Making a claim over biopolymers: what documents you need and what can be proved

First of all, an honest clarification about what this page is and what it is not.

This is not legal advice. We do not say whether you have a case, by what route, or within what deadline: that is a solicitor’s job and it depends on circumstances that cannot be settled on a website. What we can explain, because it is our ground, is what medical documentation exists, how to obtain it and what it can actually establish.

And we will say the most important thing up front, which usually comes as a surprise: the hardest thing to prove in these cases is not the harm. It is the product.

If what you want is to resolve the medical side, that is in the guide to biopolymer removal and, if you have already had surgery, in a second opinion.

Three different things called a “report”

It is the commonest confusion, and it wastes time.

1. The clinical report. It is issued by the doctor treating you and describes what they find: examination, tests, diagnosis, treatment proposed or carried out. It is the ordinary document of care. It serves your treatment, and also as the documentary basis for anything else.

2. A copy of your medical record. It is not a new report: it is access to what already exists. The law recognises a patient’s right to access the documentation in their medical record and to obtain a copy of the data it contains. It is requested from the premises where you were treated.

3. The expert witness report. It is drawn up by an expert for specific proceedings, assessing the harm and answering the questions those proceedings raise. It is not the same as a clinical report, although it draws on one, and whoever decides whether it is needed and with what focus is your solicitor.

What to ask for, and from whom

If you were injected at healthcare premises:

• A copy of your medical record from those premises. It is a right recognised in law.
• The consent form you signed, if there was one.
• Any document identifying the product: name, batch, reference, invoice.

If you later had surgery to remove it:

• The theatre report. The law expressly includes it in the minimum content of a medical record, so if there was surgery that document must exist. It is also the one that says what was found and what was removed, which is the most valuable part.
• The discharge summary and the follow-up reports.
• The imaging, with the images and not just the report.

⚠️ And do it soon. Healthcare premises must keep clinical documentation for at least five years from the date of discharge of each episode of care. Beyond that legal minimum, whether premises still hold yours is no longer guaranteed by that period.

If you were injected outside healthcare premises — at home, in non-medical premises, with no record at all — then there is no medical record to ask for. It is the most frequent situation and the most difficult, and the next section is about that.

What can and cannot be proved

Here is this page’s real contribution, and it is worth reading before investing money and energy.

What medical documentation can establish

• That there is foreign material in the tissue. Imaging demonstrates it, and a biopsy, when done, shows the foreign body reaction: granulomas, giant cells, fibrosis.
• Where it is and how much there is. That is what an MRI answers, as explained in the diagnosis page.
• What harm it has caused: symptoms, complications, abnormal test results, functional limitation.
• What treatment has been needed and what is still to be done.

What almost never can be established

Which specific product it was. And this surprises everyone.

No imaging test gives the brand name of what you were injected with. A biopsy demonstrates the reaction, it does not identify the product. And material removed at surgery is not sent for analysis in routine practice.

There are laboratory techniques that can identify it, and indeed their authors expressly note their medico-legal interest: in a 2013 study a database was built of the infrared spectra of commercial fillers and with it the injected filler was identified in the tissue of seven patients with severe complications from an unknown product.

But it has a limit that works against you in exactly these cases: a commercial reference product is needed to compare against. If what was injected was industrial-grade silicone or a home-made mixture — which is the most usual scenario in clandestine injection — there is no spectrum to match. It is set out in the diagnosis page.

Who injected it and what you were told. If there were no premises, no paperwork and no invoice, medical documentation cannot make up for it. It can establish the harm; it cannot establish the origin.

The two processes are not the same

It deserves a section of its own because it is a frequent mistake and an expensive one in time.

The medical process seeks to resolve your health problem: to find out what you have, to decide whether to operate or monitor, to treat whatever appears.

The claims process seeks something else, is directed at other people and has its own timescales and requirements.

They support each other — the documentation from the first feeds the second — but they do not replace each other, and mixing them usually delays the first. Our recommendation is simple: deal with the medical side first, and gather the documentation along the way. When you want to take the legal step, you will have what you need to hand and you will have lost less time.

What we do and what we do not

So that you do not waste a consultation finding out: at the Instituto de Cirugía Plástica del Mediterráneo we do not produce reports for the purpose of a claim and we do not act as expert witnesses. Neither for nor against, neither in our own cases nor in anyone else’s.

What we do generate, like any healthcare premises, is your medical record: what is found on examination, the imaging requested and its results, the report of the procedure if you are operated on here, and the material removed, with its description and its histopathology. All of that is yours and you can ask for a copy — the right of access is a few lines above — and it is exactly the documentation a solicitor will ask you for. The difference is that it is generated because it is part of your care, not written for proceedings.

