Black Market Butt Lifts Episode 4
Want to know about the dangers of black-market butt lifts? How they can kill you? What hardware stores and hotel rooms have to do with healthcare? Or in this case, shouldn’t have to do with healthcare? Listen for more!
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patients survive this podcast? It’s up to you and the choices you make.
Want to know about the dangers of black-market butt lifts? What hardware stores and hotel rooms have to do with healthcare? Or in this case, shouldn’t have to do with healthcare? Then stay tuned.
Today’s episode starts in the resuscitation room of the emergency department. You and your team are gathered, gowned and gloved in the resuscitation bay. EMS rolls in with a middle-aged patient. One of the medics says, “Lady found down in a hotel room, unresponsive and hypoxic.” Meaning she was found unconscious with a low oxygen saturation.
With one ear, you listen to the rest of their report, while doing a quick assessment of the patient. Bottom line, the medics don’t have any other useful information about what happened. The patient is completely unresponsive, including to pain, not flinching as the nurses place IVs in both arms. Her chest wall is barely moving, indicating a weak respiratory effort. Her oxygen saturation is 80%, dangerously low.
You start at the beginning, where every doctor is taught to start in training, with the ABCs. Airway. Breathing. Circulation. Her airway and breathing are not intact. Not adequate to keep her alive. This means we stop the assessment here and intervene immediately.
The treatment for this is oxygen, a breathing tube, and a ventilator. You slide an endotracheal tube down the back of her throat and through her vocal cords. The respiratory therapist hooks her up to the ventilator. Now, on 100% oxygen, her oxygen saturation is 98%. Her pulse is on the high side at 110 bpm. Her blood pressure is 85/42. Low. The nurse hangs IV fluids to help the blood pressure while you do a physical exam. It’s unremarkable, no other abnormalities.
Once all the lines and tubes are secured, several nurses help you roll the patient on her side, carefully, to prevent dislodging the breathing tube. Checking the back is important in trauma situations, to check for gunshot wounds or injuries you might’ve missed from the front. It’s part of a complete physical exam.
In medical patients, it’s rare to discover anything useful. As expected, the back of her head and torso are unremarkable and you’re about to roll her back, when you notice an oily substance on her buttocks. It seems odd, but not of critical importance right now while you’re trying to stabilize her.
You order bloodwork and a chest x-ray. The blood work is normal.
The x-ray shows atypical patchy infiltrates. Basically, patchy spots in the lungs. Atypical because it could be caused by a number of different problems. Pneumonia is one, Covid infection is a definite cause of atypical pneumonia, but her Covid swab is negative.
Does this patient have pneumonia? It’s is a cause of respiratory failure, yes. Disease severe enough to need a ventilator, though, is more likely in the elderly, those with significant lung problems, immunosuppression, or others with severe comorbidities. It doesn’t cause sudden collapse in a healthy person. We don’t know anything about this woman’s past medical history but she appears to be in reasonably good health. Ordering antibiotics is a good idea, just in case, but something doesn’t seem quite right.
What about other causes of respiratory failure? Tons of things cause it many of which you’ve heard of Asthma and bronchitis. She isn’t wheezing, so these are ruled out. Pulmonary edema is fluid buildup in the lungs, commonly seen with congestive heart failure. A definite and common cause of respiratory failure, but we’d see it on the x-ray.
There is a medical problem we encounter frequently in the ER causing respiratory failure and sudden collapse. It’s a pulmonary embolus—blood clots in the lungs. The blood clot interferes with the circulation of oxygenated blood. It causes chest pain, shortness of breath, syncope or fainting in medical terms, hypoxia, and sudden death. You can’t see it on x-ray because the blood clot is a similar density to lung and other soft tissues in the chest. CT is the best modality for diagnosis, so you order a scan. Prothrombotic agents, ie pro-clotting agents, can obviously cause clots, otherwise, not a ton of poisons cause pulmonary embolus. While waiting for the CT scan, you call the critical care team to get her admitted to the ICU.
