Clinical significance of intracapsular fluid in patients' breast implants

Sarcoidosis Presenting as Late Seroma Mimicking Breast Implant-Associated Anaplastic Large Cell Lymphoma

ABSTRACT

Late seroma related to breast silicone implants is a rare complication. Interest for its characterization has grown after its association with the recently described breast implant-associated anaplastic large cell lymphoma. The differential diagnosis includes infectious diseases, mechanical and traumatic causes, tumors, postpartum seroma, and inflammatory, allergic, or idiopathic causes.Sarcoidosis has been associated with breast silicone implants over the last decades, but it has never been reported as a cause of breast effusion. We describe a rare presentation of sarcoidosis as a late breast implant seroma simulating the clinical features and radiologic findings of breast implant-associated anaplastic large cell lymphoma and highlight that sarcoidosis can be suspected by the presence of nonnecrotizing epithelioid granulomas in the cytology, with a characteristic inverted ratio of CD4/CD8 T cells.The aims of this article are to review the current evidence about sarcoidosis related to silicone implants and breast cancer, provide a new alternative in the differential diagnosis of late seroma, and advise the scientific community how early implant removal can improve the disease.

The Evolution of Breast Implants

The present review traces the evolution of breast implants over the past 50 years. During the early years (from 1951 to 1962), a number of different sponges were used for breast augmentation. The first of these was Ivalon, a polyvinyl alcohol sponge. Other sponges were introduced subsequently, including Etheron (a poly-ether sponge popularized by Dr Paule Regnault in Montreal) and Polystan (fabric tapes that were wound into a ball). Subsequently, polyethylene strips enclosed in a fabric or polyethylene casing were also used for breast augmentation. All of these materials had similar outcomes. Although the initial results were encouraging, within one year of augmentation, breasts became very firm and lost over 25% of their volume. This was due to capsular contracture, a process that would lead to the collapse of the sponge and would continue to plague plastic surgeons and their patients for the next 50 years. In 1963, Cronin and Gerow introduced the silicone gel ‘natural feel’ implant, which revolutionized breast augmentation surgery. Approximately 10 companies have manufactured many types of silicone gel breast implants over the years. They obtained their raw materials for gels and shells from a similar number of other companies that entered and left the market at intervals. Many of the suppliers and manufactures changed their names and ownership over the years, and most of the companies no longer exist. No formal process of United States Food and Drug Administration premarket testing was in effect until 1988. There have been three generations of gel implants and a number of other lesser variations. First-generation implants (1963 to 1972) had a thick gel and a thick wall. They have generally remained intact over the years. Second-generation implants (1973 to the mid-1980s) had a thin gel and a thin wall. They have tended to disrupt over time. Third-generation implants (mid-1980s to 1992) had a thick wall and a thick gel. Except for those made by Surgitek, these implants remain intact. The breast implant business was competitive and companies introduced changes such as softer gels; barrier low-bleed shells; greater or lesser shell thickness; surface texturing; different sizes, contours and shapes; and multiple lumens in search of better aesthetics. Ultimately, more than 240 styles and 8300 models of silicone gel breast implants were manufactured in the United States alone. Inflatable breast implants were introduced in Toulons, France in 1965 (the Simaplast implant). There have been three main eras of inflatable implants: seamed, high-temperature vulcanized and room temperature vulcanized implants. In 1973, spontaneous deflation rates of 76% to 88% over three years were reported for many types of inflatable implants. Because of this, most plastic surgeons abandoned their use. From 1963 until the moratorium on gel implants (January 6, 1992), about 95% of all breast implants inserted were silicone gel filled. Only 5% were saline filled. Since the moratorium, this ratio has been reversed and 95% of all implants have been saline-filled, with only 5% being gel filled. Polyurethane-coated (PU) silicone gel implants were introduced in 1968. Over the next 20 years, they were shown to reduce the prevalence of capsular contracture to 2% to 3%. Other forms of surface texturing (Biocell, Siltex, multistructured implant) also appear to reduce capsular contracture with gel implants, but the reduction has been much less dramatic than that seen with PU implants. Contoured (anatomical) shaping appears to have advantages in some patients with gel implants. No such advantage has been seen for texturing or shaping with saline-filled implants. The story of gel implants has culminated in the largest class action lawsuit in medical history, with US$4.2 billion being awarded to women with silicone gel implants. During the past decade, there has been a tremendous amount of research on the reaction of a woman's body to gel implants. A plethora of studies have demonstrated that silicone gel implants are not associated with the development of any medical diseases. Silicone gel-filled implants have therefore been approved for use under Health Canada's Special Access Program. Silicone gel-filled implants may now be used in certain patients in whom they would provide advantages over saline implants. Silicone gel implants have not been approved for unrestricted general use. The evolution of breast implants occupies the past half century. It has been a stormy course, with many exciting advances and many bitter disappointments. The universe of breast implants is large and the variation among the implants is substantial. The purpose of the present review is to trace the evolution of breast implants over the past 50 years.

