CASE REPORT Year : 2022  |  Volume : 30  |  Issue : 2  |  Page : 50-52

A case of necrotizing fasciitis with unusual cause: Olive oil injection as filler on the thigh

Tugba Gun Koplay1, Gokce Yildiran2
1 Department of Plastic Reconstructive and Aesthetic Surgery, Konya City Hospital, Konya, Turkey
2 Hand Surgery, Konya City Hospital, Konya, Turkey

Date of Submission21-Oct-2021Date of Acceptance20-Dec-2021Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Tugba Gun Koplay
Department of Plastic Reconstructive and Aesthetic Surgery, Konya City Hospital, Konya
Turkey

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_58_21

Necrotizing fasciitis (NF) is a rare, rapidly progressive infection with high mortality rates. Foreign body is one of the most common etiologic factors for NF. Soft tissue fillers are foreign bodies which are used for a number of indications by clinicians and nonclinicians. Besides the products approved by the Food and Drug Administration many materials such as vegetable oils are used as fillers. Herein, we evaluated an unusual case with NF due to olive oil injection together with a cloud of literature.

Keywords: Complication, filler, necrotizing fasciitis, olive oil

How to cite this article:
Koplay TG, Yildiran G. A case of necrotizing fasciitis with unusual cause: Olive oil injection as filler on the thigh. Turk J Plast Surg 2022;30:50-2
  Background 

Necrotizing fasciitis (NF) is a rare, rapidly progressive infection with high mortality rates. Surgery, insect bite, infection, foreign body, burn, and trauma are the most common etiologic factors for NF.[1] Botulinum toxin injection, blepharoplasty, and liposuction are the cosmetic procedures that were reported to be related with NF.[2],[3],[4]

Fillers are foreign bodies for the body that are used commonly for many cosmetic indications. Besides hyaluronic acid, calcium hydroxyapatite, and poly-L-lactic acid that are approved by the Food and Drug Administration (FDA); sometimes patients are looking for other options they can manage to inject themselves.[5] The most common are vegetable oils such as soybean oil.

Herein, we will report an interesting case of olive oil self-injection subcutaneously as a filler for augmentation of the thigh and was admitted to the hospital with serious complaints after 3 days.

  Case Report 

A 53-year-old female patient with a history of diabetes mellitus was presented to the hospital with swelling, erythema, pain, and tenderness on her thighs. She was transmitted from another hospital because of intensive care unit requirement. Her general condition was quite bad with sepsis and hypotension. Detailed history revealed that she had many esthetic operations, including augmentation mastopexy, gluteal augmentation, body lift, genital esthetics, and lip filling. There were also silicone implants at medial part of the thigh. According to the anamnesis that was provided from her family she had injected olive oil as filler bilaterally to her thighs subcutaneously for 3 previous days. Then, she also injected analgesics to the same area to reduce pain.

In physical examination necrosis of 30 cm in diameter, accompanied by malodor and subcutaneous crepitations, was determined around the popliteal [Figure 1]. Preliminary diagnosis was defined as NF. Her clinic condition was stage three according to the Wong and Wang's scoring[6][Table 1]. Her LRINEC (Laboratory risk indicator for NF) score was eight[7][Table 2]. Her laboratory data regarding LRINEC score are shown in [Table 3].

Figure 1: Clinical appearance of necrotizing fasciitis with the involvement of thigh (a) and skin necrosis at popliteal area after olive oil injection (b)

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The patient was operated on urgently. Fascia was necrotic and tissue was edematous with afoul smelling. Subcutaneous tissue could be easily detached from the fascia very easily [Figure 2]. Extremity amputation was not approved by the family. Extensive debridement and fasciotomies were performed. All infected and devitalized tissues were resected. Neurovascular structures were preserved. Samples were taken for cultures and pathologic examination. Tissue was irrigated with saline and rifamycine. Hyperbaric oxygen treatment was advised postoperatively but could not be applied because of her general condition. Large spectrum antimicrobial therapy was started. Methicillin-resistant Staphylococcus was identified at cultures and antimicrobial therapy was re-created according to these results. NF was confirmed by histopathological evaluations.

