**8. Diagnosis**

Granuloma is a form of localized nodular inflammation, which is found in tissues [7]. On examination, there is a tumor-like mass or node of granulation tissue with active fibroblast growth and capillaries that contain epithelial-like macrophages surrounded by mononuclear cells, lymphocytes, and sometime multinucleated Datia cells present at the central core of granuloma [16].

On clinical point of view, silicone granuloma is characterized by the presence of complications of silicone. There are usually granuloma nodes, migrating silicone, wider nose, and signs of inflammation such as redness and swelling depending on the stage (**Figure 4**).

#### **Figure 4.**

*Granuloma due to nasal silicone injection. The photograph shows granuloma node, migrating silicone, wider nose, and signs of inflammation such as edema and redness.*

#### **9. Management**

The management of silicone-induced granuloma is often difficult due to migrating silicone and some of the silicone penetrating into the skin reaching the epidermis. In general, the management of granuloma can be categorized into two, i.e., surgical and pharmacological treatments. The management of nasal silicone granuloma is adjusted for the occurring complications. We must remove granuloma, which is under the skin; afterward, we perform excision of the excessive skin or implant insertion, creating a firmer and cosmetically more attractive skin. Remaining fibrosis or granuloma can be treated using steroid injection, and laser therapy is performed for redness.

#### **10. Recommendation for surgical care**

Granuloma formation occurs due to the presence of foreign body. Skin granuloma will cause a cosmetic problem; therefore, it should be removed.

#### **11. Preoperative preparation**

The preoperative preparation is similar to all kinds of skin surgery. A consultation prior to surgical procedure is necessary so that the doctor can perform both physical and psychological evaluation for the candidate. The patient should be informed about surgical procedure and the result may not be perfect as clean silicone injection can never be performed and there is a possibility of swelling. Patients with extreme high expectation will file their complaints in the future.

During the consultation, we must find out about coagulation disorder, either primary or secondary, either due to medication of pharmacological treatment or supplementation. The patients are advised to avoid food or medication that may prolong the bleeding time within 1 or 2 weeks prior to the procedure such as anticoagulants, aspirin, ginseng, garlic, cod liver oil, anticholesterol agent, vitamin E, warfarin, and *Ginkgo biloba*.

Curettage procedure of nasal silicone granuloma is similar to skin graft procedure, in which the covering skin must be viable. On curettage, the skin will be thinner, and it can be necrotic if there is poor vascularization. Other issues that should come into our consideration are alcohol intake, smoking habit, metabolic disorder, and poor nutrition. Blood pressure and diabetes mellitus must be well-controlled [17–19].

#### **12. Informed consent**

When a skin surgeon decides to perform a surgical procedure, both doctor and patient must consequently understand the impact, risk, and advantages of the procedure. First, the doctor needs to explain the diagnosis and the procedure that will be performed. Treatment of nasal silicone injection is a combination of medical therapy and cosmetic procedure because when it is left untreated, there will be changes such as migration, granuloma, and continuous inflammation. The risks and the advantages of the procedure should be emphasized. Moreover, the procedure during the surgery and the expected result after surgery need to be explained. Possible risks that may develop such as infection and its prevention including the use of antibiotics must also be explained. Patients must know other probable risks such as bleeding, crooked nose, wound scar that probably occurs, asymmetrical nostrils, an implant impression on the skin, granuloma or fibrosis that cannot be cleaned up, persistent redness of skin color,

**9**

**Figure 5.**

*Elliptical excision of granuloma on the nasal skin.*

*Management of Nasal Silicone Granuloma DOI: http://dx.doi.org/10.5772/intechopen.87188*

**13. Technique and procedure**

tage kit for cases that need curettage.

has been discussed with the patient.

tage and subsequently install a nasal implant.

**14. Preoperative planning**

anesthetic drugs.

performed on it (**Figure 5**).

and other modalities of treatment that need to be carried out after the surgical procedure. It should also be explained that the results probably may be imperfect, particularly for patients with unrealistic wish. Results of discussion and patient's consent are written on an informed consent form, which is subsequently signed by the doctor and patient.

