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Illegal Silicone Injections Create Unique Reconstructive Challenges in Transgender Patients

Murariu, Daniel M.D., M.P.H.; Holland, Michael C. B.S.; Gampper, Thomas J. M.D.; Campbell, Christopher A. M.D.

Plastic and Reconstructive Surgery: May 2015 - Volume 135 - Issue 5 - p 932e–933e
doi: 10.1097/PRS.0000000000001192

Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, Va.

Correspondence to Dr. Campbell, Department of Plastic and Maxillofacial Surgery, University of Virginia, P.O. Box 800376, Charlottesville, Va. 22908-0376

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“Pumping” is an illegal and potentially deadly practice of injecting liquid silicone directly into tissues for enhanced cosmesis. Often performed by unskilled individuals in unsanitary conditions, this practice is becoming increasingly popular within the transgender community to achieve more feminine features at a reduced cost.1 The cosmetic use of liquid silicone, often industrial grade, gained popularity after World War II, as initial studies showed it to be a quick, permanent solution that was biologically inert.2 Because it is easy to use and readily available, thousands of patients worldwide have undergone soft-tissue augmentation of the breasts, buttocks, thighs, and face with liquid silicone.

Complications reported with the use of liquid silicone range from local tissue reaction to pulmonary embolism and death.3 However, given favorable short-term aesthetic results, injection of industrial grade liquid silicone remains common, and the more frequent reporting of its misuse in the news compared with previous decades may suggest increasing abuse.2

We present the case of a 47-year-old, male-to-female transgender patient with painful hardening of the breasts after silicone injections over a 5-year period for breast feminization. Her breasts were rock hard, tender, and enlarged. The overlying skin was thin, adherent, hyperpigmented, and accompanied by peau d’orange (Fig. 1).

Fig. 1

Fig. 1

After discussing multiple options, the patient elected bilateral mastectomies with immediate autologous reconstruction. The right breast was reconstructed with a muscle-sparing 2 free transverse rectus abdominis musculocutaneous flap and the left breast with a deep inferior epigastric perforator flap. The postoperative course was uncomplicated and she was discharged on the sixth day. Pathologic examination demonstrated extensive fibrosis, chronic inflammation, and a foreign body giant cell reaction in the 2.48- and 2.46-kg specimens. Further surgery was performed at 5 months for scar revision and nipple-areola reconstruction, with favorable aesthetic results 11 months later (Fig. 2).

Fig. 2

Fig. 2

Pumping has been around for decades in countries outside the United States, but U.S. Food and Drug Administration approval exists for the use of liquid silicone only in treating retinal detachment. However, early clinical studies under U.S. Food and Drug Administration supervision by Edgerton and Wells demonstrated safe, consistent results when using low-volume injections for facial soft-tissue augmentation.4 Its use came with the caution of never injecting the breast, buttocks, or vascular spaces, or large quantities.

Misconceptions regarding the safety of injecting liquid silicone persist, and pumping remains a popular form of body modification. Plastic surgeons may need to use complex reconstructive options to provide a balance between reconstruction and aesthetics in patients who have created complicated surgical fields.

The caution against injecting liquid silicone is worth repeating, as devastating results continue to be seen. As civil and legislative rights of transgender individuals are increasing, the rate of those seeking medical treatment has grown at 14 percent per year in Europe.5 Reconstructive surgeons may see an increase in patients requiring complex reconstructions to correct the catastrophic consequences of poorly performed aesthetic surgery while maintaining the patient’s primary aesthetic goals. It is up to all health care providers to educate patients about the complications of these dangerous procedures and direct them to qualified providers.

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The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

Daniel Murariu, M.D., M.P.H.

Michael C. Holland, B.S.

Thomas J. Gampper, M.D.

Christopher A. Campbell, M.D.

Department of Plastic and Maxillofacial Surgery

University of Virginia

Charlottesville, Va.

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1. Hage JJ, Kanhai RC, Oen AL, van Diest PJ, Karim RB.. The devastating outcome of massive subcutaneous injection of highly viscous fluids in male-to-female transsexuals. Plast Reconstr Surg. 2001;107:734–741
2. Chasan PE.. The history of injectable silicone fluids for soft-tissue augmentation. Plast Reconstr Surg. 2007;120:2034–2050; discussion 2041
3. Narins RS, Beer K.. Liquid injectable silicone: A review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006;118(Suppl):77S–84S
4. Edgerton MT, Wells JH.. Indications for and pitfalls of soft tissue augmentation with liquid silicone. Plast Reconstr Surg. 1976;58:157–165
5. Reed B, Rodes S, Schofeild P, Wylie KGender Identity Research and Education Society. Gender variance in the UK: Prevalence, incidence, growth and geographic distribution. Available at:
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