Cosmetic injections by unlicensed, untrained practitioners in nonclinical settings have dramatically increased as the demand for cosmetic procedures has increased among the general public. Illicit subcutaneous injections with liquid silicone for enhancement of bodily features have been the cause of a wide range of reported complications, including death.1 Herein described are the first reported cases of subcutaneous injections of corn oil, performed by an unlicensed cosmetic practitioner, that eventuated in the death of one of her clients, life-threatening systemic illness of other, and serious complications in several others that required medical treatment. The local and systemic pathologic manifestations of subcutaneous corn oil instillation are described and discussed, as are the analytical methods applied to successfully confirm the identity of the injected substance.
A 46-year-old Hispanic female experienced feeling hot, dizzy, and thirsty a few minutes after receiving “French polymer” injections into her buttocks by an unlicensed practitioner at home. Her symptoms rapidly progressed to mental confusion and restlessness, followed by reduction in consciousness. Emergency responders initially found her blood pressure to be 190/114 and pulse 130, with respiratory rate of 20. Two recent injection sites were observed on the lower buttocks. She was transported to the hospital, where she presented with confusion, agitation, increasing hypotension and tachycardia, hypothermia, and diaphoresis. Blood gases indicated metabolic acidosis and severe hypoxemia. Admission chest x-ray and venous pressures were consistent with noncardiogenic acute respiratory distress syndrome. She was given vasopressors, sedated, intubated, and placed on mechanical ventilation. Admission laboratory screening tests revealed a slightly elevated prothrombin time and increased D-dimer suggestive of fibrinolysis, with normal liver profile, renal function tests, and cardiac enzymes. Serum albumin was slightly decreased, with 2+ proteinuria detected through urinalysis. Urine drug screen was negative for tricyclics, barbiturate, benzodiazepines, cannabinoids, cocaine, and opiates, but was positive for amphetamines, although no confirmatory tests were performed. White blood cell count was mildly elevated and platelet count moderately decreased. Ocular examination demonstrated mild bilateral papilledema without hemorrhages and without venous pulsations. Corneal and optical reflexes were absent except sluggish papillary response to light. Neurologic impression was that of a diffuse encephalopathy with brainstem dysfunction, uncertain etiology. Broad spectrum antibiotic treatment and corticosteroid administration were added. The day after admission the patient experienced cardiac arrest from which she was resuscitated, but subsequent neurologic evaluation indicated irreversible anoxic brain injury. Aggressive treatment was withheld and death eventuated 7 days after admission.
Postmortem examination, performed 4 days after death, revealed a mildly obese, middle age female with generalized anasarca and pitting pretibial and pedal edema. Scattered petechial hemorrhages were observed on the eyelids, forehead, and conjunctiva. Medical devices attached to the body were consistent with the medical history of life support.
Two separate 1-cm diameter circular areas of dark red skin bruising were observed on the lower left buttock adjacent to the skin crease adjoining the thigh. Incisions into the underlying soft tissues revealed at least 2 linear hemorrhagic tracts, consistent with needle punctures, extending deeply into the adipose tissue of the left buttock. Further incisions demonstrated numerous areas of cyst formation associated with chronic inflammation, scarring, and fat necrosis (Fig. 1). Cyst contents ranged in character from thin, clear, oily fluid to thick, sticky, yellow-tan resin-like semisolid material, similar in character to bathtub caulk (Fig. 2). The distribution of the material was widespread within the subcutaneous fatty tissues, extending beyond the needle puncture tracts, and involved both buttocks.
Postmortem examination was remarkable for serous effusions within all body cavities, probe patent foramen ovale, diffuse rubbery consolidation, and bronchial inflammation of both lungs, and diffusely swollen brain with numerous petechial hemorrhages involving the white and gray matter of the cerebral hemispheres, cerebellum, and brainstem (Fig. 3). Unfortunately, no hospital admission blood or body fluid samples remained available for analysis. Samples of adipose tissue and foreign semisolid encysted material from the left buttock were recovered for analytical testing.
