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The Devastating Outcome of MassiveSubcutaneous Injection of Highly ViscousFluids in Male-to-Female TranssexualsJ. Joris Hage, M.D., Ph.D., Robert C. J. Kanhai, M.D., Ayke L. Oen, M.D., Paul J. van Diest, M.D., Ph.D.,and Refaat B. Karim, M.D., Ph.D.Amsterdam, The Netherlands

Illicit subcutaneous injections of massive quantities ofhighly viscous fluids are still performed, often by unqual-ified persons. Fifteen male-to-female transsexuals con-sulted the authors regarding their devastating long-termoutcomes after the injection of up to 8 liters of allegedsilicone or mineral oil to feminize their bodies. After alatency period of up to 17 years, these injections led tocomplications ranging from scarring and deformity toinfections. These patients were treated conservatively forinflammation and infection or surgically by resection ofthe oil-infested areas. In view of the potential dangers,feminization by the injection of high-viscosity fluidsshould be soundly condemned. (Plast. Reconstr. Surg.107: 734, 2001.)

For more than 100 years, physicians and lay-men have been interested in the subcutaneousinjection of high-viscosity fluids for the resto-ration and improvement of body contour.1,2

Initially, paraffins (mineral oil) and Vaseline(petroleum jelly) were used; the resultant com-plications were predominately reported in thefirst half of the past century. Liquid siliconeinjections became popular after World War IIbecause early investigation indicated that sili-cone was well tolerated by the tissues and pro-voked little local and no systemic response.Although it became obvious that silicone wasnot as inert as initially anticipated, the subcu-taneous injection of preparations containingmineral oil or silicone oil remained popular asa cheap and fast alternative to conventionalplastic surgery in some subcultures.3 As such, itis offered to male-to-female transsexuals as aminor procedure to feminize the face, breasts,

buttocks, hips, or calves (Fig. 1).4–7 Rather thanthe small quantities used for the correction ofrhytides, many liters of fluids are injected fortotal body feminization. The apparent simplic-ity of this technique tends to disguise the majorcomplications that can follow such careless orimproper injections.8 We present our experi-ence with the devastating long-term outcomeof massive-volume subcutaneous injections inmale-to-female transsexuals of highly viscouspreparations alleged to contain mineral oil orsilicone oil. This documentation of the devas-tating sequelae of such injections serves to sup-port the prohibitions against it.

PATIENTS AND WORK-UP

From July of 1990 to November of 1999, 15male-to-female transsexuals consulted us re-garding their unfavorable outcomes from sub-cutaneous and intramuscular injections ofhighly viscous liquids. Thirteen of the patientswere of South American origin, and the re-maining two patients came from Israel andThailand, respectively. The average age at thetime of injection was 26 years (range, 17 to 33years), and 1.5 to 8 liters of fluid (mean, 4.5liters) had been injected. The location of theinjection varied, but most patients had under-gone an augmentation of the hips and buttocks(Table I). They presented on average 6 yearsafter the injection (range, 0.5 to 17 years). Thereasons for consultation varied from acute in-flammation or severe fibrosis of the injected

From the Departments of Plastic and Reconstructive Surgery at the Antoni van Leeuwenhoek Hospital, Academisch Ziekenhuis VrijeUniversiteit, and Slotervaartziekenhuis, and the Departments of Radiology and Pathology at the Academisch Ziekenhuis Vrije Universiteit.Received for publication March 9, 2000; revised May 16, 2000.

734

area (Figs. 2 and 3) to carcinophobia. Four-teen patients claimed to have been injectedwith “silicone oil,” and the remaining patientreported that “mineral oil” had been used. Innone of the cases was information availableabout formula, trademark, quality grade, orpurity of the injected fluids. One patient (caseM) had previously undergone liposuction ofthe hips and upper legs to try and reduce theoil load and subsequent deformity. One pa-tient (case L) had multiple excisions of granu-lomata in the breast, and another patient (caseJ) had undergone a bilateral mastectomy andbreast reconstruction by the transplantation oflatissimus dorsi myocutaneous flaps, skingrafts, and implants.

All patients were physically examined forproof of gravitative migration of the oil, andthe relevant parts of the body were photo-graphed. Magnetic resonance imaging (MRI)using conventional and silicone-specific se-quences was performed in 13 patients. Conven-tional T1-weighted MRI typically showed a widedistribution of silicone droplets and migrationof the silicone outside the original injectionlocation through the subcutaneous fat (Fig. 4).

