and individuals claim that self-injection of these materials is safe because HA and PPC exist naturally
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Each of these other materials can also be bought on the Internet. Others websites advise drinking a Chinese “diet tea” in addition to performing self-injections. Individuals on these sites report suffering from compli cations such as hematoma formation, induration, transfor mation, recurrent edema, keloids, and infections. When complications are experienced, patients typically consult a physician and claim that they received injection therapy at a beauty clinic. Overall, the information about self-injec tion available online is of significant concern, in that it tends to exclude information about the risks inherent in self-injection.
Legality According to the website of the Japanese Ministry of Health, Labor, and Welfare (and information provided on the telephone by the person in charge of the pharmaceuti cal department), medicines, cosmetics, and medical equip ment are restricted by legislation concerning quality, effectiveness, and safety. Therefore, only products that are certified based on scientific data can be marketed domesti cally. Individuals can import these products only for per sonal use and if they sell or transfer these products to other people, it becomes illegal. It is also illegal to import medicines that pose a serious health hazard if they are administered without a physician’s supervision or without a prescription. However, in recent years, brokers who undertake these purchases in the name of a personal import agency are rampant, leading to sales to a third person without a doctor’s prescription. To improve the situation with respect to the importation of these products by some individuals and brokers through a loophole in the law, the aesthetic surgery community in Japan is making an effort to warn and provide accurate information to the public about this problem. Television broadcasters (both public and commercial), three newspa per companies, and several major websites ran headlines about this issue in January 2009. Information about the dangers of self-injection was also posted on the website of the Japan Society of Aesthetic Plastic Surgery (JSAPS). Furthermore, we are continuing negotiations with the government to gain insights into the prevalence of selfinjection, reporting systems, and watchdog activities.
Complications After HA and PPC Injection Figure 2. Clinical image after self-injection of PPC.
in the human body and that these materials will be absorbed by the body over time. Some individuals seek out injection partners through these message boards because the dorsal area is difficult to reach. There are some examples of patients self-injecting a “cocktail” con taining lidocaine, carnitine, placenta, ascorbic acid, deoxy cholic acid, and saline along with the lipolysis injection.
It is widely asserted that injection of HA gels into the der mis is generally well tolerated, with a few mild and tran sient side effects.10 However, complications do occur. The most common adverse reactions are self-limited and include bruising, erythema, edema, and slight discomfort at the treatment sites. Most of these reactions resolve within one to three days.11 On the other hand, severe delayed cases of complications, such as systemic hyper sensitivity11 and skin necrosis,12,13 have also been reported. PPC injections can result in hematomas,14 panniculitis,15,16
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atypical mycobacterium infection,17 and subcutaneous nodules.18 Atypical mycobacterium infection is of particu lar concern because it induces intractable ulcers. There are few reports of complications arising after PPC injection because this material has come into usage only relatively recently. If doctors encounter patients without any infor mation or knowledge about the product they injected, it will be difficult to select prompt and proper treatment options. The risk also exists for more severe complica tions, including blindness caused by retrobulbar hemor rhage and facial nerve palsy and, in the case of PPC (a soy derivative), anaphylactic shock. Obviously, in self-injec tion cases, these complications could occur at any time. It is essential that the public be provided with accurate infor mation about these complications.
Conclusions The general public can now purchase injectable aesthetic products, as well as injection syringes and needles for medical treatment, over the Internet without a doctor’s prescription. Particularly in Japan, businesses and indi vidual clinics are selling these products illegally. Many instructional websites and message boards concerning self-injection can be easily found, and wrong and danger ous information (with the message that “self-injection is cheap, simple, and safe”) is being widely disseminated. With this in mind, the number of cases of complications (including potentially life-threatening complications such as fat embolisms) will only increase in proportion with the number of self-injection cases. Therefore, we believe that governments and the academic community must address this risky behavior to prevent unnecessary complications and poor outcomes for these patients.
Disclosures The authors declared no conflicts of interests with respect to the authorship and/or publication of this article.
Funding The authors received no financial support for the research and/or authorship of this article.
References 1. Broder KW, Cohen SR. An overview of perma nent and semipermanent fillers. Plast Reconstr Surg 2006;118(suppl):7S-14S. 2. Routunda AM, Kolodney MS. Mesotherapy and phospha tidylcholine injections: historical clarification and review. Dermatol Surg 2006;32:465-480.
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3. Tümerdem B, Aydin A, Kesim SN. An unusual case of self-injected bovine fat in liquid form to the face for cos metic reasons. Aesthetic Plast Surg 2004;28:251-253. 4. Bhagat R, Holmes IH, Kulaga A, et al. Self-injection with olive oil: a cause of lipoid pneumonia. Chest 1995; 107:875-876. 5. Behar TA, Anderson EE, Barwick WJ, et al. Sclerosing lipogranulomatosis: a case report of scrotal injection of automobile transmission fluid and literature review of subcutaneous injection of oils. Plast Reconstr Surg 1993;91:352-361. 6. Cohen JL, Keoleian CM, Krull EA. Penile paraffin oma: self-injection with mineral oil. J Am Dermatol 2001;45:222-224. 7. Thomas P, Boussuges A, Gainnier M, et al. Fat embolism after intrapenile injection of sweet almond oil. Rev Mal Respir 1998;15:307-308. 8. Darsow U, Bruckbauer H, Worret WI, et al. Subcutane ous oleomas induced by self-injection of sesame seed oil for muscle augmentation. J Am Acad Dermatol 2000;42: 292-294. 9. Kiyokawa H, Utsumi K, Kasuga I, et al. Fat embolism syndrome caused by vegetable oil injection. Intern Med 1995;34:380-383. 10. Duranti F, Salti G, Bovani B, et al. Injectable hyaluronic acid gel for soft tissue augmentation: a clinical and histo logical study. Dermatol Surg 1998;24:1317-1325. 11. Lupton JR, Alster TS. Cutaneous hypersensitivity reac tion to injectable hyaluronic acid gel. Dermatol Surg 2000;26:135-137. 12. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006;32:276-281. 13. Steinsapir KD, Steinsapir SM. Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments. Ophthal Plast Reconstr Surg 2006;22:344-348. 14. Brandão C, Fernandes N, Mesquita N, et al. Abdominal haematoma: a mesotherapy complication. Acta Derm Venereol 2005;85:446. 15. Davis MD, Wright TI, Shehan JM. A complication of mesotherapy: noninfectious granulomatous panniculitis. Arch Dermatol 2008;144:808-809. 16. Rivera-Olivero IA, Guevara A, Escalona A, et al. Softtissue infections due to non-tuberculous mycobacteria following mesotherapy: what is the price of beauty? [in Spanish] Enferm Infect Microbiol Clin 2006;24:302-206. 17. Sañudo A, Vallejo F, Sierra M, et al. Nontuberculous mycobacteria infection after mesotherapy: preliminary report of 15 cases. Int J Dermatol 2007;46:649-653. 18. Lee DP, Chang SE. Subcutaneous nodules show ing fat necrosis owing to mesotherapy. Dermatol Surg 2005;31:250-251.