Microscopic examination of skin and adipose tissues from the left buttock showed extensive acute and chronic inflammation of gluteal fat with areas of recent hemorrhage. Evidence of older injury was evidenced by hemosiderin-laden macrophages, extensive foreign body reaction to pale yellow, lipid-like material, and areas of scarring with cyst formation (Fig. 4). Brain sections exhibited widespread neuronal necrosis and gliosis associated with thrombosis and rupture of innumerable capillaries throughout all areas of the brain (Fig. 5). Lungs displayed extensive, severe, diffuse alveolar damage with widespread pulmonary capillary thrombosis, and hemorrhage, and occasional areas of capillaries ballooned with clear colorless contents, most likely lipid in nature, associated in some areas with lipid-laden macrophages (Fig. 6). Renal glomeruli exhibited frequent ballooned capillary loops with accumulation of proteinaceous material inside some glomeruli (Figs. 7, 8), but relatively infrequent capillary thrombosis. Liver sections displayed severe acute passive congestion with minimal hepatocellular necrosis. Other organ sections lacked noteworthy pathologic findings.
The cause of death was attributed to multiple organ failure that followed systemic fat embolism from injection of foreign material into the buttocks. Initially it was believed that the source of embolic material was liquefied subcutaneous fat related to local trauma and fat necrosis.
ANALYSIS OF FOREIGN MATERIAL
Encysted foreign material recovered from the left buttock of the decedent at autopsy was sent to Microtrace, a microscopy, microchemistry, and consulting laboratory. Upon receipt the material was described as semisolid and gel-like, with slight yellow coloration. Amorphous in appearance under polarizing light microscopy, it contained small spheres of clear fluid dispersed throughout. Elemental analysis using energy dispersive x-ray spectroscopy indicated it was organic in nature with detection of only minor amounts of sodium, sulfur, and calcium. No silicone was identified. A small portion of the sample was mounted on a sodium chloride plate and analyzed by Fourier transform infrared microspectrophotometry, resulting in a spectrum that was a good match, albeit nonspecific, for many vegetable or seed oils. When the Fourier transform infrared microspectrophotometry spectra for the sample was compared with Mazola brand corn oil, the 2 spectra were found to be nearly the same except for a broad peak at approximately 3500 cm−1, which likely represented water. To discriminate differences in oils by quantifying their individual fatty acid components analysis, gas chromatography with mass spectrometry was performed on a hexane extract of another small portion of the sample and compared with a similarly prepared hexane extract of Mazola brand corn oil. The total ion chromatographs prepared from both samples demonstrated that both samples contained the same fatty acids in roughly the same proportions. A large split peak at approximately 7.5 minutes represents 2 similar fatty acids differing in saturation, the difference in ratios likely caused by oxidation of some of the fatty acid in the sample. Additional minor peaks in the chromatogram may have resulted from chemicals in the body dissolving into the oil. Hexane insoluble sample residue, likely representing polymerized oil, was digested in sodium hydroxide and the soap converted back to the free fatty acids by addition of hydrochloric acid. After hexane extraction of free fatty acids, conversion to their methylsilyl esters by silylation with N,O-Bis(trimethylsilyl)trifluoro-acetamide was accomplished, and a chromatogram prepared, which showed the same major fatty acid components as corn oil, plus some dissolved cholesterol and a trace amount of azelaic acid, often used as a topical skin treatment.
After further consideration of the investigative background of the case and conclusive identification of the injected substance, the cause of death was more accurately stated as multiple organ failure due to systemic fat embolism that resulted from corn oil injections of buttocks. The Monterey County District Attorney's Office filed charges of second degree murder against the hairdresser who had performed the injections.
CRIMINAL INVESTIGATION AND PROSECUTION
Investigations conducted by the Monterey County Sheriff and District Attorney′s Offices subsequently incriminated a local hairdresser who eventually admitted injecting Mazola corn oil (ACH Food Companies, Cordova, TN) into the buttocks of the decedent shortly before the onset of her symptoms, information she had withheld from emergency responders at the scene and treating medical staff at the hospital. In addition, 22 months earlier the decedent had received similar oil injections into her buttocks at the hairdressing salon, witnessed by her daughter. Upon filing charges of involuntary manslaughter, practicing medicine without a license, and consumer fraud, the case received widespread public media coverage, resulting in a number of individuals coming forward to report instances of having been injured by injections performed by the defendant. One victim and his friend described in detail a near-fatal complication caused by injections by the defendant, including a harrowing trip to the hospital in the company of the defendant, 8 days of hospitalization, and the defendant's promise to never perform the injections again. Their statements provided the prosecution excellent evidence establishing the defendant's awareness of the potential danger of these corn oil injections. With this testimony, the prosecution was able to upgrade the involuntary manslaughter charge to murder. In California the difference between murder and involuntary manslaughter is whether the defendant “was aware of the risk to life that his or her actions created and consciously disregarded that risk.” The punishment for murder as charged in this case in California is 15 years to life; the punishment for involuntary manslaughter is 2, 3, or 4 years. Ultimately, the defendant pled to a number of lesser charges and enhancements and received a stipulated 15 years in state prison.
