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Pluvy I, Randrianaridera E, Tahmaz I, Melin M, Gindraux F, Keime C, Ponche A, Petithory T, Pieuchot L, Anselme K, Brigaud I. Breast implant silicone exposure induces immunogenic response and autoimmune markers in human periprosthetic tissue. Biomaterials 2025; 317:123025. [PMID: 39719745 DOI: 10.1016/j.biomaterials.2024.123025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 09/13/2024] [Revised: 11/18/2024] [Accepted: 12/13/2024] [Indexed: 12/26/2024]
Abstract
Silicone-based breast implants are commonly used, but there are concerns about their long-term safety. While implantation results in the formation of a periprosthetic tissue that isolates the implant from the rest of the host body, silicone can leak and reach surrounding tissues. We combined histological analysis and gene expression profiling (RNA sequencing) of samples from human patients with silicone breast implants with different fillers (silicone or serum), surface topographies and/or shell rupture, and performed systematic cross-comparisons. Our study shows that exposure to silicone gel filler, even in clinically asymptomatic cases, induces an immune response. This response includes the expression of markers associated with various autoimmune diseases. This study provides the first biological evidence of an association between silicone implants and autoimmune markers, highlighting the need for further research and stricter implant safety regulations. We suggest that implant design factors, such as filler type and surface texture, may influence the inflammatory response. Re-evaluation of existing clinical trials is warranted to investigate the association between implant characteristics and potential health risks.
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Affiliation(s)
- Isabelle Pluvy
- Université de Franche-Comté, CHU Besançon, Laboratoire SINERGIES, Service d'orthopédie, traumatologie et chirurgie plastique, F-25000, Besançon, France
| | - Eve Randrianaridera
- Institut de Science des Matériaux de Mulhouse (IS2M), UMR 7361 CNRS/, Université de Haute Alsace (UHA), 15 rue Jean Starcky, 68057, Mulhouse Cedex, France
| | - Ismail Tahmaz
- Institut de Science des Matériaux de Mulhouse (IS2M), UMR 7361 CNRS/, Université de Haute Alsace (UHA), 15 rue Jean Starcky, 68057, Mulhouse Cedex, France
| | - Martine Melin
- Novotec, ZAC du Chêne, Europarc, 11 rue Edison, 69500, Bron, France
| | - Florelle Gindraux
- Université de Franche-Comté, CHU Besançon, Laboratoire SINERGIES, Service d'orthopédie, traumatologie et chirurgie plastique, F-25000, Besançon, France; Orthopaedic, Traumatology and Plastic Surgery Department, University Hospital of Besançon, 25000, Besançon, France
| | - Céline Keime
- GenomEast platform, IGBMC, CNRS UMR 7104, INSERM U1258, Université de Strasbourg, F-67400, Illkirch, France
| | - Arnaud Ponche
- Institut de Science des Matériaux de Mulhouse (IS2M), UMR 7361 CNRS/, Université de Haute Alsace (UHA), 15 rue Jean Starcky, 68057, Mulhouse Cedex, France
| | - Tatiana Petithory
- Institut de Science des Matériaux de Mulhouse (IS2M), UMR 7361 CNRS/, Université de Haute Alsace (UHA), 15 rue Jean Starcky, 68057, Mulhouse Cedex, France
| | - Laurent Pieuchot
- Institut de Science des Matériaux de Mulhouse (IS2M), UMR 7361 CNRS/, Université de Haute Alsace (UHA), 15 rue Jean Starcky, 68057, Mulhouse Cedex, France
| | - Karine Anselme
- Institut de Science des Matériaux de Mulhouse (IS2M), UMR 7361 CNRS/, Université de Haute Alsace (UHA), 15 rue Jean Starcky, 68057, Mulhouse Cedex, France
| | - Isabelle Brigaud
- Institut de Science des Matériaux de Mulhouse (IS2M), UMR 7361 CNRS/, Université de Haute Alsace (UHA), 15 rue Jean Starcky, 68057, Mulhouse Cedex, France.