Is late seroma a phenomenon related to textured implants? A report of rare complications and a literature review

BACKGROUND

Late seroma is an infrequent complication that manifests as fluid collection in the periprosthetic space at least 1 year after breast enlargement surgery. Interest in late seroma has grown with the potential connection between breast implants and anaplastic large cell lymphoma (ALCL), which presents with clinical symptoms similar to those of late seroma. This report presents a case of late seroma experienced by a patient with a history of multiple implant ruptures and a review of the relevant literature.

METHODS

Details are reported for a patient who presented with sudden swelling of an augmented breast that was initially suspected to be symptomatic of ALCL. A literature search of PubMed regarding this phenomenon also was conducted.

RESULTS

The literature review identified 14 articles on late seroma involving 60 patients, including the reported case. Analyses included epidemiology, etiology, and management strategy. Although a detailed statistical analysis was not performed, 55 cases (92 %) of late seroma occurred that involved patients with textured implants. No evidence-based guideline for the management of late seroma has been established, although the patients were managed successfully in all cases using various strategies.

CONCLUSIONS

The reported case and data from the literature provide evidence of a relationship between textured implant use and late seroma. Based on their review, the authors offer "sequential treatment steps," from conservative treatment to surgical management, which will be helpful for successful management of future late seroma cases. However, further study is needed to clarify the relationship, if any, between a particular type of textured implant and the development of late seroma.

LEVEL OF EVIDENCE V

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 .

Late unilateral breast enlargement after insertion of silicone gel implants: A histopathological study

Late unilateral breast enlargement after the insertion of silicone gel breast implants is a very rare phenomenon. The present study reports five women who presented with this finding over the past 20 years. Three of these patients presented with late unilateral hematomas, which developed nine, 12 and 14 years, respectively, after initial breast augmentation, in the absence of any known trauma. These patients presented for treatment one, four and 12 months, respectively, after their breast enlargements initially appeared. Two of these patients had developed chronic expanding hematomas. Extensive histopathological analyses of the capsules of all three patients provided explanations for the etiologies and progressions of the findings in these patients. In each of the three patients, the etiology of the hematoma was consistent with erosion of a capsular artery. Numerous large vessels were seen within the wall of the capsules. In each case, there was a class IV capsular contracture, which could have increased the friction of the intact implant against the capsule, and there was both old (hemosiderin deposits) and new bleeding into the pocket from the capsules. This supports the concept that numerous episodes of bleeding had occurred in each case. Histopathology also demonstrated the progression of the hematomas. After four weeks, only liquefied hematoma was present, while after four months, there were both liquefied hematoma and blood clotting. The hematoma on the surface of the capsule was becoming organized peripherally, but not centrally. After 12 months, the hematoma was becoming very well organized compared with the hematoma at four months. In one of the two remaining cases, late infection was the cause of the breast enlargement. Histopathology of this capsule showed that the involved capsule was six times as thick as the other side. It also showed edema and infiltration by scattered mononuclear cells, polymorphonuclear cells, and irregular crenated and degenerating nuclei. In the final patient, chronic inflammation appeared to be the cause of the breast enlargement. The histopathology of this capsule was unique. Its inner surface showed re-epithelialization and metaplasia of the ductal epithelium to form stratified squamous epithelium with early surface keratinization. These findings are consistent with synovial metaplasia. Several areas of the fibrous portion of the capsule showed patchy loss of cellular staining with loss of nuclei, indicative of necrosis. This produced a 'washed out' staining appearance. This tissue was paucivascular and fibrotic, and showed areas of fibrinoid necrosis, suggestive of mechanical abrasion and increased pressure.