DESCRIPTIONS OF OTHER CASES
Local media attention given to the fatality and subsequent prosecution of the hairdresser resulted in 8 other victims of corn oil injections by the accused coming forward, 6 who had experienced complications for which they sought medical attention. The medical records and/or investigative reports from these individuals were made available to the author for review in preparation for criminal prosecution of the hairdresser. The procedures and complications experienced are described below.
A 30-year-old Hispanic woman (M.R.), paid $300 for a session of injections to enlarge her buttocks in October 2000. The injections were performed at M.R. home by her hairdresser friend, claiming to having been trained and licensed to perform the procedure. The procedure was performed with 1 large needle, and consisted of at least 20 separate injections of fluid. Over the next 6 months MR repeatedly presented to the local hospital emergency room and outpatient clinic with recurring complaints of severe pain, swelling, and redness of the left buttock where she reported she had been given “vitamin” injections in Mexico. The medical records describe incision and drainage of pus from abscesses of the left buttock on 3 separate visits as well as multiple courses of oral antibiotic treatment before the abscesses ceased draining and eventually healed.
A 29-year-old Hispanic woman (I.C.), responded to a Spanish language radio advertisement for cosmetic injections and paid $1000 for 2 sessions of buttock injections in mid 2001. Injections with about 16 ounces of yellow fluid were instilled using a couple of syringes that were refilled multiple times from the bottle of liquid. The needle used was estimated to be 2 inches long and the procedure was painful, being performed without local anesthesia. Two months later the patient presented at the local hospital outpatient clinic with a 10-cm diameter mass of the left buttock. Incision and drainage was performed, yielding over 150 mL of bloody, cloudy fluid, with a second procedure required to facilitate drainage. The wound healed slowly over an 8-week period, with prolonged drainage of fluid from the site. The victim continued to experience pain and discomfort in the right buttock 4 years later, and the left buttock was disfigured by scarring.
Another patient (M.C.) reported to have paid at least $300 for a session of injections in the spring of 2002 when age 19. She described being injected about 25 times in each buttock while lying down in a backroom of the hairdressing salon. The procedure itself was extremely painful, and she experienced difficulty walking and sitting because of gluteal pain and swelling after it was done. Pale yellow oily fluid and blood seeped from the injection sites over a period of days, requiring the need for wearing a diaper. Several days later she developed a pruritic rash that spread from the buttocks to the thighs for which she sought medical attention at the local hospital emergency room. The treating physician described an erythematous and pruritic rash that was spreading down the inner thighs, with some macular patches and raised urticarial lesions, consistent with a contact dermatitis. Prednisone and Atarax were prescribed and the rash resolved without further treatment.
A 29-year-old transvestite (A.H.) responded to a Spanish language radio advertisement for body enhancing cosmetic injections of “French polymer” at a local beauty salon in August of 2001. He paid a total of $900 for 3 courses of injections of oily liquid into the thighs and buttocks, 20 injections per session, totaling about a half liter per session. The injections were performed in the beauty salon by the hairdresser who had run the advertisement. Three weeks after the thigh injections, A.H. sought medical treatment at Doctors on Duty, then the local hospital emergency department, for increasing thigh pain, swelling, and redness. Physical examination revealed cellulitis surrounding an area of marked induration of the back of the right thigh. Incision and drainage yielded large amounts of serosanguinous and purulent fluid containing small yellow granules. Despite a 7-day course of oral antibiotics, drainage from the wound continued for over 2 weeks, but the wound had largely healed by 4 weeks. Four months later A.H. received another round of injections, this time in the buttocks. Immediately following the injections, A.H. became nauseated and began vomiting, flowed by lethargy, confusion, and difficulty standing, and walking. Several hours later he was taken to the emergency room where she was noted to be semiconscious, confused, and unable to speak or follow commands. On admission, his temperature was 101.9 °F, WBC count was elevated, but drug screen, CSF and blood cultures, and chemistry panels were negative. Blood gases indicated hypoxemia and chest x-rays showed diffuse increased interstitial markings. MRI brain scan showed minimal nonspecific periventricular white matter disease and slight cerebral volume loss. Physical examination revealed multiple needle punctures of both buttocks overlying subcutaneous “knots” which were leaking oily fluid. Over his 7-day hospital course, A.H. gradually regained normal mental function and was discharged in good condition.
M.G. paid $1500 for 5 sessions of injections in early 2003, after which she sought and received medical treatment in Mexico for leg swelling and infection.