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Schoberleitner I, Faserl K, Lackner M, Coraça-Huber DC, Augustin A, Imsirovic A, Sigl S, Wolfram D. Unraveling the Immune Web: Advances in SMI Capsular Fibrosis from Molecular Insights to Preclinical Breakthroughs. Biomolecules 2024; 14:1433. [PMID: 39595609 PMCID: PMC11592141 DOI: 10.3390/biom14111433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 10/07/2024] [Revised: 11/06/2024] [Accepted: 11/07/2024] [Indexed: 11/28/2024] Open
Abstract
Breast implant surgery has evolved significantly, yet challenges such as capsular contracture remain a persistent concern. This review presents an in-depth analysis of recent advancements in understanding the immune mechanisms and clinical implications associated with silicone mammary implants (SMIs). The article systematically examines the complex interplay between immune responses and capsular fibrosis, emphasizing the pathophysiological mechanisms of inflammation in the etiology of this fibrotic response. It discusses innovations in biomaterial science, including the development of novel anti-biofilm coatings and immunomodulatory surfaces designed to enhance implant integration and minimize complications. Emphasis is placed on personalized risk assessment strategies, leveraging molecular insights to tailor interventions and improve patient outcomes. Emerging therapeutic targets, advancements in surgical techniques, and the refinement of post-operative care are also explored. Despite notable progress, challenges such as the variability in immune responses, the long-term efficacy of new interventions, and ethical considerations remain. Future research directions are identified, focusing on personalized medicine, advanced biomaterials, and bridging preclinical findings with clinical applications. As we advance from bench to bedside, this review illuminates the path forward, where interdisciplinary collaboration and continued inquiry weave together to enhance the art and science of breast implant surgery, transforming patient care into a realm of precision and excellence.
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Affiliation(s)
- Ines Schoberleitner
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Müllerstraße 44, 6020 Innsbruck, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Klaus Faserl
- Protein Core Facility, Institute of Medical Chemistry, Biocenter, Medical University of Innsbruck, Innrain 80-82, 6020 Innsbruck, Austria
| | - Michaela Lackner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstraße 41, 6020 Innsbruck, Austria
| | - Débora C. Coraça-Huber
- BIOFILM Lab, Department of Orthopedics and Traumatology, Medical University of Innsbruck, Müllerstraße 44, 6020 Innsbruck, Austria
| | - Angela Augustin
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Anja Imsirovic
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stephan Sigl
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Dolores Wolfram
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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Kabir R, Stanton E, Sorenson TJ, Hemal K, Boyd CJ, Karp NS, Choi M. Breast Implant Illness as a Clinical Entity: A Systematic Review of the Literature. Aesthet Surg J 2024; 44:NP629-NP636. [PMID: 38636098 DOI: 10.1093/asj/sjae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 01/16/2024] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Breast implant illness (BII) has become a contentious subject in recent years. Although some studies have reported associations between breast implants and autoimmune diseases, others have failed to establish a definitive link. OBJECTIVES The objective of this study was to provide a comprehensive, up-to-date evaluation of the literature surrounding BII, with an emphasis on identifying patient-related factors that may be associated with BII. METHODS A systematic review was performed following PRISMA guidelines by searching the PubMed (MEDLINE), Embase, and Cochrane databases for relevant studies published in the last 20 years. RESULTS Thirty-one studies were included, which covered 39,505 implant patients with a mean [standard deviation] age of 44.2 [9.30] years. Fifteen studies reported implant explantation status, with 72.4% patients choosing to remove their implants. Among these, 9 studies reported symptom improvement in 83.5% patients. Fifty-three percent of patients undergoing explantation had total capsulectomy. Twenty-eight studies documented total numbers of patients experiencing symptoms related to