|Ahead of print publication
Neelam Gupta1, Karishma Sarin1, Lav Behl1, Sanjeev Uppal2
1 Department of Pathology, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
2 Department of Plastic Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
|Date of Submission||25-Nov-2022|
|Date of Acceptance||09-Jan-2023|
|Date of Web Publication||10-Feb-2023|
Department of Pathology, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti - 173 229, Solan, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Use of dermal fillers has increased over the years. Various injectable implants are used for soft-tissue augmentation. Penile augmentation practice using dermal fillers is not prevalent in India. Its debilitating effect has been known and the development of chronic granulomatous reaction into a sclerosing lipogranuloma/paraffinoma might occur. Identification and differentiation of certain dermal fillers and their tissue reaction are possible by histopathological examination. We report an unusual case of sclerosing lipogranuloma/paraffinoma of the penis in a 36-year-old married Indian male, following self-administering multiple penile filler injections leading to penile deformity.
Keywords: Histopathology, penis, sclerosing lipogranuloma
| Introduction|| |
Variety of temporary and permanent dermal fillers have been used in soft-tissue augmentation., The practice of penile dermal filler injection is not prevalent in India but is commonly being practiced for many years in Southeast Asia, Korea, the Middle East, some Eastern European countries, and Indonesia.,,
Its adverse effects are classified according to their time of course, filler, and host factors. Sclerosing lipogranuloma, the name was pioneered by Smetana and Bernhard in 1950, is sclerosing chronic inflammatory reaction often leading to functional impairment., Histopathological examination (HPE) has proven out to be extremely helpful in the identification of these fillers as they yield specific changes.,,
| Case Report|| |
A 36-year-old married Indian male, working as a laborer in Malaysia, presented in our surgery outpatient department with a swelling and deformity of the penis for the past 2 years. He gave a history of self-injecting some oil (the nature of it was not known to him) into the penis to increase its girth, 2.5 years back. He was influenced by his friends and was assured that it has no side effects. After 5 months of injections, he gave a history of itching over the shaft leading to skin ulceration which was subsided with medications but was left with a permanent swelling and deformity of the penis.
He had no history of difficulty in micturition, painful erection, premature ejaculation, or weight loss. On general physical examination, the entire shaft appeared to be swollen and disfigured with sparing of glans, soft to firm in consistency with irregular margins. No redness, induration, or discharge was noticed [Figure 1]a. Magnetic resonance imaging was suggestive of diffuse circumferential enhancement of skin and subcutaneous thickening and edema of the penile shaft [Figure 1]b. On the basis of a detailed clinical examination, the patient was planned for surgical excision with split-skin grafting. The excised specimen was dipped in 10% neutral-buffered formalin and was sent for HPE.
|Figure 1: (a) Penile swelling, involving the entire shaft, (b) T1-weighted image showing hypointense soft-tissue growth over the penile shaft, (c) Grossly, multiple skin-covered gray white to gray brown soft-tissue masses, (d) Microscopic view showing epidermis lined tissue piece, dermis showing multiple scattered lipid vacuoles along with variably dilated cystic spaces (pseudocysts) and cholesterol crystals (H and E, ×40), Microscopically, (e) High power view of micrograph D (H and E, ×400), (f) Perivascular and perineural inflammatory cell infiltrate chiefly comprising of foamy histiocytes and lymphoplasmacytic infiltrate (H and E, ×400), (g) Multinucleated foreign body giant cells and at places surrounding the lipid vacuoles (H and E, ×400), (h) Subcutaneous tissue showing extensive areas of sclerosis giving a swiss cheese appearance (H and E, ×400)|
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Grossly, we received multiple skin-covered gray-yellow to gray-brown soft-tissue pieces, the largest measuring 7 cm × 3 cm × 1 cm. The rest of the smaller tissue bits altogether measure 5 cm × 2.5 cm × 0.7 cm. The overlying skin was unremarkable. The cut section was gray-yellow to gray-white, soft to firm in consistency [Figure 1]c. Microscopically, it showed keratinized stratified squamous epithelium showing spongiosis, increased melanin pigment, and vacuolar degeneration of the basal layer [Figure 1]d. Dermis showed diffuse hyalinization and multiple scattered lipid vacuoles along with variably dilated cystic spaces (pseudocysts) and cholesterol crystals surrounded by the foreign body type of multinucleated giant cells. Extensive perivascular and perineural inflammatory cell infiltrate, chiefly comprising foamy histiocytes and lymphoplasmacytic infiltrate was also seen [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h.