Seroma as a late complication after breast augmentation

This report with late seromas occurring in the periprosthetic cavity. This complication is a rare development after breast augmentation. From 1996 to 2009, the authors performed 568 initial breast augmentation procedures. During this period, they observed late seromas in six cases. In five of the six cases, the initial operations were performed by the authors (0.88% of all breast augmentation operations performed at the authors' center during the respective period). In one case, the operation had been performed in another clinic. Late seromas occurred at various intervals 2 to 10 years after the initial breast augmentation. In five of the six reported cases, revision surgery was required. In one case, conservative treatment was applied. An implant rupture was observed in only one case. In the remaining five cases, the implants were intact. In the authors' opinion, seromas may occur when any sliding surfaces are present and as a result of micromotion of implants in cavities. The inner surface of a capsule with a synovial metaplasia becomes a target for chronic infections.

Breast autoinflation with sterile pus as a marker of implant rupture: single-stage treatment and outcome for five consecutive cases

Augmentation mammaplasty is one of the most common aesthetic procedures performed. Early complications of the procedure are hematoma and infection, and late complications include capsular contracture and device failure or its displacement. Failure of saline implants is readily identifiable, whereas rupture of silicon gel implants can occur without symptoms due to lack of volume loss. Autoinflation of the breast caused by intracapsular and intraprosthetic collection of sterile pus has been reported. A series of five consecutive breast autoinflations with sterile pus is presented. All the patients presented with acute swelling of the breast 2-10 years after prostheses implantation. Intracapsular sterile pus with macroscopic shell tear was seen in four cases. In the remaining case, an intracapsular and intraprosthetic collection of sterile pus with a tear in an otherwise intact implant was seen under the microscope. All five cases showed no microbial growth on culture or sensitivity, and all were treated using a single-stage procedure. The follow-up periods ranged from 8 weeks to 1 year without recurrence of symptoms.

Les complications postopératoires en chirurgie d'augmentation mammaire

Augmentation mammoplasty is one of the most popular and frequently performed aesthetic operations. The implants are not, however, without complications; and many have been reported in order to this surgical procedure: hematoma, infection, seroma, capsular contracture, rupture ... Current surgical practices and modern implants used for breast augmentation produce fewer complications than procedures and devices of the past. The aim of this work is to index most common post operative breast complications. The prevention and the treatment procedure of these complications are also reported. A good knowledge of all these points seems to be essential to improve the quality of the final results and patients satisfaction.

The infected or exposed breast implant: management and treatment strategies

Among the potential complications associated with the use of breast implants are the risks of periprosthetic infection and device extrusion. There is little published information about the effective management of these situations. Conservative recommendations include antibiotic therapy and removal of the implant until resolution of the infection or until the wound has healed. A retrospective review identified patients with periprosthetic infection or threatened or actual device exposure treated by the senior author. Twenty-four patients encompassing 26 affected prostheses were available for review and were classified into seven groups based on initial presentation as follows: group 1, mild infection (n = 8); group 2, severe infection (n = 4); group 3, threatened exposure without infection (n = 3); group 4, threatened exposure with mild infection (n = 3); group 5, threatened exposure with severe infection (n = 1); group 6, actual exposure without clinical infection (n = 5); and group 7, actual exposure with infection (n = 2). To salvage the prosthesis in these patients, various treatment strategies were utilized. All patients with a suspected infection or device exposure were started immediately on appropriate antibiotic therapy (oral antibiotics for mild infections and parenteral antibiotics for severe infections). Salvage methods included one or more of the following: antibiotic therapy, débridement, curettage, pulse lavage, capsulectomy, device exchange, primary closure, and/or flap coverage. Twenty (76.9 percent) of 26 threatened implants with infection or threatened or actual prosthesis exposure were salvaged after aggressive intervention. The presence of severe infection adversely affected the salvage rate in this series. A statistically significant difference exists among those patients without infection or with mild infection only (groups 1, 3, 4, and 6); successful salvage was achieved in 18 (94.7 percent) of 19 patients, whereas only two of seven of those implants with severe infection (groups 2, 5, and 7) were salvaged (p = 0.0017). Ten (90.9 percent) of 11 devices with threatened or actual exposure, not complicated by severe infection (groups 3, 4, and 6), were salvaged. Several treatment strategies were developed for periprosthetic infection and for threatened or actual implant exposure. Patients with infection were placed on oral or intravenous antibiotics; those who responded completely required no further treatment. For persistent mild infection or threatened or actual exposure, operative intervention was required, including some or all of the following steps: implant removal, pocket curettage, partial or total capsulectomy, débridement, site change, placement of a new implant, and/or flap coverage; the menu of options varied with the precise circumstances. No immediate salvage was attempted in five cases, due to either severe infection, nonresponding infection with gross purulence, marginal tissues, or lack of options for healthy tissue coverage. Based on the authors' experience, salvage attempts for periprosthetic infection and prosthesis exposure may be successful, except in cases of overwhelming infection or deficient soft-tissue coverage. Although an attempt at implant salvage may be offered to a patient, device removal and delayed reinsertion will always remain a more conservative and predictable option.

