SYSTEMIC INFLAMMATORY DISORDER RELATED TO FIBROUS BREAST CAPSULES AFTER SILICONE IMPLANT REMOVAL (for Sandy et al)

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SYSTEMIC INFLAMMATORY DISORDER RELATED TO FIBROUS BREAST CAPSULES AFTER SILICONE IMPLANT REMOVAL

Author: Copeland M, Kressel A, Spiera H, Hermann G, Bleiweiss IJ Address: Dept. Surgery, Mt Sinai School of Medicine, City Univ of New York, NY Source: Plastic & Reconstructive Surgery Journal, Nov., 1993, 92:6, 1179-81

Silicone breast implants have been implicated in inflammatory disorders of connective tissue. The fibrous capsules that form around these implants are usually inert and are not generally removed when the prostheses are explanted. We report patient in whom reactive bilateral submammary cysts and systemic inflammation developed when intact silicone breast implants were removed without capsulectomy.

The improvement in systemic symptoms which followed excision of the capsules and the histopathologic findings raise the possibility that retained silicone material within the wall of the capsule may contribute to adverse reactions in susceptible patients.

CASE REPORT

A 56 year old Caucasian woman underwent bilateral augmentation mammaplasty with silicone implants in the submammary position 16 years before reevaluation. Firmness of both breasts had developed in the first year postoperatively, and closed capsulotomies, were performed three times with softening of breast texture. Six years after implantation, open capsulotomies were carried out along with insertion of new silicone implants.

Nine years later, though the breasts remained supple, polyarthralgias developed. Rheumatologic evaluation revealed an antinuclear antibody, and the erythrocyte sedimentation rate was accelerated at 40 mm/h. Six months after the onset of arthralgia, the fibrous walls of the breast capsules were incised and the implants removed; the capsular shells were left in situ. Intraoperatively, gel " bleed " was observed extending into the walled breast cavities.

Postoperatively, arthralgia subsided, but a month later spiking fevers developed, reaching a peak of 105 F. Physical examination revealed bilateral axillary lymphadenopathy and mammary erythema without wound purulence. The hemogram, blood chemistry profile, and urinalysis were unremarkable. Fever persisted despite empirical antibiotic therapy, and blood cultures grew no pathogens.

Computed tomography of the thorax revealed a 5 x 3 x 5 cm cystic lucency in the region of the right breast capsule containing radiopaque densities and a similar structure measuring 4.5 x 1.5 x 5 cm on the left (Figure not included). Six months after open capsulotomies, there was bilateral breast tenderness, and submammary masses were palpable. Axillary lymphadenopathy was more prominent on the right than on the left. Mammography revealed fluid- filled masses in the right and left submammary positions, 5 and 3.5 cm in diameter, respectively, incorporating radiopaque densities (Figure not included).

The breasts were surgically explored and the submammary collections removed. Well-encapsulated cystic masses were encountered in continuity with dense fibrous and mammary tissue. The cysts contained serosanguineous fluid with fragments of silicone embedded in the walls.

The cyst walls and surrounding fibrous material were excised, and suction drainage was provided through the inframammary incisions. A single 8-mg dose of dexamethasone was given intraoperatively; a cephalosporin antibiotic was administered preoperatively and continued orally for 10 days postoperatively. The drains were removed on the second postoperative day. Breast tenderness and pain subsided along

with axillary lymphadenopathy, and there were no further episodes of fever.

Grossly, the excised specimen consisted of multiple fragments of thick, fibrous capsular wall with surrounding fatty tissue and small amounts of interspersed breast tissue. Microscopically, the capsule appeared densely fibrotic and hyalinized, lined by organized hematoma. Many vacuolated histiocytes were present within and next to fibrous tissue; these cells contained refractile, nonstaining, nonpolarizable material, consistent with foreign-body reaction (Figure not included). This material also was present in the extracellular spaces in large and small aggregates. Areas of granulation tissue, fat necrosis, and a minimal lymphoplasmacytic inflammatory infiltrate were identified in the scant breast tissue.

DISCUSSION

While identification of silicone gel in the capsules around mammary implants has been described previously, the fate of retained fibrous capsules after removal of silicone implants is not widely recognized. Review of the literature yielded only a single case report of a serous cyst that developed after replacement of a subglandular silicone implant in the submuscular position because of capsule contraction. Silicone leakage was not described, and the authors speculated that cyst formation was a reaction to residual fibrous capsular material, termed a pseudosheath. Cyst formation as a consequence of retained silicone implant capsules has not been reported previously.

Although silicone is a chemically inert substance, the biologic response to silicone granuloma.3-6 Histologically, such granulomas are characterized by macrophage accumulation, fibroblastic reaction, and giant-cell infiltration. This cellular response produces chronic inflammation, which is thought to mediate the immune phenomena associated with silicone breast implants. Silicone implants have been associated with an inflammatory syndrome characterized by pain, swelling, palpable capsular contracture, arthralgia, systemic symptoms, or serologic abnormalities, as well as manifestations of systemic sclerosis or other immune disorders of connective tissue.7-11

Thomsen et al described dense fibroblast accumulation in the fibrous capsules around silicone implants and related the local inflammatory response to the concentration of silicone. In contract, Jennings et al found no consistent relationship between the amount of silicone in adjacent breast tissue and the extent of capsular contracture.

Silicone leached from the implants was limited to the inner 2 mm of the capsule, and the amount of silicone in the capsules was different in the right and the left breasts of the same individual. We cannot exclude the possibility that silicone that dispersed to other body locations than the capsule in our patient might have contributed to the systemic inflammatory response, but the amount detected in the capsule seems sufficient to have been responsible, and symptoms subsided once this was removed.

The American Society of Plastic and Reconstructive Surgeons has recommended that fibrous capsules be left in place when silicone implants are removed, unless thickening of the capsule produces breast distortion or rupture of the implant is complicated by extrusion of silicone contents.

SUMMARY

Silicone breast implants have been associated with connective-tissue inflammatory syndromes such as systemic sclerosis, and as with other artificial breast prostheses, fibrous capsules tend to form around the implants. The capsular tissue is generally considered inert and typically is left in situ when the prostheses are explanted. We report a patient who formed symptomatic bilateral submammary cysts associated

with pain, swelling, arthralgia, fever, axillary lymphadenopathy, accelerated erythocyte sedimentation rate, and antinuclear antibody following removal of intact silicone breast implants without capsulectomy.

Clinical improvement followed removal of the capsules, which histologically displayed fragments of silicone, fibrous tissue, and inflammatory cells. Our experience suggests that when silicone breast implants are thought to be the cause of a clinical inflammatory syndrome characterized by mammary pain, swelling, arthralgia, or serologic abnormalities, consideration should be given to removing the capsules entirely so that the chance of a perpetuating reaction will be reduced.

Copeland, D.M.D., M.D. Mount Sinai Medical Center, Box 126 Fifth Avenue at 100th Street New York, NE 10029

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