BII, with 31.3% patients reporting such symptoms. Among these, 16 studies of 4109 BII patients distinguished whether the reason for implantation was cosmetic augmentation or reconstruction. When specified, more patients experiencing BII-related symptoms received implants for "cosmetic" vs "reconstructive" reasons (cosmetic, 3864/4109 [94.0%] vs reconstruction, 245/4109 [5.96%]; P < .001). CONCLUSIONS This review provides an overview of the current state of knowledge regarding BII. The study highlights a potential relationship between BII and indication for implants (cosmetic vs reconstructive) among other variables, offering valuable insight on factors associated with BII and directions for future research. LEVEL OF EVIDENCE: 3
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Nepon H, Allgayer R, Julien C, Petrecca S, Kalashnikov N, Safran T, Murphy A, Dionisopolous T, Davison P, Cerruti M, Vorstenbosch J. Altered Foreign Body Response at the Posterior Surface Compared to the Anterior Surface of Human Silicone Breast Implants. ACS Biomater Sci Eng 2024; 10:3006-3016. [PMID: 38640484 DOI: 10.1021/acsbiomaterials.3c01961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 04/21/2024]
Abstract
Soft implantable devices are crucial to optimizing form and function for many patients. However, periprosthetic capsule fibrosis is one of the major challenges limiting the use of implants. Currently, little is understood about how spatial and temporal factors influence capsule physiology and how the local capsule environment affects the implant structure. In this work, we analyzed breast implant capsule specimens with staining, immunohistochemistry, and real-time polymerase chain reaction to investigate spatiotemporal differences in inflammation and fibrosis. We demonstrated that in comparison to the anterior capsule against the convex surface of breast implants, the posterior capsule against the flat surface of the breast implant displays several features of a dysregulated foreign body reaction including increased capsule thickness, abnormal extracellular remodeling, and infiltration of macrophages. Furthermore, the expression of pro-inflammatory cytokines increased in the posterior capsule across the lifespan of the device, but not in the anterior capsule. We also analyzed the surface oxidation of breast explant samples with XPS analysis. No significant differences in surface oxidation were identified either spatially or temporally. Collectively, our results support spatiotemporal heterogeneity in inflammation and fibrosis within the breast implant capsule. These findings presented here provide a more detailed picture of the complexity of the foreign body reaction surrounding implants destined for human use and could lead to key research avenues and clinical applications to treat periprosthetic fibrosis and improve device longevity.
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Affiliation(s)
- Hillary Nepon
- Division of Surgical and Interventional Sciences, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
- Division of Plastic & Reconstructive Surgery, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
| | - Raphaela Allgayer
- Department of Materials Engineering, McGill University, Wong Building, 3610 Rue University, Montreal, Quebec H3A 0C5, Canada
| | - Cedric Julien
- Research Institute of the McGill University Health Centre, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
| | - Sarah Petrecca
- Faculty of Medicine and Health Sciences, McGill University, 3605 de la Montagne, Montreal, Quebec H3G 1M1, Canada
| | - Nikita Kalashnikov
- Division of Surgical and Interventional Sciences, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
- Faculty of Medicine and Health Sciences, McGill University, 3605 de la Montagne, Montreal, Quebec H3G 1M1, Canada
| | - Tyler Safran
- Division of Plastic & Reconstructive Surgery, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
| | - Amanda Murphy
- Division of Plastic & Reconstructive Surgery, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
| | - Tassos Dionisopolous
- Division of Plastic & Reconstructive Surgery, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
| | - Peter Davison
- Division of Plastic & Reconstructive Surgery, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
| | - Marta Cerruti
- Department of Materials Engineering, McGill University, Wong Building, 3610 Rue University, Montreal, Quebec H3A 0C5, Canada
| | - Joshua Vorstenbosch
- Division of Plastic & Reconstructive Surgery, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