Thickening of the overlying skin was seen in sixcases, and oil dispositions within the muscle inthree cases were discriminated on silicone-specific, fat, and water-suppressing MRI se-quences (Fig. 5).

The erythrocyte sedimentation rate, bloodcounts, and serum levels of g-glutamyltrans-ferase, SGOT, SGPT, and alkaline phosphatasewere obtained in nine patients. The erythro-cyte sedimentation rate ranged from 4 to 69mm in the first hour, but blood counts showedno increase of neutrophile granulocytes. Theliver function tests were normal, indicatingthat the injected fluids had not yet interferedwith liver function. Anti-nuclear factors, anti-nDNA (crithidia test), and anti-extractable nu-clear antigen were determined in the samecases as a possible indication of systemic soft-tissue disease.9,10 Anti-nuclear factors wereslightly or dubiously positive in three patientsand negative in six patients. Anti-nDNA andanti-extractable nuclear antigen tests were neg-ative in all nine patients.

Treatment

All these patients had injections to improvetheir body contour and, as a result, they poseddifficult therapeutic problems. They were con-cerned about their appearance, and the com-plications resulting from the injected foreignmaterial did not change their desire for femi-nization. Most patients did not understand theseverity of the problem and could not acceptthe mutilating disfigurement of inflammationor migrated silicone. All were informed of themutilating outcome of possible radical excisionof the scarred and oil-infested subcutaneoustissues and subsequent skin grafting of the un-derlying muscle. Despite detailed explana-tions, they expected to have a “good result”even after conservative or surgical treatment ofthe deformities.11

Cases A, B, and N were treated intravenouslywith prednisolone (25 mg daily for 1 week) andantibiotics (1200 mg of Augmentin three timesa day for 1 week, followed by 100 mg of clin-damycin once a day for 12 weeks) for inflam-mation and infection of the lower legs (TableI). Local excision of scar tissue infested with oilwas performed in cases C, D, E, and N. Ampu-tation of both mineral oil–infested breasts wasperformed in case L (Fig. 6).

The other patients chose to await furtherdeterioration of their situation and were kept

FIG. 1. Subcutaneous injection of high-viscosity fluids isoffered to male-to-female transsexuals as a minor procedureto feminize the face, breasts, buttocks, hips, or calves. A totalof 5 liters was injected in this patient (case C) to augment thehips, buttocks, and face (see Fig. 5).

Vol. 107, No. 3 / SUBCUTANEOUS OIL INJECTION IN TRANSSEXUALS 735

under observation in the outpatient clinic.Cases B and C found other plastic surgeonswilling to perform liposuction of the affectedareas. We were later informed that this was notpossible in case B and that total resection of

the affected subcutaneous tissues of the lowerleg needed to be performed subsequently.12

DISCUSSION

Injectable Silicone

The history of the various grades of siliconeoil and of their (mis-)use as injectables wasdescribed elegantly by McDowell13 and byDuffy.2 Besides its industrial, or electrical,grade 200 Silicone Fluid, Dow-Corning alsodeveloped a 350-centistoke Medical Grade 360Liquid Silicone to be used as a lubricant forneedles, syringes, and intravenous tubing. Itwas never intended or authorized for soft-tissueaugmentation and may induce hepatitis andpancytopenia.2 In 1965, the company pro-duced a highly purified and filtered 350-

FIG. 3. Breakdown of the skin of the right lower leg andfoot in case B as a result of infection of migrated oil andtreatment with intravenous corticosteroids and antibiotics.

TABLE ILocation and Quantity of Injected Oil and Age at the Time of Injection

CaseAge(y)

