In the ensuing months, she began to develop cicatricial ectropion of the right lower eyelid and mechanical ptosis of the right upper eyelid. Ten months after initial self-injection, staged surgical excision was initiated by an oculoplastic surgeon (I.V.) with the goal of debulking the periorbital region to correct the ectropion and mechanical ptosis. A transconjunctival approach was used to carefully excise the material while still maintaining the architecture of the lower eyelid. The ectropion was surgically corrected concurrently.
One month after excision, serial injections of 5-fluorouracil (5-FU) and triamcinolone acetonide 40 mg/mL were administered to the right lower eyelid and anterior orbit for 3 months. Fifteen weeks after the first surgery, a second surgery was performed to address residual medial right lower eyelid induration, right upper eyelid mechanical ptosis, and left orbital inflammation. During the postoperative period, serial monthly injections of 5-FU and triamcinolone acetonide were again performed beginning at the first postoperative month.
The surgical excisions resulted in notable improvement 3 months following excision (Figure 4). The patient noted improved ocular surface comfort with decreased foreign-body sensation and tearing. She also was pleased with the improved cosmetic outcome.
Figure 4. Clinical improvement of the plaques and swelling was noted 3 months following excision.
Crude substances such as paraffin, petroleum jelly, and lanolin were used for aesthetic purposes in the late 19th and early 20th centuries, initially with satisfying results; however, long-term adverse effects such as hardening of the skin, swelling, granuloma formation, ulceration, infections, and abscesses have discouraged its use by medical professionals today.5 Since paraffin is resistant to degradation and absorption, foreign-body reactions may occur upon injection. These reactions are characterized by replacement of normal subcutaneous tissue by cystic spaces of paraffin oil and/or calcification, similar to the appearance of Swiss cheese on histology and surrounded by various inflammatory cells and fibrous tissue.9,10
Clinically, there is an acute inflammatory phase followed by a latent phase of chronic granulomatous inflammation that can last for years.10 Our patient presented during the acute phase, with erythematous and edematous warm plaques around the eye mimicking an orbital infection.
The treatment of choice for paraffin granuloma is complete surgical excision to prevent recurrence.6,9 However, intralesional corticosteroids are preferred in the facial area, especially if complete removal is not possible.10 Intralesional corticosteroid injections inhibit fibroblast and macrophage activity as well as the deposition of collagen, leading to reduced pain and swelling in most cases.11 Additionally, combining antimitotic agents such as 5-FU with a corticosteroid might reduce the risk for cortisone skin atrophy.12 In our case, the patient did not respond to combined 5-FU with intralesional steroids and required oral corticosteroids while awaiting serial excisions.
Our case highlights several important points in the management of paraffin granuloma. First, the clinician must perform a thorough patient history, as surreptitious use of non–medical-grade fillers is more common than one might think.13 Second, the initial presentation of these patients can mimic an infectious process. Careful history, testing, and observation can aid in making the appropriate diagnosis. Finally, treatment of these patients is complex. The mainstays of therapy are systemic anti-inflammatory medications, time, and supportive care. In some cases, surgery may be required. When processes such as paraffin granulomas involve the periorbital region, particular care is required to avoid cicatricial lagophthalmos, ectropion, or retraction. Thoughtful surgical manipulation is required to avoid these complications, which indeed may occur even with the most appropriate interventions.