- Research Institute of the McGill University Health Centre, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Room T5-204, Montreal, Quebec H3G 1A4, Canada
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Atkins DJ, Chau AL, Rosas JM, Chen YT, Chan ST, Urueña JM, Pitenis AA. Silicone Implant Surface Roughness, Friction, and Wear. SURFACE TOPOGRAPHY : METROLOGY AND PROPERTIES 2023; 11:014010. [PMID: 37193116 PMCID: PMC10181813 DOI: 10.1088/2051-672x/ac9f5a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Academic Contribution Register] [Indexed: 05/18/2023]
Abstract
Textured silicone breast implants with high average surface roughness ("macrotextured") have been associated with a rare cancer of the immune system, Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Silicone elastomer wear debris may lead to chronic inflammation, a key step in the development of this cancer. Here, we model the generation and release of silicone wear debris in the case of a folded implant-implant ("shell-shell") sliding interface for three different types of implants, characterized by their surface roughness. The "smooth" implant shell with the lowest average surface roughness tested (Ra = 2.7 ± 0.6 μm) resulted in average friction coefficients of μavg = 0.46 ± 0.11 across 1,000 mm of sliding distance and generated 1,304 particles with an average particle diameter of Davg = 8.3 ± 13.1 μm. The "microtextured" implant shell (Ra = 32 ± 7.0 μm) exhibited μavg = 1.20 ± 0.10 and generated 2,730 particles with Davg = 4.7 ± 9.1 μm. The "macrotextured" implant shell (Ra = 80 ± 10 μm) exhibited the highest friction coefficients, μavg = 2.82 ± 0.15 and the greatest number of wear debris particles, 11,699, with an average particle size of Davg = 5.3 ± 3.3 μm. Our data may provide guidance for the design of silicone breast implants with lower surface roughness, lower friction, and smaller quantities of wear debris.
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Affiliation(s)
- Dixon J Atkins
- Department of Biomolecular Science and Engineering, University of California, Santa Barbara
| | - Allison L Chau
- Materials Department, University of California, Santa Barbara
| | - Jonah M Rosas
- Department of Biomolecular Science and Engineering, University of California, Santa Barbara
| | - Yen-Tsung Chen
- Department of Chemical Engineering, University of California, Santa Barbara
| | - Samantha T Chan
- Molecular, Cellular, and Developmental Biology Department, University of California, Santa Barbara
| | - Juan Manuel Urueña
- NSF BioPACIFIC Materials Innovation Platform, University of California, Santa Barbara
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Elaissi S, Alsaif NAM. Modelling of Nonthermal Dielectric Barrier Discharge Plasma at Atmospheric Pressure and Role of Produced Reactive Species in Surface Polymer Microbial Purification. Polymers (Basel) 2023; 15:polym15051235. [PMID: 36904476 PMCID: PMC10007475 DOI: 10.3390/polym15051235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 02/07/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
A nonthermal atmospheric plasma reactor was used to sterilize polymer surfaces and satisfy safety constraints in a biological medium. A 1D fluid model was developed using COMSOL Multiphysics software® 5.4 with a helium-oxygen mixture at low temperature for the decontamination of bacteria on polymer surfaces. An analysis of the evolution of the homogeneous dielectric barrier discharge (DBD) was carried out through studying the dynamic behavior of the discharge parameters including the discharge current, the consumed power, the gas gap voltage, and transport charges. In addition, the electrical characteristics of a homogeneous DBD under different operating conditions were studied. The results shown that increasing voltage or frequency caused higher ionization levels and maximum increase of metastable species' density and expanded the sterilization area. On the other hand, it was possible to operate plasma discharges at a low voltage and a high density of plasma using higher values of the secondary emission coefficient or permittivity of the dielectric barrier materials. When the discharge gas pressure increased, the current discharges declined, which indicated a lower sterilization efficiency under high pressure. A short gap width and the admixture of oxygen were needed for sufficient bio-decontamination. Plasma-based pollutant degradation devices could therefore benefit from these results.