Special stains including, Masson trichrome stain (highlighted the intervening sclerotic fibers), Alcian blue stain (to rule out use of hyaluronic acid) were done. However, oil red O stain (to highlight the lipid vacuoles) could not be done as we received a formalin-dipped specimen. Keeping in view, the above clinical details and histopathological findings, a final diagnosis of sclerosing lipogranuloma/paraffinoma of the penis was made.
| Discussion|| |
Use of dermal fillers is quite frequent and an important part of cosmetic medicine. These have been extensively used in various soft-tissue augmentation. Widely accepted treatment for this is complete surgical resection of the lesion. Commonly used dermal fillers include mineral oil, petroleum jelly, beeswax, paraffin, silicone, hyaluronic acid, collagen, poly-L-lactic acid, and polymethyl methacrylate., They are categorized, according to their stability into resorbable (such as bovine collagen, hyaluronic acid, and poly-L-lactic acid) and permanent (such as silicone oil or gel, paraffin, and polymethyl methacrylate).
All fillers are considered foreign substances that may stimulate the immune system leading to varying degrees of tissue reactions. Some reports proposed that most complications are, however, caused by the technique of injection. The common technical errors leading to filler complications include improper volume (too much or too little), improper depth (superficial or deep), wrong location (unfavorable or incorrect anatomic location), and inappropriate material.,
Early complications develop within <2 weeks and include erythema, edema, and allergy. Late complications include chronic inflammation, allergic reactions, nodules/granulomas, hypertrophic scars, telangiectasia, and filler migration. Delayed complications are considered to be largely because of biofilm formation although this is still under debate. For the treatment, the responsible substance needs to be identified. The problem with the treatment of late and the delayed complications is commonly noted as the patients do not know, or are reluctant to disclose, which filler had been injected as was seen in our case.
Identification of dermal filler deposits in a tissue is important and few of them can be easily identified histopathologically like, collagen is paucicellular eosinophilic material and resembles native collagen. It might have an inflammatory reaction but is rarely granulomatous. Hyaluronic acid is amorphous basophilic material which might be present the histiocytes, but is rarely granulomatous., Special stain (Alcian blue) came out to be negative in the present case. Based upon the morphology, the possibility of the use of collagen and hyaluronic acid was ruled out.
Silicone is the common encountered substance in pathology and is commonly used in breast implants. Similar to paraffin, it imparts a swiss cheese appearance, with variably dilated cystic spaces (pseudocysts) and foamy histiocytes.,, Sclerosing lipogranuloma is a characteristic feature of paraffin injection. Typical morphology was noted in the present study with extensive tissue hyalinization. In addition, in contrast to silicone, paraffin typically creates larger pseudocysts and generally is associated with a more exuberant granulomatous reaction which was noticed in the present study.
The role of histologic assessment in immediate- or early-onset complications is usually limited, whereas in delayed- or late-onset complications, it is crucial. Granuloma formation is considered the most common late complication of dermal fillers. Other histologic responses that are usually observed are chronic inflammation, fibrosis, fat necrosis, and panniculitis.
| Conclusion|| |
Use of dermal fillers for soft-tissue augmentation is widely practiced and is mostly done by nonmedical professionals. Penile augmentation using dermal fillers is not prevalent in India. Its debilitating effect has been known and development of various complications might occur. Integrating the detailed clinical history along with the HPE (including the special stains), we report an unusual case of sclerosing lipogranuloma/paraffinoma of the penis, following subsequent use of dermal filler injections.
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Conflicts of interest
There are no conflicts of interest.
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