This is a toxicology podcast so what are the toxic causes of respiratory failure? The answer here is also, a lot of things. Pneumonitis, inflammation in the lungs, is caused by exposure to many different poisons, including toxic gases and occupational hazards. It’s pretty unlikely either of these occurred in a hotel room, otherwise the whole hotel would be sick. Combining cleaning fluids can cause lung irritation and toxicity. It’s possible the patient was cleaning the hotel room, though she isn’t wearing a uniform and EMS would’ve mentioned if she was an employee. So again, seems unlikely.
The nurse tells you the patient’s daughter is waiting in the family room. The younger woman is sitting on a hard plastic chair, crying. She’s so distraught she’s barely able to speak. She tells you her mother has no medical problems and that she was perfectly fine until a few moments prior to arrival. The patient said she couldn’t breathe, then collapsed. The daughter says they are visiting from out of town and staying together in the hotel room where EMS picked her up.
The patient keeps asking to see her mother and it’s clear she can’t give us much more information right now. You bring her to the patient’s bedside. She clutches her mother’s hand and cries even harder at the sight of all the tubes and monitors.
You give the daughter a few minutes in the hopes she’ll collect herself so you can ask her more questions about what happened. While waiting, an oily yellow stain spreads across the sheet underneath the patient. It isn’t urine, and it isn’t stool. The nurse gets clean sheets to change the bed.
After a few minutes the daughter stops sobbing for long enough to ask, “Is that the silicone leaking out? She just got the butt lift. Can you put her on her stomach so it doesn’t all come out?”
Question number 1. True or false. Silicone can cause respiratory failure.
Answer: True.
It’s hard to believe that injecting something into the buttocks could cause respiratory failure, but it can. Back to this in a minute.
As soon as she asks, we have a valuable clue to the diagnosis. You question the daughter more closely, confirming your suspicion. The mother and daughter arrived at the hotel yesterday and are here for silicone injections. A friend recommended the “nurse” after getting a cosmetic procedure herself. Both the mother and the daughter got injections today.
You ask for more details. The daughter’s reluctance to share more information confirms your suspicion it was an unlicensed procedure. Eventually she says the procedure wasn’t done in an operating room or even a doctor’s office. It was done on a massage table in a hotel room. One floor below the room they are staying in. Pretty much a guarantee it wasn’t done by a medical practitioner, not a real nurse or at least not a licensed one. The odds the substance was medical grade silicone? Low.
You pull up the patient’s chest CT images. The lungs are filled with clumps and spots of white. Lungs are supposed to be black on imaging, filled with air, if they’re working properly. The diagnosis? Silicone embolism syndrome. A life-threatening complication of liquid silicone injection.
First, let’s discuss cosmetic injections in general. In modern medicine, they started in the 1800s, since that time, all sorts of different substances have been used as fillers. Paraffin was tried first, then things like mineral oil and beef collagen—from cows. Fat has been transplanted, removed from one part of the body and injected in another for reconstructive purposes. Silicone yielded desirable results and was initially thought to be inert. After extensive complications were noted by doctors, it’s fallen out of favor in medicine.
Unfortunately, it’s still often used in illicit circumstances. No procedure is without complications even so called minor procedures performed in the best medical facilities by the best physicians. So why would anyone take the risk of injections with an unlicensed practitioner in a hotel room or a basement?
Cost is a common reason. You don’t need me to tell you plastic surgery is expensive and unaffordable for many. In addition, some patients seeking care feel ostracized by the medical establishment, preferring to obtain care from within their own community where they don’t fear judgment. And friends or family may recommend procedures after obtaining desirable results, at least in the short term, themselves.
These illegal operations are called “pumping parties” and the person injecting, the “pumper.” Recommendations are spread by word of mouth. It’s not uncommon for clients to fly in from out-of-state, or even from other countries, in the hopes of improving their appearance.
The risks of silicone? Some aren’t hard to guess. Hotel rooms and basements aren’t sterile, so infection is an obvious concern. The silicone can leak out afterwards. Pumpers might seal the leaks with Crazy Glue. It’s not surprising that infection and sepsis are reported after this.
While infection might not be an unpredictable side effect, I doubt that most participants are aware of the potential for life-threatening complications and long-term consequences.
Plastic surgeons rarely use liquid silicone these days given its myriad of complications. Those who do recommend micro doses only. When silicone is encapsulated, like in breast implants, complications occur only if the implant leaks. Leaks are the reason saline implants are safer and currently recommended. Nevertheless, if the silicone implant remains intact, the body isn’t directly exposed to the material inside.