R.M. paid $1200 for 4 sessions of injections in the summer of 2003, after which she experienced a “rash” on her legs. The rash cleared up after taking some pills supplied by the woman who had performed the injections.
Subcutaneous corn oil injections for cosmetic enhancement are a hitherto undescribed cause of the fat embolism syndrome (FES). Most familiar as a complication of traumatic long-bone fractures, FES can also occur in association with burns, acute pancreatitis, joint reconstruction, diabetes mellitus, parenteral infusion of lipids, cardiopulmonary bypass, decompression sickness, and liposuction.2 More recently, a condition with clinical features virtually indistinguishable from FES has been attributed to cosmetic enhancing liquid silicone injections.1,3 Two cases of FES caused by subcutaneous injection of vegetable oil for the purpose of cosmetic enhancement have been previously reported,4,5 neither of which were fatal.
In the presently described cases of illicit vegetable oil injections for cosmetic enhancement, corn oil was instilled by needle into the buttocks and/or thigh areas of at least 8 individuals who subsequently experienced complications, 2 of whom required emergency hospital care with signs and symptoms typical of FES. The death of one of the victims represents the first reported human fatality from the subcutaneous injection of vegetable oil, with postmortem examination yielding findings characteristic of systemic fat embolism. In neither case was the clinical diagnosis of FES made by attending medical staff, suggesting that there may a low level of diagnostic suspicion for this condition in the general medical community. Seven individuals experienced local complications from corn oil injections, most frequently manifesting as subcutaneous abscesses, cellulitis, or rashes that required medical treatment. In none of the cases was the causative subcutaneous injection of oil brought to the attention of treating medical staff (or law enforcement officers). It is hoped that the cases presented herein will raise the level of awareness about the presenting signs and symptoms that illicit cosmetic oil injection victims can exhibit.
Of considerable pathologic interest is the fact that thin clear vegetable oil injected into subcutaneous tissue can polymerize over time into thick yellow liquid and semi-solid tan resinous deposits that may be misidentified unless properly collected and subjected to biochemical analysis. In none of our reported cases were the patients forthcoming about what procedures had been performed on them that brought on their presenting signs and symptoms. In fact, many of the victims themselves were unaware of the nature of the material with which they were injected. The result of the collective lack of awareness was a 5-year span of time during which the perpetrator performed injections of corn oil into numerous members of her local community without being reported to public health or law enforcement agencies. In view of the long period of activity by the practitioner it remains likely that many more individuals received similar injections who never were identified or who failed to seek medical or legal attention. This implies that, despite the subcutaneous instillation of as much as half a liter of corn oil into each buttock, many recipients of such injections either did not develop severe local or systemic complications or those who did were simply misdiagnosed, owing to the lack of clinical recognition of the practice and refusal of patients to divulge important historical information.
The syndrome of fat embolism is known to occur in only a small percentage of individuals who sustain long bone fractures or other forms of trauma to tissues rich in fat. In most cases many hours or even a couple days may intervene between the time of injury and the time signs and symptoms of FES arise. For this reason, it is believed by some that the resultant microvascular injury seen in most classic cases of FES is not directly caused by circulating fat droplets, but rather by mediator-induced coalescence of chylomicrons or release of free fatty acids. The virtual immediate signs and symptoms of FES experienced by the 2 victims in our cases of corn oil injection suggests that the pathophysiology of such direct oil embolism may differ from other forms of posttraumatic and nontraumatic FES. Interestingly, unlike recently described cases of silicone oil embolism1 and classic FES, none complained first of respiratory system impairment. Instead, the earliest symptoms of our victims of corn oil injection who required hospital admission were neurologic, with pulmonary damage recognized by laboratory tests and radiography. This observation, however, could have been simply the result of shunting through a patent foramen ovale, which is present in about 1/3 of individuals. In our fatal case, right to left shunting through the autopsy-confirmed patent foramen ovale would have been expected with increased pulmonary vascular resistance due to fat emboli. In our nonfatal case, neurologic symptoms immediately followed vomiting, which could have caused right to left shunting by episodically raising intrathoracic pressure, provided a patent foramen ovale was present.
The authors thank Detectives J. D. Davidson and J. David Luna, of the Monterey County Sheriff-Coroner's Office; Detective Martin Sanchez and Deputy District Attorney Steven Somers, of the Monterey County District Attorney's Office; and Mark E. Palinek, Senior Research Microscopist, Microtrace Scientific, Elgin, IL.
© 2009 Lippincott Williams & Wilkins, Inc.