If you need an expert witness report, it is issued by a medico-legal expert, and your solicitor will be able to guide you: it is a different role from that of the surgeon treating you, and that separation works in your favour.

Frequently asked questions

Do I have the right to ask for my medical record?

Yes. The Spanish patient autonomy act recognises the right to access the documentation in a medical record and to obtain a copy of the data it contains.

I had surgery and was not given any report. Is that normal?

The theatre report is part of the minimum content of a medical record, so if there was surgery it must exist. You can ask the premises for it.

How long do they keep my record?

Premises must keep clinical documentation for at least five years from the date of discharge of each episode of care. That is why it is worth asking as soon as possible.

Can it be proved what I was injected with?

Rarely. Imaging gives no brand names, a biopsy demonstrates the reaction but does not identify the product, and material removed is not routinely analysed. There are laboratory techniques capable of identifying it, but they need a reference product to compare against, and with industrial silicone or home-made mixtures that reference does not exist.

I had it done in a house, with no paperwork. Can I do anything?

From a medical point of view, yes: what you have, where it is and what harm it has caused can be documented. From the point of view of a claim, the absence of any record is a real difficulty, and assessing it is a matter for a solicitor.

Is a medical report any use in court?

A clinical report describes your care situation. For proceedings an expert witness report is usually produced as well, answering the specific questions those proceedings raise. Who needs one and with what focus is decided by your solicitor.

Can I make a claim and have surgery at the same time?

They are different processes and they do not rule each other out. What we recommend is not delaying your medical care while the other one moves along.

And if what I want is a sick note, not to make a claim?

That is a different thing again and it also has its rules: who issues the note and what part the surgeon’s report plays is in recovery and sick leave.

Sources

• Spain. Act 41/2002 of 14 November, the basic act regulating patient autonomy and rights and obligations regarding clinical information and documentation. BOE no. 274, 15 November 2002. Article 18.1: “The patient has the right of access, with the reservations set out in paragraph 3 of this article, to the documentation in their medical record and to obtain a copy of the data it contains”. Article 15.2: among the minimum content of a medical record is, in point (k), “the theatre report or record of the birth”. Article 17.1: healthcare premises are obliged to keep clinical documentation “for at least five years from the date of discharge of each episode of care”. https://www.boe.es/buscar/act.php?id=BOE-A-2002-22188
• Persichetti P, Palazzolo D, Tenna S, Poccia I, Abbruzzese F, Trombetta M. Dermal filler complications from unknown biomaterials: identification by attenuated total reflectance spectroscopy. Plast Reconstr Surg. 2013;131:597e-603e. A pilot study in which a database of the infrared spectra of commercial fillers was built and pathological tissue from seven patients with severe complications from unknown fillers was then analysed; comparing the absorption bands with the reference database made it possible to identify the injected filler; the authors note that knowing which filler was previously injected can be crucial both for selecting treatment and for resolving medico-legal questions. https://pubmed.ncbi.nlm.nih.gov/23542278/
• Cinotti E, Perrot JL, Labeille B, et al. Identification of a soft tissue filler by ex vivo confocal microscopy and Raman spectroscopy in a case of adverse reaction to the filler. Skin Res Technol. 2015;21:114-118. A single case in which confocal microscopy on the fresh specimen and Raman spectroscopy identified methacrylate; the authors present them as tools complementary to conventional histopathology. https://pubmed.ncbi.nlm.nih.gov/25066771/
• Hormaza-Jaramillo A, Peñaloza Gonzalez D, Benavides-Ibarra SA, et al. Severe Complications Due to Biopolymers in a Patient With Autoimmune Disease: A Case Report and Review of the Literature. Aesthet Surg J Open Forum. 2025;7. MRI showed exogenous material with signs of severe inflammation of the surrounding tissue and the biopsy was consistent with foreign body granulomas with a “Swiss cheese” morphology. https://pubmed.ncbi.nlm.nih.gov/40979311/

Book your consultation

Whatever you do next, there is one step worth taking now that depends on no legal decision: gathering your documentation. The medical record from wherever you were treated, the theatre report if there was surgery and the imaging with its files.

And if you do not yet have documented what you are carrying right now, that starts with an assessment with imaging.

Clinical confirmation by the surgeon

Dr Enrique Salmerón González

Specialist in Plastic, Aesthetic and Reconstructive Surgery
Registration no. 46/4624077

Dr Elena García Vilariño

Specialist in Plastic, Aesthetic and Reconstructive Surgery
Registration no. 46/4624503

Last reviewed: 6 September 2026. This content is for information only and does not replace an individual assessment by a healthcare professional.