Lip and Face Pumping: Underground Enhancements to Avoid

Pippa Wysong; Julius Few, MD


November 18, 2011

Lip and face pumping is an underground activity where nonmedical practitioners inject non-US Food and Drug Administration (FDA)-approved fillers to plump up lips and other facial features. The practice leads to deformities and other complex problems. Julius Few, MD, is director of the Few Institute, and a clinical associate of plastic surgery at the University of Chicago. He is also a founding member of the Physicians Coalition for Injectable Safety. He spoke to Medscape's Pippa Wysong about lip pumping and what plastic surgeons need to know.

Medscape: Can you give Medscape readers some background on what underground lip pumping is all about?

Julius Few, MD: This is an underground activity where untrained people offer services to pump, or plump up, lips or other facial features at a rate far cheaper than legitimate medical practitioners. They use materials that are not FDA approved for medical purposes, and sometimes groups of people even hire these underground lay-person injectors to attend a "lip-pumping party" where they give several people the treatment. The problem is that over time, because the plumping and pumping are not done properly, and are done using the wrong sort of materials, patients end up with noticeable disfigurement of the lips or other parts of the face.

Medscape: Who performs these procedures?

Dr. Few: They tend to be people who are not medically trained to inject these agents, often gels, into the tissue. Obviously, these lay-person injectors aren't "licensed" to practice medicine. Some of them have a following, and pumping is popular in big cities such as New York, Chicago, and Los Angeles. It's less common in small towns. Some of the lay-injectors learn the basics of injecting from Websites, which isn't the best way to learn medical procedures. Sometimes nurses do this, but they are practicing well outside the scope of what they should be doing, and are operating independently.

Medscape: What do they use to do the pumping?

Dr. Few: There are hand-pump devices that can connect to a syringe to push the gel through when pumped. There are also motorized pumps that can deliver gel. There are a variety of devices. No matter what device is used, pumping is not medically appropriate.

Medscape: What materials are used in the pumping?

Dr. Few: The most common is silica, with the most frequently used being industrial grade silica. It's easy to buy online, but this type of silicone is designed to reduce industrial friction and is used in machinery. Anyone can purchase it. It comes in a clear gel and it can be injected. It's obviously not approved for medical use.

Medscape: Who goes for this underground pumping?

Dr. Few: The most common group of people who use these services is members of the transgender community who want to feminize the face in an inexpensive way. Another group is people who are less educated about this and who get caught up in an injection party, thinking it's the same thing as legitimately injecting approved products such as Restylane®, Juvéderm®, or Radiesse®. There is a medical-grade silicone that is used off-label to inject as well, but even it is not appropriate when pumped. In legitimate practice, medical-grade silicone is generally used in small-quantity, small-volume injections by highly skilled and trained professional injectors. Typically, dermatologists use it to treat acne scars and other small problems. It's not normally appropriate for larger areas like filling lips. Still, some of the underground lay pumpers get a hold of medical grade silicone, which is intended for these smaller volume applications.

Medscape: Are other parts of the face being pumped, too?

Dr. Few: Yes. The list includes cheeks, temples, jaw line, chin, and forehead. Pumping causes problems in all of these areas. For instance, I currently have a female patient I'm trying to figure out how to help. She had injections in her cheeks and temples 6 years ago. Her face is now completely distorted, worse on one side than the other, making her look unusually asymmetrical. Another surgeon had tried to remove some of the material that had been injected, and it made things even worse. Trying to correct the damage done by these procedures is very difficult. A key issue for the surgeon is that the injected material tends to become integrated with the patient's tissue. It's very hard, if not impossible, to go in and completely remove it all.

Medscape: Is this material toxic too?

Dr. Few: The gels used by the underground pumpers are physically inert. They don't have direct toxicity, but the reaction the body has towards it is not good. Basically, the body tries to remove the injected material. In the process of trying to remove it, it creates inflammation, a lot of scarring, and distortion of the anatomy. Because the body is working so aggressively to get rid of the foreign material, in some cases it can even cause skin ulcerations.

Medscape: What causes the deformities?

Dr. Few: The silicone doesn't change over time, but the tissue around it does. The body can't break the silicone down but it keeps trying. A lot of scar tissue forms over time, and the scarring wraps around the injected material. Over time more scar tissue forms near the injection site. It can take 5-10 years for all the trouble to show.

Medscape: What are the challenges for the plastic surgeon performing the repairs?

Dr. Few: Because it's injected well under the skin, under the lip-lining surface, it becomes intertwined with muscles and nerves. It's like trying to pick the blue playdough out of the big thing of yellow playdough. We're dancing between nerves that allow people to smile, to close their eyes, and to express themselves. It's very complicated.

Medscape: What are some tips for other plastic surgeons who may encounter these patients?

Dr. Few: After doing an exam, get imaging. One shouldn't go into surgery without good knowledge of where the material is located anatomically. I typically have patients get an MRI to look at the affected tissue. Then it can be seen where the blood vessels and nerves are in relation to the silicone. Next, the physician needs to have a good discussion with the patient. Show them where the silicone is, where the nerves are, then explain what the likelihood is for damaging the nerves, potentially permanently -- if surgery is used to remove the foreign material. The patient needs to decide how severe the issue is relative to the surgical risks. Some physicians get into trouble thinking this will be a superficial or minor surgery.

The primary problem is the inflammation and scarring that occurs around the silicone particles. When cutting through the scar tissue, a surgeon encounters important nerves and blood vessels that can cause all kinds of problems such as permanent paralysis. They may have to avoid an entire anatomic region to avoid devastating side effects, such as tissue death and paralysis. Some patients will have to undergo surgery similar to cancer surgery in order to control symptoms. Complex reconstruction is then necessary, changing the cosmetic patient to a reconstructive patient.

Medscape: Is the scar tissue removed?

Dr. Few: Removing scar tissue begets more scar tissue. It's best to try to smooth it out. Also to try to restore normal anatomy -- that often involves removing some scar tissue, but not all of it.

Medscape: After you've removed as much silicone and scar tissue as possible, are legitimate materials re-injected to restore the shape?

Dr. Few: Usually in a situation like this, a surgeon tries to reposition the tissue to try to camouflage the defect that may be left after removing the silicone. Then they can go back in and make adjustments as needed. Fat injections or fat grafts can be used to help fill in the defect as a more long-term solution.

Medscape: Do patients need multiple procedures?

Dr. Few: There are many long-term problems as a result of any of these surgeries. I tell the most severe patients they should expect some permanent deformity or disfigurement -- it's a question of how severe. It's vital for the surgeon to set realistic expectations for the patients. These cases always result in some sort of deformity. Typically, these patients come in to be cosmetically enhanced. Their expectation, if not informed otherwise, is that they're going to be enhanced when the procedure is complete. That's not realistic. A more appropriate goal is to get them close to where they started.

Medscape: How many patients are showing up in clinics to have these deformities corrected?

Dr. Few: There is no database set up for this. In my own practice I see 4 or 5 severe cases a year. It's also likely there are people out there with damage who don't seek medical help.

Medscape: What is Coalition for Injectable Safety doing about this issue?

Dr. Few: We're basically trying to raise awareness about unsafe injection practices like this one so people can avoid it. Many people don't know there are differences between injectable products. Some people, especially outside of medicine, have few scruples and try to convince prospective patients that they're using legitimate materials. Doing these injections is practicing medicine without a license, but it's hard tracking these people down.

Medscape: Thanks for telling us about this practice.