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de Faria Castro Fleury E, Castro C. Magnetic resonance classification proposal for fibrous capsules in breast silicone implants. Clin Imaging 2022; 91:26-31. [PMID: 35986974 DOI: 10.1016/j.clinimag.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 05/09/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To propose a new classification system for evaluating fibrous capsules around silicone implants using magnetic resonance. METHODS We retrospectively evaluated 90 consecutive patients who underwent breast MRI scans at a single center from February to March 2022. All patients with silicone implants and contrast dynamic sequences were included. Two radiologists classified the fibrous capsules according to the proposed classification in four grades. Interobserver variability was calculated for the final score. For comparison purposes, the inter-rater agreement of background parenchymal enhancement and the amount of fibroglandular tissue were also calculated. RESULTS Reader 1 classified 2 (2.2) fibrous capsules as grade 1, 7 (7.8) as grade 2, 18 (20.0) as grade 3, and 63 (70.0) as grade 4, whereas reader 2 classified 1 (1.1), 9 (10.0), 24 (26.7), and 56 (62.2) fibrous capsules, respectively, for each grade. The interobserver agreement for fibrous capsule classification was moderate (ĸ = 0.65). The inter-rater agreement of background parenchymal enhancement and amount of fibroglandular tissue were fair: ĸ = 0.50 and ĸ = 0.44, respectively. CONCLUSION Our study proposes classifying FC by MRI in patients with SI to standardize the description and classification of the findings with good interobserver agreement.
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Affiliation(s)
| | - Caio Castro
- Femme Laboratório da Mulher, São Paulo/ Brazil
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de Faria Castro Fleury E, Brawer AE. Fundamentals of Breast Implant Illness and Device Imaging. Int J Inflam 2022; 2022:4155530. [PMID: 35996624 PMCID: PMC9392643 DOI: 10.1155/2022/4155530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 05/08/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
The past six decades of silicone breast implant history encompass manufacturing secrecy, regulatory laxity, inadequate informed consent, clever advertising, overly simplistic research methodology, diverse and controversial opinions, changing social patterns, safety issues, information ambiguity, speculation, and deception. This review addresses the verifiable clinical, radiological, and pathological aspects of these devices, particularly with regard to silicone bleeding. This information can favorably assist practitioners and radiologists facing diagnostic challenges encountered in patients with silicone breast implants.
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Affiliation(s)
| | - Arthur E. Brawer
- Drexel University, Philadelphia, PA, USA
- Robert Wood Johnson, New Brunswick, NJ, USA
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Atiyeh B, Emsieh S. Effects of Silicone Breast Implants on Human Cell Types In Vitro: A Closer Look on Host and Implant. Aesthetic Plast Surg 2022; 46:2609-2611. [PMID: 35267065 DOI: 10.1007/s00266-022-02821-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 11/01/2022]
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Atiyeh B, Emsieh S. Breast Implant Illness (BII): Real Syndrome or a Social Media Phenomenon? A Narrative Review of the Literature. Aesthetic Plast Surg 2022; 46:43-57. [PMID: 34231017 DOI: 10.1007/s00266-021-02428-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 05/02/2021] [Accepted: 06/13/2021] [Indexed: 12/16/2022]
Abstract
Breast implant illness (BII) is a condition characterized by elusive diagnostic criteria and self-reported diverse disabling and distressing physical and psychological symptoms. With currently significant increase in public awareness, BII is perhaps becoming the most controversial subject in aesthetic and reconstructive breast surgery, generating heated debates between those who do not believe such a condition exists and those who demand its acceptance as a recognized diagnosis. Silicone incompatibility has been associated with "autoimmune/inflammatory syndrome induced by adjuvants" (ASIA syndrome) or Shoenfeld's syndrome. It is still unclear, however, whether BII symptoms would have occurred if no implants had been placed in the first place. The purpose of this literature review is to analyze critically the current state of scientific evidence related to this condition. Though the psychosomatic theory is most likely, the mechanism of BII symptoms is probably multifactorial. At present, BII being an underlying connective tissue disorder cannot be confirmed; moreover, whether improved aesthetic outcome and patient's overall satisfaction with the profile of their reconstructed or augmented breasts translate into decreased self-reported BII symptoms is still not well elucidated. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Bishara Atiyeh
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Saif Emsieh
- American University of Beirut Medical Center, Beirut, Lebanon.
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Cooter RD. Commentary on: Particulate Debris Released From Breast Implant Surfaces Is Highly Dependent on Implant Type. Aesthet Surg J 2021; 41:NP794-NP795. [PMID: 33765115 DOI: 10.1093/asj/sjab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/13/2022] Open
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