Quantity(liters) Location of Injection

Intervalbetween

Injection andPresentation

(y)Principal Reason for

Consultation Management

A 22 2 Hip, knee 3 Infection in legs Corticosteroids, antibioticsB 22 Unknown Hip, calf 3 Infection in leg Corticosteroids, antibioticsC 27 5 Hip, gluteus, face 6 Pain, deformity Local excisionD 17 5 Hip, gluteus, arm, leg, breast 6 Deformity of the feet Local excisionE 32 1.5 Hip, gluteus, face, hand 7 Infection in buttock Local excisionF 33 4 Gluteus, face 4 Swollen eyelids Ongoing observationG 27 8 Hip, gluteus, face, leg 4 Deformity of the nose Ongoing observationH 32 2.5 Hip, gluteus 0.5 Deformity of the feet Ongoing observationI 29 4 Hip, gluteus, arm 9 Deformity Ongoing observationJ 22 7.5 Hip, gluteus, face, breast 2 Infection legs Bilateral mastectomy*K 29 3 Hip, gluteus, leg 4 Inflammation Under observationL 20 Unknown Breast 17 Scarring Bilateral mastectomyM 29 2.5 Hip, breast 4 Carcinophobia Liposuction*N 23 4 Hip, gluteus, legs 8 Inflammation in leg Local excisionO 25 8 Hip, gluteus, leg, breast 7 Pain in buttock Ongoing observation

* Performed in another hospital.

FIG. 2. The gravitational migration of the silicone oil in-jected to augment the hips resulted in an inflammation of theleft lower leg, ankle, and foot in this patient (case N). She wasrepeatedly treated with intravenous corticosteroids andantibiotics.

736 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2001

centistoke silicone fluid (MDX 4-4011) to beused for the restricted clinical investigations ofsoft-tissue augmentation by injection super-vised by the U.S. Food and Drug Administra-tion. Although injectable silicone is no longergenerally available for use in humans, prepara-tions containing silicone of varying grades andpurities have found their way into the hands ofmany professional medical and nonprofes-sional personnel who continue to inject it intopatients for a variety of indications.14–16 Advo-

cates discuss the improvements in condition,the careful techniques used and, lastly andmost importantly, the absence of side effects.There is typically a comment in these articlesthat unfavorable side effects are due to “mate-rial of unknown purity,” “too much injectedmaterial,” and the “poorly trained physicians”injecting silicone.13,16

The widespread misunderstanding regard-ing the terminology of the purity or grade ofsilicone led Orentreich to coin the term “in-jectable-grade silicone” to designate a sterilesilicone fluid of 350-centistoke viscosity that isessentially of his own manufacture.2,17 Unfortu-nately, the introduction of yet another termhas further confused the terminology of alleg-edly injectable silicone oil. To confuse mattersmore, purified silicone fluids have been inten-tionally adulterated by adding tissue irritants inan attempt to provoke a stronger fibroblasticreaction and induce better encapsulation toprevent the migration of large volumes of sili-cone injected in one sitting. Adulterants varyfrom region to region and from country tocountry, but the best known is the Sakuraiformula.2 Some investigators maintain thatthese adulterants, rather than the silicone it-self, cause the granulomatous reactions andother complications after injection.17 The pa-tients are generally told that the injected fluidis silicone and, should any foreign-body reac-tions occur, they are attributed by the patient

FIG. 5. Silicone-specific, fat, and water–suppressing MRIof the hips of case C showed thickening of the overlying skinand oil deposits within the muscle (see Fig. 1).

FIG. 4. (Above) The coronal T1-weighted MRI of the in-jected hips of case D typically showed wide subcutaneousdistribution of silicone droplets and subsequent edema andfibrosis. (Below) Sagittal gradient-echo MRI of the ankle andfoot proved that the oil had migrated outside the originallocation of the injection and throughout the subcutaneous fat(see Fig. 8).


and physician to the silicone. Moreover, a vastnumber of materials, including mineral oil,linseed oil, flax oil, and fatty acids, are com-monly mislabeled as being silicone and areindiscriminately injected into the skin.2

According to Orentreich and Orentreich17

and Duffy,2 the satisfactory results obtainedwith injectable-grade material and proper (mi-crodroplet) techniques of injection must notbe confused with the untoward results andcomplications arising from the injection oflarge volumes of silicone. Edgerton and Wells8

recommended that the total volume injectedin any one patient not exceed 100 cc.8 The 25cc indicated by Duffy2 as “a large volume” con-trasts greatly with the average 4.5 liters injectedin the patients in this series. We are not awareof any report on patients in whom such vastquantities have been injected. Moreover,

rather than being treated by “poorly trainedphysicians,” at least six of our patients wereinjected by nonmedically trained peers.