Every granuloma in the skin that causes cosmetic problem must be removed. Granuloma at inflammatory phase must also be removed to prevent the extension of inflammation. Local or general anesthesia could be used for procedures of skin excision, granuloma curettage, or installation of nasal implant. Instruments that must be prepared included minor surgery set, which can be equipped with curet-

The management of silicone-induced granuloma depends on the affected area; however, basically a doctor will first make a design planning. Next, the doctor will perform procedures according to the design or images and following the plan that

Depending on the occurring complication, we evaluate whether we need to remove the excessive skin from the nasal columella or should only perform curet-

Mark the area that will be excised and the protruding granuloma on the dorsal of the nose; therefore, during the surgery we emphasize on the location where the curettage will take place. If we plan to place a solid nasal implant, then we need to make a midline to ensure the implant stays straight when the swelling occurs due to

Depending on the problem, when the nasal dorsum has become wider along with inflammation and the damaged skin, an elliptical vertical excision can be

*Cosmetic Surgery*

**9. Management**

**10. Recommendation for surgical care**

**11. Preoperative preparation**

E, warfarin, and *Ginkgo biloba*.

**12. Informed consent**

The management of silicone-induced granuloma is often difficult due to migrating silicone and some of the silicone penetrating into the skin reaching the epidermis. In general, the management of granuloma can be categorized into two, i.e., surgical and pharmacological treatments. The management of nasal silicone granuloma is adjusted for the occurring complications. We must remove granuloma, which is under the skin; afterward, we perform excision of the excessive skin or implant insertion, creating a firmer and cosmetically more attractive skin. Remaining fibrosis or granuloma can be treated using steroid injection, and laser therapy is performed for redness.

Granuloma formation occurs due to the presence of foreign body. Skin granu-

The preoperative preparation is similar to all kinds of skin surgery. A consultation prior to surgical procedure is necessary so that the doctor can perform both physical and psychological evaluation for the candidate. The patient should be informed about surgical procedure and the result may not be perfect as clean silicone injection can never be performed and there is a possibility of swelling. Patients

During the consultation, we must find out about coagulation disorder, either primary or secondary, either due to medication of pharmacological treatment or supplementation. The patients are advised to avoid food or medication that may prolong the bleeding time within 1 or 2 weeks prior to the procedure such as anticoagulants, aspirin, ginseng, garlic, cod liver oil, anticholesterol agent, vitamin

Curettage procedure of nasal silicone granuloma is similar to skin graft procedure, in which the covering skin must be viable. On curettage, the skin will be thinner, and it can be necrotic if there is poor vascularization. Other issues that should come into our consideration are alcohol intake, smoking habit, metabolic disorder, and poor nutrition. Blood pressure and diabetes mellitus must be well-controlled [17–19].

When a skin surgeon decides to perform a surgical procedure, both doctor and patient must consequently understand the impact, risk, and advantages of the procedure. First, the doctor needs to explain the diagnosis and the procedure that will be performed. Treatment of nasal silicone injection is a combination of medical therapy and cosmetic procedure because when it is left untreated, there will be changes such as migration, granuloma, and continuous inflammation. The risks and the advantages of the procedure should be emphasized. Moreover, the procedure during the surgery and the expected result after surgery need to be explained. Possible risks that may develop such as infection and its prevention including the use of antibiotics must also be explained. Patients must know other probable risks such as bleeding, crooked nose, wound scar that probably occurs, asymmetrical nostrils, an implant impression on the skin, granuloma or fibrosis that cannot be cleaned up, persistent redness of skin color,

loma will cause a cosmetic problem; therefore, it should be removed.

with extreme high expectation will file their complaints in the future.

**8**

and other modalities of treatment that need to be carried out after the surgical procedure. It should also be explained that the results probably may be imperfect, particularly for patients with unrealistic wish. Results of discussion and patient's consent are written on an informed consent form, which is subsequently signed by the doctor and patient.
