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Introduction

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References

Paraffinoma is a granulomatous foreign body reaction that results from the injection of oily substances containing long-chain acyclic hydrocarbons.[1] Paraffin or mineral oil injections are used for tissue augmentation, elimination of wrinkles, and treatment of male pattern baldness. Paraffinoma has a distinctive histopathological pattern that demonstrates the substitution of normal subcutaneous tissue by cystic spaces of different sizes.[2] The most definitive treatment for paraffinoma is surgical excision but, in cases with severe adhesion, successful excision is very difficult.

Radiofrequency represents the most recent skin-rejuvenation technique in the field of esthetic medicine and has allowed patients to reduce flaccidity, wrinkles, and skin aging by generating thermal effects at the treated site.[3] We present a case of facial paraffinoma that was unresponsive to conservative treatment but successfully treated with radiofre-quency therapy. After three treatment sessions, the lesions had almost cleared, and the patient was satisfied with the results.

Case report

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References

A 61-year-old woman visited our clinic with a 1-month history of an asymptomatic violaceous, indurated plaque on the left cheek, which had been increasing gradually in size (Fig. 1a). She had received cosmetic paraffin injections to both cheeks three years prior to visiting our clinic.

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Figure 1. Photographs of the patient's left cheek with paraffinoma (a) before treatment and (b) 3 months after the final treatment with the bipolar radiofrequency therapy system

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Laboratory investigations, including complete blood count, electrolytes, liver function test, and urinalysis, were within normal limits. Histopathological examination revealed dense inflammatory infiltrates involving the entire dermis and non-caseating epithelioid granulomas. Round or ovoid-shaped clear vacuoles of various sizes were scattered in the dermis (Fig. 2). A diagnosis of paraffinoma was made, and she received systemic and intralesional corticosteroid therapy. Unfortunately, the lesion was refractory to these treatments. Because the patient did not want surgical excision and post-surgical scars, we decided to treat the lesion with a less invasive modality after obtaining the patient's informed consent.

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Figure 2. (a) Skin biopsies of the left cheek showed dense inflammatory infiltrates involving the entire dermis and destruction of subcutaneous fat tissue. Round or ovoid clear cavities scattered in the dermis and subcutaneous layer. (b) High-magnification view showing many variably sized clear vacuoles. Hematoxylin and eosin, original magnification (a) ×40; (b) ×100

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We treated the indurated lesion with a bipolar radiofrequency device (INNOFill; PACIFIC PHARMA, Seoul, Korea). The system consists of a main body part, disposable needle-electrode with luer lock syringe, and foot switch (Fig. 3). It generates bipolar electric waves, emitting either a 1 or 2 MHz sine wave. It has maximum output power equal to 20 W. Treatment was performed under local anesthesia using 2% lidocaine hydrochloride solution (Jeil Pharmaceutical, Daegu, Korea). We inserted the needle-electrode through a tiny puncture in the mandibular angle and penetrated along the indurated skin lesion. We used a frequency of 1 MHz, power of 20 W and 21-gage electrode size. Bipolar radiofrequency was emitted through the needle electrode, and treatment duration was 1 min/session. Then, after radiofrequency treatment, we gently massaged the treated area for three minutes. A total of three treatments were performed at 4-week intervals, and the patient was followed up for one year. Excellent post-treatment outcomes were observed (Fig. 1b), which have been sustained for one year.

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Figure 3. Main body of bipolar radiofrequency therapy system (a), disposable needle-electrode with hand piece (b), and foot switch (c).

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Discussion

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References

Subcutaneous injection of liquid paraffin for cosmetic purposes was first practiced in the 20th century. Eckstein replaced liquid viscous paraffin with melted solid paraffin, which has a higher melting point and thus is not prone to changing shape with changing body temperature when used to create a facial prosthesis.[4] Unfortunately, even with initial good results, secondary or late severe complications may appear due to the dispersion of paraffin. Foreign body granulomas, a delayed complication of paraffin injections, are also known as “paraffinomas”, “lipogranulomas”, or “sclerosing lipogranulomas” according to their etiology. These are distinguished from other granulomatous reactions that have similar histological appearances but do not result from foreign materials.[5] Characteristically, complications appear a few years after injection, with severe symptoms and clinical signs. Complete surgical excision is still considered to be the most definitive treatment for paraffinomas,[6] but the treatment of choice for the facial area is intralesional administration of corticosteroids.[7] Glucocorticoids, both intralesional and oral, are often used because of their immunosuppressant and anti-inflammatory properties.

Radiofrequency is one of the most innovative recent dermatological techniques for rejuvenating the skin.[8] It produces an electrical current that generates heat due to the resistance of components of the dermis and subcutaneous tissues.[9] Radiofrequency treatment creates thermal coagulation zones, known as radiofrequency thermal zones, in the dermis or subcutaneous layer.[10]

There are two major therapeutic mechanisms of radiofrequency in the treatment of paraffinoma. First, radiofrequency may induce a wound-healing response that activates dermal remodeling and replacement of radiofrequency thermal zones with new collagen and elastin. Second, heat generated by radiofrequency may cause aggregated paraffin substances to melt, allowing horizontal dispersal of paraffin droplets by manual manipulation after radiofrequency therapy.

To the best of our knowledge, this is the first reported case of facial paraffinoma successfully treated using a bipolar radiofrequency device. By sharing our experience, we propose that radiofrequency is an effective and safe modality of treatment for paraffinoma. Controlled studies with larger numbers of patients are needed to confirm the effects of radiofrequency for paraffinoma.

References

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References
  • 1
    Lever WF, Elder DE. Foreign-body reactions. In: Elder DE, Murphy GF, Johnson, Jr. BL, Xu X, ed. Histopathology of the Skin, 10th edn. Philadelphia, PA: Lippincott, 2009: 373374.
  • 2
    Oertel YC, Johnson FB. Sclerosing lipogranuloma of male genitalia. Review of 23 cases. Arch Pathol Lab Med 1977; 101: 321326.
  • 3
    Hsu TS, Kaminer MS. The use of nonablative radiofrequency technology to tighten the lower face and neck. Semin Cutan Med Surg 2003; 22: 115123.
  • 4
    Glicenstein J. The first “fillers”, vaseline and paraffin. From miracle to disaster. Ann Chir Plast Esthet 2007; 52: 157161.
  • 5
    Al-Khalil N, Panchev P, Tsvetkov M, et al. A case of penis self-injection of liquid paraffin-operative treatment and results. Khirurgiia 2004; 60: 6566.
  • 6
    Mounios-Perchenet AS, Le FB, Hepner-Lavergne D, et al. Paraffinomas: history, clinical features and treatment. A case report. Ann Chir Plast Esthet 1997; 42: 2730.
  • 7
    Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with artecoll: 10-year history, indications, techniques, and complications. Dermatol Surg 2003; 29: 573587.
  • 8
    Sarradet MD, Hussain M, Goldberg DJ. Electrosurgical resurfacing: a clinical, histologic, and electron microscopic evaluation. Lasers Surg Med 2003; 32: 111114.
  • 9
    Sadick NS. Update on non-ablative light therapy for rejuvenation: a review. Lasers Surg Med 2003; 32: 120128.
  • 10
    Hantash BM, Ubeid AA, Chang H, et al. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Lasers Surg Med 2009; 41: 8795.