Symptoms

Early or late complications of silicone in-jections are many, and they can be causeddirectly or by a suspected immunologicmechanism.3 Typically, there is a latency pe-riod of up to 24 years in duration duringwhich the patient is asymptomatic and with-out apparent lesions.14 –16,18 –20

The local complications of silicone andother injectable viscous liquids includechanges in skin color and/or texture, granulo-matous inflammation, skin sloughs, drainingsinuses, contractures, and deformities.21 Theterm siliconoma was popularized in 1965 tocharacterize a foreign body reaction similar tothat described after the injection of oil or par-affin.15 Because of the migration of silicone,8the region of potential siliconoma formationand ulceration is not restricted to the injectionsite; it extends to the abdominal wall and in-guinal region, the lower leg, and even the dor-sum of the foot.11,14,22

The noxious effects of free silicone injectedinto mammary tissue have been well docu-mented, but there is no evidence that siliconeis implicated in the origin of breast can-cer.20,21,23,24 Still, some claim that the injectionmethod is more often complicated by breastcarcinoma than is the implantation of a bagprosthesis, and Morgenstern et al.21 suggesteda possible enhancing effect of the free siliconeon tumor spread due to the abnormal openingof lymphatic channels in silicone mastopathy,the inhibition of tumor-induced desmoplasia,or some alteration in immune mechanisms as-sociated with silicone-induced granulomatosis.The changes in the breast tissue that can becaused by silicone injections make it difficult tointerpret clinical signs and mammograms, andso the possibility of an early diagnosis of breastcancer is reduced (Fig. 7).20 With little excep-tion, these patients’ prognoses have been dis-mal because of diagnostic delays.23

Regional lymphadenopathy, with or withoutinfiltration of adjacent soft tissue, and com-pression of surrounding organs have also beenrecognized as long-term complications of oilinjections.21 Acute and chronic respiratory im-pairment and clinical or subclinical signs ofvascular collagen disease have been describedas systemic complications. Injections can in-

FIG. 6. (Above) Case L presented 6 years after the injectionof the breasts with “mineral oil.” She had already undergonemultiple excisions of granulomata. A bilateral mastectomywas performed because an interpretation of clinical signs andmammograms indicated that an early diagnosis of breast can-cer was no longer possible. (Below) The surgical specimenshowed widespread, large, round-to-oval cystic spaces oftenlined by foreign body type giant cells, with extensive concen-tric fibrosis and calcifications. Between these empty spaces,many foam cells were present.


duce acute pneumonia, which is followed insome patients by respiratory failure.5 Thus far,two deaths have been reported as an acuteresult of silicone injections.4,25 The significanceof a possible association with autoimmune dis-ease or the so-called human adjuvant disease isstill not clear.9,21 Our limited immunologic in-vestigations suggest that there is no correlationwith systemic soft-tissue or rheumatoiddisorders.

Apart from the risks inherent to the injectedliquid, the method of injection may carry risks.A focus group of drag queens and female im-personators in Minneapolis/St. Paul, Minne-sota, reported that silicone is injected back-stage during drag competitions and that thesame needle is used on different individuals. InSao Paolo, Brazil, more than half of 52 siliconeusers were found to be HIV-positive, but only 5percent of nonusers tested positive.7

Treatment

Diverse medical and surgical interventionsare recommended to treat the complicationsof free silicone breast injections. They includeoral and intravenous antibiotics, diphenhydra-mine hydrochloride (Benadryl), systemic corti-costeroids, nonsteroidal anti-inflammatorydrugs, the application of towels soaked in warmwater, local resection, suction-assisted removal,and mastectomy.23 However, the removal of allinjected oil is surgically impossible, and thereare no therapies that have been shown to mod-

ify the effects of silicone in the skin or on theunderlying tissues.3,8,23 Ortiz-Monasterio andTrigos11 occasionally temporized surgical treat-ment by using steroid therapy to postpone mu-tilating surgery while keeping their patientsunder observation, especially in some of theiryounger patients or in those who had onlysubcutaneous nodules. They thought, however,that a surgeon cannot accept this responsibilityindefinitely and that excision had to be pro-posed sooner or later.

Parsons and Thering18 seem to be the first tosuccessfully treat a silicone-injected breast byaspirating a single large silicone cyst. Subse-quently, Grazer26 suggested liposuction for theremoval of areas injected with liquid silicone,but he did not indicate if he had used thetechnique for suctioning injected silicone.Zandi documented one patient in whom thesilicone infested tissue was removed by suc-tion19 but recently reported not having hadanother successful case.27 We thought simpledrainage would suffice in case D because theMRI was consistent with a single large siliconecyst; however, during surgery, we encountereda solid lump of silicone-infested fibrous tissue,the histology of which differed from the usualpresentation of leakage from silicone gel–filledbreast implants (Fig. 8).10 From the T2-weighted MRI made of case M after she hadundergone liposuction of the injected area atanother hospital, we conclude that liposuctionremoves the remaining healthy and nonin-fested subcutaneous fat rather than the in-jected liquid itself.