Figure 2: Typical finding of necrotizing fasciitis with very easily separation of subcutaneous tissue from the fascia during operation

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The patient was followed up in the intensive care unit because she could not be extubated postoperatively. Aggressive fluid replacement and inotropic infusion were applied. Debridement was performed again within 48 h but her general condition could not recover and she was expired at 5th day.

  Discussion 

NF is a rapidly progressive infection that starts from the fascia and affects muscle, fascia, and skin. Mortality rates are still so high in this rare and serious infection, ranges from 20% to 60%.[8] In prognosis, the most important factors are early diagnosis and treatment. Pain is the most common symptom and LRINEC scores are helpful for diagnosis.[9] NF is a surgical emergency and requires immediate and aggressive debridement as a gold standard treatment method. Serial debridements are required for reducing infection and diminishing necrotic tissue. Significant risk factors were defined as hemorrhagic bullae, peripheral vascular disease, bacteremia, and LRINEC score higher than eight.[9] Furthermore, over 60 years old, hypotension, creatinine values greater than two, delayed treatment beyond 3 days were found as poor prognostic factors.[10] Wong identified that delayed surgery after 24 h is a predictor factor for mortality.[11] The most important prognostic factor in NF is early diagnosis and immediate aggressive debridement. Surgery time is very important for the survival.[1] Antimicrobial therapy should be re-planned according to the culture results after starting with broad-spectrum antibiotherapy. Additional debridements are generally required within 24–72 h.

Surgery, insect bite, infection, foreign body, burn, and trauma are the most common etiologic factors for NF.[1] Soft tissue fillers are the foreign bodies that are used with large indications including, atrophy or asymmetry, age-related soft tissue loss, and depressed scars.

Hyaluronic acid, calcium hydroxyapatite, and poly-L-lactic acid are the components that are approved by the FDA and all of them are biocompatible, biodegradable, and unlikely to move or migrate.[5] On the other hand, fat grafts can be used as an autologous, nontoxic, biocompatible, and cost-effective method. Glass balls, vegetable oils, lanolin, mineral oil, teflon, beeswax, cartilage, sponges, and paraffin are the materials that were used for augmentation.[12] Besides, the FDA has approved certain injectable dermal fillers for use in the face (e.g., to enhance lips, cheeks, and contouring of the jawline) and the back of the hand. Fillers are not used by only plastic surgeons but by other clinicians and non-clinicians. Recently, applying fillers looks like an easy procedure from the videos that are shown on the internet. Self-injection of products is an increasing problem because of internet videos and opportunity to obtain fillers easily. Furthermore, bodybuilders rejoice in mineral and vegetable oils with steroids to augment muscle size and stretch muscle fascia. Fat embolism-like syndrome was reported due to intramuscular mineral oil injection and hypercalcemia was reported due to intramuscular self-methacrylate and paraffin injections for cosmetic procedures.[13] Patients must be aware and educated about complications and increasing costs because of incorrect treatments.

In conclusion, self-injection injuries are rare in the literature, and their complications can be life-threatening such as NF. Olive oil is pretended as an innocent material. Therefore, patients can use innocent-looking materials such as olive oil as fillers. We are in the opinion that patients are inclined to these approaches because these materials are cheap, easily accessible, and the technique is thought to be easy in injection videos. Regardless of the source, awareness should be raised that the use of homemade fillers can threaten life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
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    10.Huang KF, Hung MH, Lin YS, Lu CL, Liu C, Chen CC, et al. Independent predictors of mortality for necrotizing fasciitis: A retrospective analysis in a single institution. J Trauma 2011;71:467-73.  
    11.Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: Clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am 2003;85:1454-60.  
    12.Turk E, Karagulle E, Koksal H, Togan T, Erinanc OH, Dogru O, et al. Bilateral breast necrosis due to local injection of fish oil. Breast J 2013;19:196-8.  
    13.Hjort M, Hoegberg LC, Almind M, Jansen T. Subacute fat-embolism-like syndrome following high-volume intramuscular and accidental intravascular injection of mineral oil. Clin Toxicol (Phila) 2015;53:230-2.  
    
  [Figure 1], [Figure 2]
 
 
  [Table 1], [Table 2], [Table 3]