Long-term complications of unknown injectables
You may be familiar with the phrase "every tool has its job." This phrase means that every tool in your toolbox serves a specific purpose, essential to completing a job and delivering the best possible results. If you need a new roof for your home, will you enlist a roofing professional or use duct tape and chewing gum, hoping your DIY repairs will hold up long term? The right tools in the right hands make a difference.
Board-certified plastic surgeons have numerous tools at their disposal, from injectables to implants, to help them achieve their patients' aesthetic goals. These tools come from trusted and reputable sources and are used with a high degree of skill and precision. Yet some patients are still turning to "back-alley clinics" and medical tourist traps for injectables and other procedures, where there is no guarantee that the injectables they receive are medical-grade or even safe.
Long-term complications stemming from unknown substances such as hardware store silicone, black market knockoffs or watered-down Botox are becoming an increasingly common problem for patients and the plastic surgeons who treat them.
The growing problem of unknown injectables
The problem with unknown injectables is that the substances used to plump, volumize and contour are a mystery. In many situations, plastic surgeons do not know – and have no way of telling – which types of counterfeit, black-market, or off-the-shelf products were used to treat a patient initially.
"The bottom line is we just don't know what people are getting injected and a lot of times, the patients themselves don't know what it was that they had injected," said Josef Hadeed, MD, FACS.
He and other ASPS Member Surgeons are noticing a disturbing trend – more patients are coming to them complaining about complications from fillers and other injectables. Unfortunately, these problems are not the result of rare medical complications. Instead, they are the consequence of years of living with "fake fillers."
Kristy Hamilton, MD, has also treated patients dealing with the emotionally and physically painful side effects that come with unknown injectables.
"The most common scenario in my office is, 'Hi, I went to Mexico, I had something injected in my face, I don't know exactly what it was, and it ends up like it feels like hard rocks,'" said Dr. Hamilton.
Patients who are feeling an economic squeeze may turn to medical tourism, basement Botox parties or unlicensed or unregulated state-side clinics to maintain their appearance and feel fresh and fabulous. However, getting injectables done in these settings can lead to serious issues.
"Sometimes they do travel overseas to get it done, and then a lot of times we've heard that either somebody came over to their house or they went to a hotel room or somebody else's house," said Dr. Hadeed. "A friend of theirs had it done."
Other times, a facility may look pristine, but is operating without qualified, licensed medical practitioners or staff.
"There are also places that look very beautiful, they've got that gorgeous, kind of interior designer, med spa type look," said Dr. Hamilton. "It's just that it's not full of licensed individuals, but they've done a great job of making it look beautiful."
Unfortunately, the result tends to be the same – poor-quality work, an uneven aesthetic outcome and significant health concerns down the road.
"Across much of Latin America, aesthetic ideals have long favored dramatic body contours with fuller hips, smaller waists and accentuated curves," said Daniel Careaga, MD. "This demand, combined with inconsistent regulation, has fueled the widespread use of so-called 'biopolímeros.' The term carries a deceptive scientific tone, suggesting something natural or biodegradable. In reality, it has become a marketing label for unapproved injectables, most commonly industrial-grade silicone, paraffin or other synthetic substances of uncertain origin and purity."
He explains that non-physicians often inject these materials into patients in informal settings such as salons, spas and private homes. Sometimes, patients are assured that the injectables are safe and will integrate naturally into their tissues.
"What they are actually being given are permanent foreign substances that can trigger chronic inflammation, fibrosis and severe disfigurement over time," said Dr. Careaga.
Complications from unknown injectables
One issue with unknown injectables is that some patients may not even realize they've been treated with a counterfeit or unsuitable injectable.
"In the acute phase, typically, they may not have any symptoms or anything wrong with them," said Dr. Hadeed.
Sometimes, the injectables' effects aren't immediate, and people don't start to notice complications until months or even years later. Dr. Hamilton said that individuals who experience acute effects from unknown injectables may notice changes in the texture of the material. It may feel hard, like rocks or small pebbles, as the body tries to shield the foreign material from the rest of the body.
"That's the body's natural way of saying, 'Hey, this is not something that should be here, it's not hyaluronic acid, it's something that I'm going to wall off and separate from the rest of the body to keep the body safe,'" said Dr. Hamilton.
Just because a side effect is delayed doesn't mean it isn't serious.