Recommendations

Although patients in general are pleasedwith the initial results of injection and do notseek medical attention for a considerable num-ber of years, they should be followed carefullybecause granulomas or infection may devel-op.18 Patients with large subcutaneous depositsof silicone should be warned that severe acuterespiratory failure may be induced by localtissue damage, and they should be advised toavoid all circumstances where trauma is a po-tential hazard.5 Yearly mammography, fol-low-up MRI for questionable mammograms,close patient observation, and early and aggres-sive surgical intervention are paramount in thetreatment of patients who have undergonebreast augmentation with high-viscosityfluids.24

When inflammation occurs, we found short-

FIG. 7. Proper screening for carcinoma by mammographyis no longer possible in case M because of the injection of ahighly viscous liquid that was alleged to be silicone oil.


term intravenous treatment with corticoste-roids and antibiotics (25 mg of prednisoloneonce daily and 1200 mg of Augmentin threetimes a day for 1 week) followed by long-termoral antibiotic therapy (100 mg of clindamycinonce a day for 12 weeks) prevented recurrence.However, infection or inflammation may recurafter even a minor injury.

Whenever possible, surgical treatmentshould be restricted to the local excision ofsymptomatic siliconomas,15 but subcutaneousmastectomy should be performed in patientsin whom induration and inflammation of thebreasts have become painful or have madeproper screening for carcinoma impossi-ble.11,18,20,28 Because of the risk of inducing in-fection in other siliconomas, surgery shouldonly be performed with antibiotic prophylaxis.Liposuction will not help to achieve any reduc-tion of the load of injected fluids because itcannot remove the fibrosed oil-infested tissues.Because of the mutilating outcome of the ex-cision of all oil-infested subcutaneous tissuesand the subsequent skin grafting of the under-lying muscle, such radical surgical treatmentshould be reserved for patients with wide-spread infections not responding to a medicalregimen.

CONCLUSIONS

Illicit subcutaneous injections of massivequantities of highly viscous liquids are still per-formed, often by unqualified persons. After alatency period of up to 24 years, these injec-tions lead to complications ranging from achange in skin color to death. Impurities in theinjected fluids may contribute to the devastat-ing outcome but, usually, no records regardingthe original treatment are available. There areno therapies to modify the effects of injectedhigh-viscosity fluids. In view of the potentialdangers, feminization by injection therapyshould be soundly condemned.

J. Joris Hage, M.D., Ph.D.Dept. of Plastic and Reconstructive SurgeryAntoni van Leeuwenhoek hospitalPlesmanlaan 121, NL-1066 CX AmsterdamThe [email protected]

REFERENCES

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2. Duffy, D. M. Silicone: A critical review. Adv. Dermatol. 5:93, 1990.

3. Allevato, M. A., Pastorale, E. P., Zamboni, M., Kerdel, F.,and Woscoff, A. Complications following industrialliquid silicone injection. Int. J. Dermatol. 35: 193, 1996.

FIG. 8. (Left) We thought that simple drainage would suffice in case D because the MRI wasconsistent with a single large silicone cyst (arrow); instead, we found a solid lump of oil-infestededematous and fibrous tissue during surgery (see Fig. 4). (Right) The surgical specimen showedthe breast stroma was filled almost completely with small empty spaces, with many foam cellsbetween them.


4. Ellenbogen, R., and Rubin, L. Injectable fluid siliconetherapy: Human morbidity and mortality. J.A.M.A.234: 308, 1975.

5. Chastre, J., Brun, P., Soler, P., et al. Acute and latentpneumonitis after subcutaneous injections of siliconein transsexual men. Am. Rev. Respir. Dis. 135: 236, 1987.

6. Varella, B., Tuason, L., Proffitt, M. R., Escaleira, N., Alqu-ezar, A., and Bukowski, R. M. HIV infection amongBrazilian transvestites in a prison population. Aids Pa-tient Care STDS 10: 299, 1996.

