PMC7655241_01
(a) Photograph of the front of the face taken at the first visit. Diffuse swelling of the right cheek was seen. A fistula of about 5 mm was present near the corner of the mouth. (b) Photograph around the fistula. Pus was discharging from the fistula. (c) Cone beamed computed tomography (CBCT) image at the causal tooth in coronal image. (d) CBCT image at the causal tooth in sagittal image. There was an apical lesion of about 3 mm in the root apex of the right maxillary second premolar.
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There was a fistula of about 5 mm on the right cheek 10 mm above the oral angle, and pus was discharging from this fistula (Figures 1(a) and 1(b)). Cone beamed computed tomography (CBCT) imaging showed an apical lesion of the second premolar (Figures 1(c) and 1(d)). The MRI findings were irregular high signal intensity areas under the subcutaneous tissue on both cheeks on T2-weighted images of fat suppression, and high signal intensity areas were widely distributed on the right side (Figure 3 (a1) and (a2)). Since the MRI showed a reduction of the nodule six months later, we continued follow-up (Figure 3 (b1) and (b2)). The MRI showed unclear boundary lesions in the high signal area in T2-weighted images and the low signal area in T1-weighted images, and a foreign body-like liquid silicone was suspected again (Figure 3 (c1) and (c2)).
Histological findings from the first surgery: (a) histological examination of the resected fistula indicated the mucus-like deposition, the formation of mucous-like nodules, and the infiltration of foreign body giant cells in fat, striated muscle, and fibrous tissue, with mild calcification [hematoxylin-eosin (H-E) stain x25]. (b) Calcification was present, many fiber cells were observed around it, and vacuolated cells and foreign body giant cells were seen [H-E stain x100]. (c) Vimentin stain was positive for stromal cells and fibrocytes. Histopathological diagnosis was suspected of mucin-producing odontogenic tumor and mucinous adenocarcinoma, among other diagnoses. Histological findings from the second surgery: (d) histological examination of the removal tumor showed foreign body giant cell, vacuolated cells, fibrous tissue, and striated muscle around calcifications [H-E stain x25]. (e) H-E stain x100. (f) Silicone particles, foreign body giant cell, and fibrotic tissue of silicone granuloma [H-E stain x25].
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Histopathological diagnosis suspected a mucin-producing odontogenic tumor or mucinous adenocarcinoma, among other diagnoses (Figures 2(a)-2(c)). Histopathologic diagnoses were the silicone, silicone granuloma, and scar (Figures 2(d) and 2(e)).
MRI findings. (a1, a2) Axial and coronal images of T2-weighted image of fat suppression two months after the first surgery. Irregular high signal intensity areas under the subcutaneous tissue on both cheeks and high signal intensity areas were widely distributed on the right side. (b1, b2) Axial and coronal images of T2-weighted image of fat suppression seven months after the first surgery. The images showed a reduction of the right nodule compared with those two months after the first surgery. (c1, c2) Axial and coronal images of T2-weighted image 19 months after the first surgery. Unclear boundary lesions showed the high signal area was recognized, and foreign body-like liquid silicone injection was suspected again. The above high signal area on the buccal region was shrinking over time. These findings should develop by loss of silicone from the fistula. The high signal area on the left buccal region had not changed.
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The MRI findings were irregular high signal intensity areas under the subcutaneous tissue on both cheeks on T2-weighted images of fat suppression, and high signal intensity areas were widely distributed on the right side (Figure 3 (a1) and (a2)). Since the MRI showed a reduction of the nodule six months later, we continued follow-up (Figure 3 (b1) and (b2)). The MRI showed unclear boundary lesions in the high signal area in T2-weighted images and the low signal area in T1-weighted images, and a foreign body-like liquid silicone was suspected again (Figure 3 (c1) and (c2)).
(a) Intraoperative photograph. (b) Photograph of the removed lesions. Most of the silicone granulomas containing the mass of silicone were removed.
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Under local anesthesia, all connective tissue and granuloma, including the silicone from the buccal mucosa, were removed (Figures 4(a) and 4(b)).
(a) Extraoral photograph three months after the second surgery. (b) Intraoral photograph three months after the second surgery. Although a slight scar formation was observed around the region where the fistula was present, the healing was completed.
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After the operation, she had no complications, such as facial paralysis or facial deformity (Figures 5(a) and 5(b)).