"While delayed reactions are common, the acute complications can be just as devastating," said Dr. Careaga. "Patients may present within days of injection with severe infections: cellulitis, abscess formation, and rapid distortion of anatomy due to necrosis and tissue loss. The unsterile environments where these procedures are performed, along with the chemical irritation from the injected substances, increase the risk of permanent damage."
Other, more life-threatening issues can occur in the short term, as well.
"Even more alarming are cases of vascular compromise or embolization, where material enters the bloodstream or migrates into major vessels, leading to cardiopulmonary collapse, stroke or even death," said Dr. Careaga. "These are not isolated events but the predictable consequences of untrained injectors using untraceable substances in uncontrolled conditions."
However, many of the patients Dr. Hadeed treats come to him after suffering long-term issues associated with unknown injectables and fillers.
"Usually it seems like this is something more long-term – 10, 15, 20 years later – where they start developing, these issues frequently could be skin discoloration," said Dr. Hadeed. "It could be discomfort. It could be migration of the injected material, which results in contour irregularity or contour deformity of the area, such as swelling."
He said some patients also complain of recurrent infections and ulcerations. One patient also claims her high blood pressure, blood clots and subsequent heart attack may have been related to the unknown substance injected into her body.
"One case that has stayed with me involved a woman who had a significant amount of what was most likely silicone injected into her buttocks many years earlier," said Dr. Careaga. "When she came to see me, the material had migrated all the way down to her ankles. She suffered from chronic swelling, pain and recurrent inflammation that made walking difficult. There was no realistic way to remove all of the material without causing further harm. It was a sobering reminder of just how unpredictable and far-reaching these substances can be once they enter the body."
Another unintended side effect of coping with foreign materials in the body is the cost. Often, patients look to medical tourism in other countries or unregulated clinics or spas because they are more affordable. However, being budget-friendly today can turn into a budget buster tomorrow because the cost of correcting significant complications tends to far exceed the cost of investing in quality work in the first place. Correcting disfigurements, infections and other issues is generally more complicated, time-consuming and expensive because of the intricacies involved in managing the migration of foreign substances, which may be intertwined with delicate nerves, muscles and internal tissues.
How to tell the difference between legitimate injectables and the fakes
One of the many pitfalls of the illegitimate injectable market is price. Clinics, spas and unlicensed individuals target people looking to save money on aesthetic procedures. Now more than ever, the old saying rings true: "If something seems too good to be true, it is."
Dr. Hadeed recommended that patients protect themselves by doing their research.
"Make sure that a board-certified plastic surgeon does any procedure you have done," said Dr. Hadeed. "Make sure it's done in a fully accredited surgical facility. If it's cheap, like that, it should raise red flags and set off the alarm bells to think twice about getting it done."
Cosmetic procedures that are significantly less expensive than competitors should raise a red flag. Individuals who order products through Alibaba or third parties should also be warned. If purchasing Botox or fillers from Alibaba or unlicensed online Chinese marketplaces sounds ridiculous, that's because it is. However, it happens, and chances are, if you are preparing for an injection, you aren't asking your injector to check the product box for foreign characters on the label.
"We buy our Botox from the maker of Botox," said Dr. Hamilton. "So, we never have to worry about getting counterfeit Botox, but if you're buying it through third-party dealers because you aren't licensed to purchase these products, then you might end up purchasing counterfeit Botox by mistake. I think the number one thing you can do is to go to a legitimate healthcare professional, and the number one way to do that is to make sure you're going to a board-certified plastic surgeon."
Changing the narrative and embracing a shared responsibility
The physical pain and deformities aren't the only long-term complications associated with unknown injectables. Patients may also suffer from feelings of shame, embarrassment and humiliation that make them reluctant to seek help or talk about their experiences. ASPS Member Surgeons want patients to know they aren't there to judge. They are there to help.
"Unfortunately, shame is a very real emotion that we hear all the time, and I always tell patients, 'Look, you didn't know,'" said Dr. Hamilton.
Creating a compassionate environment where patients can share their experiences, get the help they need and educate others about the dangers of illicit injectables can help change the narrative and help others avoid the same fate.
"This issue reflects more than a failure of regulation. It underscores how language, culture and misinformation can shape patient behavior and expectations," said Dr. Careaga. "As plastic surgeons, we are often the ones left to manage the consequences, but our responsibility extends beyond reconstruction. We have an obligation to educate and advocate."
To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.
