Work

Post‐Traumatic Facial Macules

Year: 2026

Type: article

Abstract: A 23-year-old female was involved in a serious motorcycle incident in Indonesia. She suffered significant facial injuries to her left side that left her unconscious and requiring emergency facial reconstruction surgery. She is unaware of what the operation involved and has been unable to seek further information from her medical records. Four years after the road traffic collision, she developed a blue lesion on her central forehead. She has since developed further lesions on the left and right cheeks, around 13–18 years after the incident. She reports occasional itching. She is otherwise fit and well, takes no regular or over-the-counter medications. She denies the use of skin lightening creams. Examination revealed multiple well-defined bluish grey circular and linear macular lesions (Figure 1). There are palpable lines over her forehead and zygomatic arch, presumably secondary to the facial reconstruction surgery. A 4 mm punch biopsy was performed on the central forehead lesion (Figure 2). The sample subsequently underwent histopathological examination (Figure 3). Facial x-rays (Figure 4) were performed to assess if there were any metal fragments underlying the other pigmented lesions and a total of nine foreign bodies were identified: one needle-like foreign body within the soft tissues of the frontal region, three needle-like foreign bodies lateral to the left mandible, and five needle-like foreign bodies within the soft tissues at the territory of the right cheek. Argyria, either localised or generalised, is a rare dermatologic condition that presents with asymptomatic slate-grey or blue macules, secondary to silver deposits within the skin or mucous membranes. Skin discoloration is caused by the combined effects of chemical reduction of deposited silver compounds in the skin and the stimulation of melanocytes. Argyria typically shows silver granules at the edge of eccrine glands, in the walls of blood vessels, and along elastic fibres when viewed microscopically. Localised cutaneous argyria is very rare and occurs less frequently than generalised argyria [1, 2]. Localised argyria lesions can appear secondary to colloidal silver salt ingestion, occupational exposure, dental procedures (such as surgical endodontic procedure), topical silver sulfadiazine agents, acupuncture, earrings and nasal piercings [2-4]. Here we present a case of localised facial argyria post facial reconstruction surgery, which has not been previously reported to the best of our knowledge. Differential diagnosis for localised argyria often includes blue naevus, melanocytic lesions such as melanoma, angiomas and amalgam dental tattoos¹. Accidental tattoos resulting from the traumatic embedding of exogenous pigments such as asphalt, carbon particles or pencil-lead material should also be considered, as these can produce persistent grey-blue macules that closely mimic argyria both clinically and dermoscopically. Further investigations can include analysis of skin biopsies with scanning electron microscopy and energy-dispersive X-ray spectroscopy [5]. In our case, a metal staple was found on biopsy of one of the lesions and needle-like foreign bodies can be seen on x-ray underlying the pigmented areas. Histology (Figure 3) showed an unremarkable squamous epithelium with chronic inflammation and fibrosis, mainly seen deep in the dermis surrounding fragments of foreign material. These have an appearance of coarse black granules and needle-shaped non-retractile metal-like foreign bodies. In addition, yellowish-brown pigmentation of the elastic fibres throughout the dermis gives an appearance of pseudo-ochronosis with linear pigmentation seen surrounding the basement membrane of the eccrine ducts and the blood vessels, confirming the diagnosis of localised argyria. While stainless steel staples are commonly used in surgical procedures, surgical staples can sometimes be silver-coated or consist of silver-containing alloys. In most cases, the pigmentation is permanent and challenging to treat. Treatment options are limited, but conservative management, such as avoiding further silver exposure and engaging in sun protective behaviours, is recommended. Laser therapies have been shown to clear the pigment in argyria; however, pain is a major concern [6]. Our patient has opted for surgical excision of the most cosmetically sensitive areas of pigmentation and any underlying foreign bodies. Molly Papadopoullos: writing – original draft preparation. Amy Cunliffe: patient consent, editing, patient images. Rand Hawari: histology images and report. Kid Wan Shum: supervision and editing. The authors have nothing to report. All patients in this manuscript have given written informed consent for participation in the study and the use of their de-identified, anonymized, aggregated data and their case details (including photographs) for publication. Ethical Approval: not applicable. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Source: JEADV Clinical Practice

DOI: 10.1002/jvc2.70347

Authors: Molly Papadopoullos, Amy Cunliffe, Rand Hawari, Kid Wan Shum

Institution: University Hospitals of Derby and Burton NHS Foundation Trust

Language: English

Topic: Reconstructive Facial Surgery Techniques

Subfield: Surgery

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: gold

Estimated APC paid: $2,310