Complications of silicone injections: persistence, stigma, and treatment

By Howa Yeung, MD, MSc, FAAD
Jan. 18, 2023
Vol. 5, No. 3

Walking in with a cane and reporting his severe skin pain, a patient of mine recalled travelling with their friend to get buttock injections in a hotel room in another state over a decade ago.

The U.S. Food and Drug Administration issued warnings in 2017 and 2021 against the use of injectable silicone for large-scale facial and body contouring or enhancement — such as for the breasts and buttocks. Of note, silicone has never been approved by the FDA for any dermatologic indications. Stories of unlicensed silicone injectors with disastrous complications have been circulated in the news and within transgender communities.

Silicone injections have been disproportionately reported among transgender women: 3% have had silicone injections and 10% want them someday as reported in a large 2015 U.S. survey of transgender persons. (1) The prevalence of silicone injections is higher in urban settings, ranging from 10-16% in San Francisco and New York. (2-4) Notably, silicone injections are more commonly reported among transgender women facing structural barriers to access safer methods of feminization (e.g., prior use of non-prescribed hormones, lack of insurance coverage) and socioeconomic vulnerabilities (e.g., lower educational attainment, undocumented immigrant status, prior or current sex work). (3) Experiences of stigma and discrimination, internalized expectations to “pass” or be socially perceived as a woman, a desire to regain a sense of control of one’s body, and challenges in obtaining timely and affordable gender-affirming care have led some to seek silicone injections. (5) Silicone injections were often accessed via an informal social network and street-based economy that also provides access to gender-affirming hormones and services outside of medical establishments. (5)

Complications of silicone injections may occur immediately or may be delayed decades after silicone injections. In a cohort of 77 transgender women in France who reported prior large-volume silicone injections (ranging from 0.5L to 15L), all reported dermatologic complications, including subcutaneous or lymphatic migration, inflammation, edema, varicose veins, post-inflammatory pigmentary alteration, cutis laxa, and infections. (6) Cutaneous tuberculosis and atypical mycobacterial infections have been reported with silicone injections and must be ruled out. Systemically, acute pneumonitis, chronic silicone embolism, hypercalcemia, and death have resulted.

Touted for its permanent nature, silicone has been historically used by some dermatologists to treat HIV-associated facial lipoatrophy. In a multi-practice cohort of 164 patients who received silicone injections by dermatologists for severe HIV-associated facial lipoatrophy were followed for > 10 years, twelve (7%) cases demonstrated adverse effects including overcorrection, subcutaneous nodules, and temporary severe facial edema. Proponents of silicone injections have noted that smaller volume and microdroplet techniques reduce the risks of complications, while critics have noted the availability of newer FDA-approved treatments, such as poly-l-lactic acid, may obviate the risk of permanent complications of silicone injections.

For patients who experience silicone injection-related complications, surgical excision and reconstruction are definitive treatments, when feasible. However, unlike cases of silicone breast implant rupture, surgeries for liquid silicone injections may be challenging, often requiring multiple surgical procedures, given the larger extent of infiltration and migration. Many cases require careful consideration of medical comorbidities and post-surgical outcome expectations. Medical treatment options for granulomatous foreign body reactions to silicone are limited and are often based on the literature detailing the treatment of cutaneous sarcoidosis. Intralesional triamcinolone and 5-fluorouracil are often first-line treatments for small lesions, while most cases with widespread lesions require systemic therapy. Patients have been treated using hydroxychloroquine, doxycycline, minocycline, methotrexate, and anti-TNF⍺ biologics, with variable responses. (7) Fortunately, our patient case responded well to minocycline and hydroxychloroquine, with complete resolution of pain and need for cane use. In contrast, the patient’s friend, who was injected at the same time by the same injector, developed gluteal granulomas, chronic silicone embolism, silicone granuloma-related hypercalcemia, and heart failure.

As cautionary tales of silicone circulate, dermatologists have an opportunity to help patients manage their associated complications. Ultimately, expanding access to safe and effective gender-affirming dermatologic and surgical care are needed to curb future silicone injections and their complications.

Point to Remember: Large volume silicone injections are fraught with potential complications. The transgender community is particularly at risk because of a high prevalence of this procedure.