There’s a big difference between medical grade and non-medical grade silicone. Initially, medical grade silicone was thought to be inert, as I said earlier, not reacting inside the body. We know now, this isn’t the case. Patients with breast implant rupture, for example, can have complications. However, nonmedical grade silicone is far more reactive, meaning it causes inflammatory responses in the body.
Before I talk about this in more detail, let me ask Question number 2.
What substance(s) have people injected or been injected with in pursuit of an improved appearance?
A. Olive oil
B. Petroleum jelly (brand-name Vaseline)
C. Paraffin wax
D. Transmission fluid
E. All of the above
Answer E. all of the above.
What is nonmedical grade silicone? Good question. At pumping parties, it’s anybody’s guess. Silicone is a synthetic material also called siloxane. It’s used as a lubricant, a sealant, and adhesive. It’s found in things like rubber cooking utensils, toys, brake fluid and caulk.
Non medial grade means it might be purchased from a hardware store or online. Bathroom caulk is one example. Yes, you heard that right. Things like bathroom caulk and transmission fluid have been injected into unsuspecting clients. It might be cut with baby oil or Crisco. Or it might not be silicone at all. All of the substances in question two have been injected as fillers.
What body parts are injected?
All of them as far as I can tell. It’s injected into places where people want the appearance of more curves, more muscles, and more girth. The butt and breasts are very common locations. It can be injected into the face and lips. Bodybuilders inject oil into their arms to improve the appearance of their biceps. It can be injected into the penis and vagina. A man died after injecting silicone into his scrotum to give the appearance of enlarged testicles.
Some of the issues are related to volume. Massive quantities of fillers may be injected into a person as many as 1 to 2 L for example, could be injected into the buttocks. A Russian bodybuilder reportedly injected three liters of oil into each arm. Each arm. Medically approved injectables carry warnings from the FDA that they are meant to be injected only in small quantities, like areas of the face. Large volumes of these approved fillers are still considered dangerous.
Illegal fillers are far more common than most people think. Even celebrities have gotten them. That brings us to today’s Pop Culture Consult.
Question 3. Which celebrity had black market butt injections?
A. Kim Kardashian
B. Jennifer Lopez
C. Cardi B
D. All of the above.
Answer. C. Cardi B admitted to getting injections in a basement, reporting “It was the craziest pain ever.” She’s since had them removed.
What exactly are the complications of liquid silicone injections? And what’s the connection between injecting something like caulk into your butt and possible respiratory failure and death?
Silicone causes immediate, intermediate, and delayed symptoms. Delayed, like twenty-five years later. The symptoms can be local, like infection, or systemic. Some, again like infection, can be treated. Unfortunately, many are permanent.
Let’s start with the immediate complications, like those experienced by our patient. Silicone embolism syndrome is life-threatening disease with an estimated mortality rate of 24-33%. Embolization means the silicone moves into the lungs. Lung biopsies and other tests clearly show silicone material in pulmonary cells, despite the fact it hasn’t been injected inside the chest cavity. How does the material go from the butt to the lungs?
One way is via intravascular injection. If the silicone is injected directly into an artery or vein, it can be carried into the lungs. Even if the injection is in the soft tissue, like fat, it can still travel. The body treats silicone as a foreign material and attempts to break it down. This results in inflammation. Local inflammation can result in exposure to the circulation as well.
Some patients with silicone embolus syndrome do recover after treatment with various modalities including oxygen, steroids, ventilators and ECMO. We briefly discussed ECMO in episode two, it’s essentially cardiopulmonary bypass trying to do the work of the heart and lungs when those organs aren’t functioning.
However, there is no antidote for silicone. Patients have died immediately after the procedure, before leaving the unauthorized location. Others died from long-term complications of respiratory failure, like one woman who died after being in the ICU and on a ventilator for a month.
Once the silicone gets into the lungs, different reactions can occur separately, or simultaneously. Pneumonitis, as I said earlier is inflammation of the lungs. ARDS, acute respiratory distress syndrome, is when fluid builds up in the lung sacs instead of air, leading to reduced oxygenation. Alveolar hemorrhage is bleeding into the sacs.
