Foreign Body Type Nasal Pseudocyst After Augmentation Rhinoplasty: Histopathologically Mucin-Containing Pseudocyst

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To the Editor:
An 18-year-old woman presented with a one week history of a rapidly growing asymptomatic mass on the left nasal root. One year earlier, she underwent a rhinoplasty using a silicone implant. Six months after the procedure a heavy bag fell on her nose. She had no relevant past medical or drug-use history. Physical examination revealed a hyperkeratotic, firm, and protruding nodule mimicking pyogenic granuloma (Fig. 1A). Antibiotics were used with no effect. A presurgical diagnosis of pyogenic granuloma associated with trauma was made, and excisional biopsy was performed. During the excision, a translucent gelatinous material oozed out from the lesion. One week after the excision, the lesion recurred. Soft tissue ultrasonography showed a 0.4 × 0.67 cm hypoechoic lesion between the silicone implant and the overlying skin (Fig. 1B). During an open surgical approach, the mass was removed and then the silicone implant was released from the nasal bone. Intraoperatively, it was found that the silicone implant was broken into 3 pieces (Fig. 1C). Revision rhinoplasty and tip plasty with ear cartilage were also performed. Histological examination of the removed mass revealed a dermal mucous retention cystic area, devoid of any true epithelial lining (Fig. 2A). The mucin-containing dermal space was surrounded by granulation tissue. Muciphages were identified (Fig. 2B). The stromal mucin stained positively with alcian blue (Fig. 2C), whereas the gram stains and periodic acid–Schiff (PAS) stains were negative. Follow-up at 3 years after the surgery revealed no signs of recurrence.
Recently, a 42-year-old man with a nasal root mass presented to our clinic. Fifteen years earlier, he had undergone augmentation rhinoplasty with a silicone implant. Five months earlier a nasal mass suddenly developed after he suffered from a blunt trauma to his face. Physical examination showed a 1.0 × 0.8 cm, erythematous protruding cystic mass on the left nasal root (Fig. 1D). Antibiotics were used with no effect. A presurgical diagnosis of foreign body type nasal pseudocyst associated with augmentation rhinoplasty was made, and the cyst and silicone implant were removed. Grossly, the removed silicone implant had a broken edge (Fig. 1E). The cystic mass was composed of gelatinous material filled space with chronic inflammatory cells and foreign body type multinucleated cells. The cystic mass also positively stained with alcian blue.
Nasal dorsal cyst formation is a very rare complication of rhinoplasty. Since the first description in 1958 by McGregor et al,1 only 26 cases have been reported in the literature.2 Some theories have been proposed regarding their development: herniation of nasal mucosal tissue through the fractured site and nasal mucosa growth through osteotomy lines.2 The histopathological findings have been of a mucous retention cyst lined with respiratory-type epithelium; however, such a lining was not present in our case.
Rarely, a foreign body type pseudocyst after rhinoplasty has been reported; one case was similar to our patients, and the other case was caused by petroleum-based ointment.3,4 Here, we describe 2 cases of postrhinoplasty foreign body type pseudocysts containing inflammatory cells and gelatinous material without epithelial lining. It is likely that the pseudocysts were caused by foreign body inflammatory reaction from broken silicone, and overproduction of mucin by fibroblasts is probably responsible for the observed changes. Mucin has been shown to increase hydrophilicity of silicon-based and poly (ethylene terephthalate)-based biomaterials and to suppress bacterial adhesion, as well as neutrophil adhesion and activity.5 The differential diagnosis must include pyogenic granuloma, benign skin adnexal tumors, dermoid cysts, abscesses, foreign body granulomas, infections, encephaloceles, and lymphomas.

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