Our expert’s viewpoint

Erica Dommasch, MD, MPH, FAAD
Beth Israel Deaconess Medical Center
Assistant Professor, Dermatology, Harvard Medical School

The transgender population is well-known to be at increased risk of health disparities across multiple domains. These disparities range from an increased risk of mental and behavioral health issues, with 41% of transgender persons reporting a history of attempting suicide in one study compared with 1.6% in the general population, to physical health, including increased risk of HIV and other sexually transmitted infections among transgender women. (8-10) Although the reasons for these disparities are likely complex and multifactorial, transgender individuals face multiple challenges when interacting with the health care system that affect the quality of care they receive and almost certainly contribute to poor health outcomes.

The high prevalence of silicone injections and subsequent complications among transgender women as described in this article is an unfortunate example of this. When licensed medical care isn’t accessible due to a combination of social, financial, and discriminatory barriers, it’s no surprise that these individuals turn to alternatives to the medical system, even if illegal and/or unsafe. Many transgender individuals have experienced overt discrimination in the medical setting, with 28% of respondents in the National Transgender Discrimination Survey Report on Health and Health Care having reported being verbally harassed and 2% even physically attacked in a doctor’s office. (11) Transgender individuals often have difficulty finding licensed medical professionals who they can trust and who are well-trained in providing gender-affirming procedures, such as fillers for facial masculinization or feminization. FDA-approved fillers have historically not been covered by insurance for gender affirmation, and are likely cost-prohibitive for most patients, even for those with health insurance. With an estimated poverty rate of 29.4% amongst individuals who identified as transgender in the U.S., access to fillers at a physician’s office is simply out of reach for many. (12)

To improve outcomes for our transgender patients, dermatologists should be adequately trained in providing care for this population, starting in medical school and continuing through residency and beyond. We need more studies to help us better manage conditions commonly seen in these individuals, such as complications from silicone injections. And finally, gender-affirming procedures such as fillers and body-contouring should be reimbursed adequately by insurance companies to improve access to licensed care.

1. James SE, Herman J, Keisling M, Mottet L , Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality; 2016.

2. Radix AE, Lelutiu-Weinberger C , Gamarel KE. Satisfaction and Healthcare Utilization of Transgender and Gender Non-Conforming Individuals in NYC: A Community-Based Participatory Study. LGBT Health 2014;1:302-8.

3. Sergi FD , Wilson EC. Filler Use Among Trans Women: Correlates of Feminizing Subcutaneous Injections and Their Health Consequences. Transgend Health 2021;6:82-90.

4. Wilson E, Rapues J, Jin H , Raymond HF. The use and correlates of illicit silicone or "fillers" in a population-based sample of transwomen, San Francisco, 2013. J Sex Med 2014;11:1717-24.

5. Padilla MB, Rodriguez-Madera S, Ramos Pibernus AG, Varas-Diaz N , Neilands TB. The social context of hormone and silicone injection among Puerto Rican transwomen. Cult Health Sex 2018;20:574-90.

6. Bertin C, Abbas R, Andrieu V, Michard F, Rioux C, Descamps V et al. Illicit massive silicone injections always induce chronic and definitive silicone blood diffusion with dermatologic complications. Medicine (Baltimore) 2019;98:e14143.

7. Kassamali B, Kus KJB, Min MS, Villa-Ruiz C, Cobos GA, Merola JF et al. Characteristics and treatment of silicone granulomas: A retrospective multicenter cohort of 21 patients. JAAD Int 2021;3:111-4.

8. Climate Changes to Improve Health Care for Individuals Who are SGM, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators. Washington, DC: Association of American Medical Colleges; 2014.

9. Herman JL, Brown TN, Haas AP. Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey. 2019. https://escholarship.org/uc/item/1812g3hm.

10. Van Gerwen OT, Jani A, Long DM, Austin EL, Musgrove K, Muzny CA. Prevalence of Sexually Transmitted Infections and Human Immunodeficiency Virus in Transgender Persons: A Systematic Review. Transgender health. 2020;5(2):90-103.

11. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. 2011. https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf.

12. Badgett MVL, Choi SK, Wilson BDM. LGBT Poverty in the US: A study of differences between sexual orientation and gender identity groups. 2019. https://williamsinstitute.law.ucla.edu/wp-content/uploads/National-LGBT-Poverty-Oct-2019.pdf.

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