Neurological sequela like strokes and microhemorrhages are also possible. As high as the mortality rate is with pulmonary complications, the report of fatalities from neurological complications is as high as 100%. Hepatitis, liver inflammation, is reported. Like the lung, silicone is found inside the liver cells.
The local complications can occur days to years following injection. As I said earlier, the body reacts to foreign substances with inflammation. It will try to expel it. (Think of glass inside a wound, the body will eventually push it out). With a large volume of silicone, this can lead to gruesome, nonhealing wounds.
The activated immune system will attempt to wall off from the rest of the body what it can’t expel. Patients develop hard nodules in areas in and around the injection sites. Some of the hard tissue is scar tissue, others are granulomas, clumps of immune cells. They can be painful and many press on important adjacent structures. They can also be very disfiguring, especially on the face.
Unlike encapsulated silicone, like a breast implant, liquid silicone is subject to gravity and can migrate. Patients who had silicone injections into their buttocks note migration all the way down their legs with lumps of silicone ending up around their ankles. Again, the movement can cause chronic pain and an undesired appearance with random chunks and nodules in random locations.
Patients also report they can feel the silicone hardening in the winter, like rocks in their face, for example. In the heat, it softens and patients have said they feel like their face is melting.
Some of these chronic effects can be treated surgically. One illustrative case reported in the literature occurred after paraffin injection into the penis thirty-five years prior. After injection the man reported sexual dysfunction due to an irregular shape. Eventually he presented for medical care due to difficulty urinating. Evaluation revealed hardened paraffin and a large granuloma obstructing his urethra. After surgical resection, he was able to urinate and his sexual problems resolved.
However, in many cases surgery is prohibitively expensive or not an option. Surgical reconstruction or removal is typically paid out of pocket. Operative removal may not be effective or may be too dangerous. Over time, the silicone hardens, adhering to surrounding structures, including muscle and blood vessels. To remove it, significant portions of muscle, leading to loss of function could occur. If blood vessels are involved, intraoperative hemorrhage could be life-threatening.
Once again, lets get back to our patient. She requires ventilator support for two weeks. As her lungs heal, she’s gradually weaned and makes it off the vent. She wakes up and gives information about the “nurse” to the police.
Today’s episode didn’t contain many wrong choices for you to make in this patient’s care. She could easily have died from the disease. There are few wrong medical choices, however, because treatment options are limited. The main goal here is supportive care, securing her airway and keeping her on the ventilator. This is a problem we toxicologists are used to dealing with. Unfortunately. In contrast to cardiology or oncology for example, toxicologists have very little research to guide us in patient management in the case of many poisons.
Why? Several reasons.
First we can’t conduct large randomized controlled trials, the gold standards of research in medical care. It’s simply not ethical to poison half the patients in a study to see which treatment is better. Second, many types of poisonings are uncommon, so it’s difficult to gather large amounts of data to arrive at statistically significant conclusions. As such, we do the best we can for patients with the limited data we have.
This case is fictional as are all our cases to protect the innocent. However, these complications are very real. Numerous “pumpers” have been convicted of crimes from the unlicensed practice of medicine to manslaughter.
It’s easy to sympathize with someone who wants to improve their appearance and visits a “nurse” recommended by a friend. I suspect few patients understand the very real risk of permanent disability and death from these so-called cosmetic procedures.
The legal details are as disturbing as the medical ones. A woman who said her patients called her “the Michelangelo bodywork” served only a year in prison after a client died in her basement in Queens. She injected the woman with silicone obtained on eBay, then left the client on the floor dying, holding her mother’s hand and advised them not to call 911. The next day the woman fled on a flight to the UK. The extradition agreement was that she serve only one year. At the trial judge said she literally got away with murder. A person in Florida was convicted after injecting Fix-A-Flat, cement, and superglue into patients.
This brings us to question number 4 and the last one in today’s interactive podcast.
Use of fillers started shortly after discovery/invention of which of the following?
A. Operating Rooms
B. Syringes
C. Antibiotics
D. Lidocaine (numbing medicine)
Post your answers in our Twitter poll @pickpoison1. I’ll post the answer in the next 24 hours.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.