The influence of time on human breast capsule histology: smooth and textured silicone-surfaced implants

Although the histology of capsular tissue is well described in the literature, most studies in humans do not correlate histologic findings with implant age (number of years an implant was in place before sampling). As such, questions regarding the long-term histology in humans remain. The microanatomy of 93 human periprosthetic capsular tissues surrounding 22 textured and 71 smooth silicone-surfaced prostheses was studied. The implants were divided into two groups according to the time between implantation and capsulectomy: between 0 and 5 years or more than 5 years. Hematoxylin and eosin and Masson trichrome-stained sections were analyzed by light microscopy, with and without polarization. Eighteen of the textured implants contained silicone gel and four contained saline. Sixty of the smooth implants contained silicone gel, eight contained saline, and in three, the filler type was not known. For the majority of patients, surgery was performed for augmentation mammaplasty, and the implants were removed because of capsular contracture. The following histologic features were assessed: synovial-like metaplasia, villous hyperplasia, density of the collagenous capsule, alignment of collagen fibers within the capsule, and the presence of foreign material and of a foreign body reaction. The following trends were observed. In smooth implants, increasing implant duration was associated with a decrease in the presence of synovial-like metaplasia (p = 0.003) and villous hyperplasia; there was no significant difference in the presence of a dense collagenous capsule, the orientation of collagen fibers, or the presence of a foreign body reaction. An increase was observed in the presence of foreign material (p = 0.01). In textured implants, increasing implant duration was associated with a decrease in the presence of synovial-like metaplasia, villous hyperplasia (p = 0.003), dense collagenous architecture, and parallel orientation of collagen fibers (p = 0.017). An increase in the presence of a foreign body type reaction and foreign material (p = 0.024) was observed. In comparing textured and smooth-surfaced implants, synovial-like metaplasia was observed more often in the textured group, both at 0 to 5 years (p = 0.01) and at greater than 5 years (p < 0.01). Textured implants more often had villous hyperplasia at 0 to 5 years (p = 0.03) but not beyond 5 years. Smooth implants more often had a dense collagenous capsule than textured implants after 5 years. No significant difference was seen in the orientation of collagen fibers in capsules around smooth and textured implants at 0 to 5 years. After 5 years, the incidence of capsules with collagen fibers arranged parallel to the implant surface was significantly greater in the smooth group than in the textured group (p = 0.01). The presence of a foreign body type reaction was seen more often in the textured group between 0 and 5 years (p = 0.01) and at greater than 5 years (p < 0.01), and the presence of foreign material was more often seen in the textured group between 0 and 5 years (p = 0.06) and at greater than 5 years (p < 0.01). In summary, the cytologic changes around implants seem to be dynamic in nature, and implantation duration and shell type play a significant role. Synovial-like metaplasia, villous hyperplasia, and foreign material were more often observed in the textured group within the 0 to 5 year interval. Beyond 5 years, synovial-like metaplasia, a foreign body type reaction, and foreign material were more often observed in the textured group. Differences in the density of collagenous capsules were not significant at any time point, and collagen fibers oriented parallel to the implant surface were more often observed in the smooth group after 5 years. The significance of these findings awaits further investigation.