Management of Synthol-induced Fibrosis

Summary:

Site enhancement oils, such as synthol, are sometimes used by bodybuilders to artificially increase muscle size and shape. However, these injections can lead to severe complications, including fibrosis, infections, and impaired muscle function. We report the case of a 45-year-old male patient who presented with severe fibrosis and recurrent infections in the pectoral region following synthol injections. The patient experienced several episodes of infection in the left pectoral area, which were treated with antibiotics, resulting in indurated, erythematous skin. The patient underwent surgical removal of the fibrotic tissue under general anesthesia. This case highlights the severe complications associated with synthol injections and underscores the importance of a meticulous surgical approach to manage these complications. Excision of fibrotic tissue is essential for reducing the risk of reinfection and restoring a normal appearance while carefully weighing the extent of tissue removal to avoid unnecessary damage to healthy structures. Preparing for potential blood loss and balancing the extent of tissue removal with the need to preserve normal function and appearance are crucial for successful outcomes.

Site-enhancing oils are sometimes injected by bodybuilders into the muscles as a form of liquid body contouring for immediate volume enlargement. Among site-enhancing oils, synthol is a substance consisting of oil, benzyl alcohol and lidocaine. It consists of 85% oil, 7.5% lidocaine, and 7.5% alcohol.¹ However, these injections are not without side effects and can lead to both acute and chronic complications. Among these complications are fibrosis and infections. We present a case of fibrosis and recurrent infections following synthol injections and detail the surgical treatment of these complications.

CASE PRESENTATION

We present the case of a 45-year-old male patient with a body mass index of 27.7 kg/m² without comorbidities (Fig. 1). He was injected twice with synthol in the pectoral, biceps and triceps muscles to increase muscle volume 10 years ago. Several episodes of infection occurred in the left pectoral area over the past 2 years, with the most recent happening 3 months before surgery. These episodes were treated with antibiotics, resulting in an area of indurated, erythematous skin. A chest magnetic resonance imaging (MRI) showed diffuse and severe inflammatory changes, as well as multiple nodular images in both breasts that may correspond to the injected material. (See figure, Supplemental Digital Content 1, which displays MRI with red arrows showing nodular images in both breasts that correspond to the injected material. http://links.lww.com/PRSGO/D700.)

Fig. 1.

Preoperative photographs showing the patient with upper thoracic fullness depicting the synthol material. Note the erythematous skin on the left.

On examination, limited mobility of the arms in abduction was noted due to the injected material. Upon palpation, the injected areas were extremely stiff but not painful. The patient presented for the removal of the anomalous tissues in the pectoral area.

The patient was operated on under general anesthesia. Antibiotic prophylaxis with first-generation cephalosporins was administered during surgery and until the seventh postoperative day. The area to be excised was infiltrated with a solution of xylocaine and adrenaline 1 of 100,000. The incision was made directly over the fibrotic tissue on the right and the erythematous skin on the left, extending down to the muscular plane. Dissection was carried out with monopolar cautery until normal adipose tissue was found. The tissue was highly fibrotic and inflammatory, causing extensive bleeding during the dissection. The fibrotic tissue was adherent to the pectoralis muscle, with no clear cleavage plane. However, the muscle was preserved to prevent additional damage beyond that already caused by the product. (See figure, Supplemental Digital Content 2, which displays tissue excised during the operation. http://links.lww.com/PRSGO/D701.) Careful control of hemostasis was achieved, and the wounds were closed. One drain was used on each side, and the patient had an uneventful postoperative course. Four months postoperatively, the incision had healed well, and no postoperative infections occurred (Fig. 2). Arm mobility improved, though it remained partially restricted due to prior injections in the biceps and triceps muscles.

Fig. 2.

Postoperative photograph 4 months after the operation.

DISCUSSION

Bodybuilders sometimes inject synthol or other site enhancement oils to artificially increase the size and shape of their muscles. These substances are typically composed of lidocaine, alcohol, and oil. They are injected directly into the muscle tissue to create the appearance of larger, more defined muscles by unqualified professionals. Synthol, one of the most popular site enhancement oils, is used to rapidly augment muscle size without the need for extensive training. However, the use of such oils carries significant risks and can even have potentially life-threatening consequences for users.²

Short-term complications can include pain, swelling, and localized infections.^3,4 Long-term use can lead to more severe issues such as chronic inflammation, granuloma formation, and significant fibrosis.^5–7 These fibrotic changes can impair muscle function and mobility, as the injected areas become hardened and lose elasticity. Additionally, the nonbiodegradable nature of these oils means that they remain in the tissue, potentially leading to complications years after the initial injection.⁵ Severe complications including nerve damage, muscle necrosis, and systemic infections have been reported.^5,8 The case presented illustrates these risks, with the patient developing severe fibrosis and recurrent infections that necessitated surgical intervention.

Nonsurgical treatment includes antibiotics and steroids during inflammatory attacks in the acute phase of the disease.⁶ The use of compression bandages has been described to limit oil diffusion and dissemination into deeper and surrounding tissues.⁹ Surgical treatment is necessary for long-term fibrotic complications. It is an effective treatment modality for pain reduction, rehabilitation of range of motion of adjacent joints, and for side effects caused by compression of surrounding tissues.¹⁰

Very few articles discuss the surgical technique for removing lesions resulting from synthetic oil injections. From our experience treating multiple cases in addition to this one, we refined our surgical technique to effectively remove the substance and abnormal tissue while minimizing complications. MRI can be a valuable guide in planning tissue excision by providing detailed images of the affected areas.¹⁰ However, the true extent of the damaged tissue that needs to be excised often becomes apparent only after the incision is made.

Large incisions are necessary to ease the removal of fibrotic tissue and facilitate thorough dissection. Although wide excision is ideally necessary to remove as much anomalous tissue as possible and reduce the risk of reinfection, in practice, this must be balanced with the reality that not all fibrotic tissue can always be completely excised. This is particularly true when there is no clear delimitation between fibrotic and normal tissues, making it challenging to achieve complete removal without causing additional damage to healthy structures. In such cases, it is essential to preserve normal tissue, ensure proper skin closure without tension, and avoid further harm to surrounding muscle and skin. Therefore, the surgical approach must be both comprehensive and realistic, tailoring the extent of excision to each case. Additionally, it is crucial to be cautious of blood loss during the operation, as the lesions are highly inflammatory and highly vascularized, necessitating the preparation of blood units beforehand.

Technically, regarding the electrosurgical modality, we found the coagulation mode to be more effective in cutting through the tissues, as the heat generated can dissolve the oil component, making dissection easier compared with the cutting mode. Additionally, antibiotic prophylaxis is necessary to decrease the risk of infection following surgery, particularly if previous episodes of infection have been reported.

CONCLUSIONS

Site enhancement oils can result in disastrous complications, leading to severe deformities, recurrent infections, and systemic reactions. Surgery is the only effective treatment for long-term complications, with the aim to remove the anomalous fibrotic tissue to decrease the risk of reinfection and eliminate foreign material. The extent of resection must be carefully balanced with the need to preserve normal tissues. Tedious surgical dissection and meticulous hemostasis are required, as these lesions are highly inflammatory and challenging to treat surgically.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. The authors confirm that all data generated or analyzed during this study are included in this published article.