7. Bockting, W. O., Robinson, B. E., and Rosser,B. R. S. Transgender HIV prevention: a qualitativeneeds assessment. AIDS Care 10: 505, 1998.

8. Edgerton, M. T., and Wells, J. H. Indications for andpitfalls of soft tissue augmentation with liquid silicone.Plast. Reconstr. Surg. 58: 157, 1976.

9. Sergott, T. J., Limoli, J. P., Baldwin, C. M., Jr., and Laub,D. R. Human adjuvant disease, possible autoim-mune disease after silicone implantation: A review ofthe literature, case studies, and speculation for thefuture. Plast. Reconstr. Surg. 78: 104, 1986.

10. van Diest, P. J., Beekman, W. H., and Hage, J. J. Pa-thology of silicone leakage from breast implants.J. Clin. Pathol. 51: 493, 1998.

11. Ortiz-Monasterio, F., and Trigos, I. Management of pa-tients with complications from injections of foreignmaterials into the breasts. Plast. Reconstr. Surg. 50: 42,1972.

12. Hofer, S. O. P., Damen, A., and Nicolai, J. P. A. Liquidsilicone injection in the hips. Eur. J. Plast. Surg. (inpress).

13. McDowell, F. Complications with silicones: What gradeof silicone? How do we know it was silicone? (Edito-rial). Plast. Reconstr. Surg. 61: 892, 1978.

14. Granick, M. S., Solomon, M. P., Mosely, L. H., andMcGrath, M. H. Devastating granulomata of thelower extremities resulting from cosmetic injection ofadulterated liquid silicone. Plast. Reconstr. Surg. 94:536, 1994.

15. Wassermann, R. J., and Greenwald, D. P. Debilitatingsilicone granuloma of the penis and scrotum. Ann.Plast. Surg. 35: 505, 1995.

16. Rapaport, M. J., Vinnik, C., and Zarem, H. Injectable

silicone: cause of facial nodules, cellulitis, ulceration,and migration. Aesthetic Plast. Surg. 20: 267, 1996.

17. Orentreich, D. S., and Orentreich, N. Leg ulcers fol-lowing subcutaneous injection of a liquid siliconepreparation. Arch. Dermatol. 125: 1283, 1989.

18. Parsons, R. W., and Thering, H. R. Management of thesilicone-injected breast. Plast. Reconstr. Surg. 60: 534,1977.

19. Zandi, I. Use of suction to treat soft tissue injected withliquid silicone. Plast. Reconstr. Surg. 76: 307, 1985.

20. Chen, T.-H. Silicone injection granulomas of thebreast: Treatment by subcutaneous mastectomy andimmediate subpectoral breast implant. Br. J. Plast.Surg. 48: 71, 1995.

21. Morgenstern, L., Gleischman, S. H., Michel, S. L., Rosen-berg, J. E., Knight, I., and Goodman, D. Relation offree silicone to human breast carcinoma. Arch. Surg.120: 573, 1985.

22. Rae, V., Pardo, R. J., Blackwelder, P. L., and Falanga,V. Leg ulcers following subcutaneous injection of aliquid silicone preparation. Arch. Dermatol. 125: 670,1989.

23. Ko, C., Ahn, C. Y., and Markowitz, B. L. Injected liquidsilicone, chronic mastitis, and undetected breast can-cer. Ann. Plast. Surg. 34: 176, 1995.

24. Talmor, M., Rothaus, K. O., Shannahan, E., Cortese, A. F.,and Hoffman, L. A. Squamous cell carcinoma of thebreast after augmentation with liquid silicone injec-tion. Ann. Plast. Surg. 34: 619, 1995.

25. Rollins, C. E., Reiber, G., Guinee, D. G., Jr., and Lie,J. T. Disseminated lipogranulomas and suddendeath from self-administered mineral oil injection.Am. J. Forensic Med. Pathol. 18: 100, 1997.

26. Grazer, F. M. Suction-assisted lipectomy, suction lipec-tomy, lipolysis, and lipexeresis (Discussion). Plast. Re-constr. Surg. 72: 620, 1983.

27. Zandi, I. Failure to remove soft tissue injected with liq-uid silicone with use of suction and honesty in scien-tific medical reports. Plast. Reconstr. Surg. 105: 1555,2000.

28. Wustrack, K. O., and Zarem, H. A. Surgical manage-ment of silicone mastitis. Plast. Reconstr. Surg. 63: 224,1979.


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