Breast Implant-Associated Immunological Disorders

Oxylipins in Breast Implant-Associated Systemic Symptoms

BACKGROUND

A subset of females with breast implants have reported a myriad of nonspecific systemic symptoms collectively termed systemic symptoms associated with breast implants (SSBI). SSBI symptoms are similar to manifestations associated with autoimmune and connective tissue disorders. Breast tissue is rich in adipose cells, comprised of lipids. Insertion of an implant creates an oxidative environment leading to lipid oxidation. Oxylipins can influence immune responses and inflammatory processes.

OBJECTIVES

In this study we explored the abundance of a spectrum of oxylipins in the periprosthetic tissue surrounding the breast implant. Because oxylipins are immunogenic, we sought to determine if they were associated with the SSBI patients. We have also attempted to determine if the common manifestations exhibited by such patients have any association with oxylipin abundance.

METHODS

The study included 120 patients divided into 3 cohorts. We analyzed 46 patients with breast implants exhibiting manifestations associated with SSBI; 29 patients with breast implants not exhibiting manifestations associated with SSBI (control cohort I, non-SSBI); and 45 patients without implants (control cohort II, no-implant tissue). Lipid extraction and oxylipin quantification were performed with liquid chromatography mass spectrometry (LC-MS/MS). LC-MS/MS targeted analysis of the breast adipose tissue was performed.

RESULTS

Of the 15 oxylipins analyzed, 5 exhibited increased abundance in the SSBI cohort when compared to the non-SSBI and no-implant cohorts.

CONCLUSIONS

The study documents the association of the oxylipins with each manifestation reported by the patient. This study provides an objective assessment of the subjective questionnaire, highlighting which symptoms may be more relevant than the others.

LEVEL OF EVIDENCE: 4

Connective Tissue and Autoimmune Diseases Associated With Postsurgical Breast Augmentation: An Updated Review

This review provides an updated overview of the association between breast augmentation and connective tissue diseases (CTDs). A narrative review of recent literature was conducted. Various autoimmune disorders, such as Raynaud's syndrome, rheumatoid arthritis (RA), and Sjögren's syndrome, have been reported in association with breast implants, particularly silicone implants. Symptoms can be diverse and systemic, including fatigue, joint stiffness, muscle pain, skin rashes, and neurological and gastrointestinal issues. Explantation has shown promise in alleviating symptoms, but the exact pathogenesis remains unclear. Recent studies emphasize the need for informed consent, vigilant monitoring, and multidisciplinary management. The association between breast implants and CTDs remains contentious. While advancements in implant technology have improved patient outcomes, concerns about long-term health implications persist. Continuous research is necessary to elucidate the mechanisms underlying these potential risks and to develop informed patient care guidelines. In this narrative review, we discuss the history of breast implants, illness associated with breast augmentation, and treatment of CTDs and autoimmune diseases associated with breast augmentation.

Decreased Use of Anti-Inflammatory Medications in Autoimmune Connective Tissue Disease Patients Following Breast Implant Removal: A National Analysis

Background

Recent case studies demonstrate resolution of rheumatologic symptoms following implant explantation, raising concern around breast implant illness and associated inflammatory symptomatology. In patients with connective tissue disorders (CTD) and breast implants, we quantified the number of anti-inflammatory medications as a proxy for inflammation and disease burden before and after implant removal.

Methods

Using the Clinformatics Data Mart Database, adult female patients from 2003 to 2021 were queried. Current Procedural Terminology codes were used to identify patients who underwent implant-based reconstruction and subsequent implant removal. International Classification of Diseases, Ninth (ICD-9) and Tenth Revision (ICD-10) codes identified patients with CTD. Filled prescriptions of anti-inflammatory drugs were quantified for each patient during the preoperative, perioperative, and postoperative windows surrounding breast implant removal.

Results

Of 1015 patients meeting criteria (mean age 56 ± 12 years), 821 (81%) filled prescriptions during the preoperative window, 753 (74%) filled during the perioperative window, and 735 (73%) filled during the postoperative window. Patients filled significantly fewer postoperative prescriptions than preoperative prescriptions (P < .001).Statistically significant predictors of the number of anti-inflammatory prescriptions filled in the postoperative window included additional anti-inflammatory prescriptions filled in the preoperative (P < .001) and perioperative (P < .001) windows. Experiencing a complication was not associated with the number of prescriptions filled in the postoperative window (P = .935).

Conclusions

We found a significant decrease in filled anti-inflammatory prescriptions in patients with known CTD following implant removal, suggesting that breast implant removal may help diminish inflammatory symptomology in predisposed patients.

Antioxidant Status in Patients after Breast Mastopexy and Augmentation

Background and Objectives: Mammary gland surgery has become very common, but there are complications of these operations, including the concept of breast implant illness (BII) in women with silicone gel breast implants (SBI), who suffer from various symptoms such as myalgia, arthralgia, fatigue, fever, dry eyes, or dry mouth. Silicone biomaterials are synthetic polymers that have their own physical and chemical properties and can exert their effect at the site of use and possibly on the general status of the body, causing inflammation and oxidative stress signs. The aim of the study was to examine components of the blood antioxidant system (AOS) of the mastopexy and breast augmentation patients before the operation, on the first post-op day, and 6 months after surgery. Materials and Methods: Healthy breast surgery patients (women aged 31 to 60 years without visible pathologies) were selected for the study and formed 2 groups: breast lift-mastopexy without silicone biomaterials (I group, 30 patients) and breast augmentation using silicone biomaterials (II group, 28 patients). All patients underwent standard preoperative tests. Glutathione peroxidase (GPxSe) and gamma-glutamyl transferase (GGT) in blood, selenium (Se), selenium protein P (SelPP), and total antioxidant status (TAS) in plasma were measured as AOS parameters. The concentration of vitamin D was also determined. A total of 174 blood tests were performed. Results: Overall, there were no differences in both groups in measured antioxidant system indicators over time; neither changes in objective nor subjective status were observed. However, baseline activity of GPxSe was relatively high but restored to normal values 6 months after surgery. In the mastopexy group, GPxSe decreased from 12,961.7 U/L by 18.9% to 10,513.4 U/L, and in the breast augmentation group, from 15,505.0 U/L by 25.1% to 11,265.5 U/L, which is a decrease of 18.9% and 25.1%, respectively. The patients did not note any complaints; other indicators of standard biochemical tests were within normal limits. Conclusions: The two types of surgical interventions, breast mastopexy and augmentation of the mammary glands, do not significantly impact blood AOS and are physiological in nature.

Increased Risk of New-Onset Rheumatoid Arthritis Among Osteoarthritis Patients Received Total Knee Arthroplasty: a global federated health network analysis

Background: Complications of total knee arthroplasty (TKA) had been widely discussed. However, whether TKA influence risk of rheumatoid arthritis (RA) in osteoarthritis patients remained uncertain. We intend to evaluate the risk of RA in osteoarthritis patients underwent TKA. Methods: In this retrospective cohort study, data was retrieved from the US collaborative networks in TriNetX research network. Within the study period between 2005 and 2017, osteoarthritis patients underwent TKA were enrolled as case cohort whereas osteoarthritis patients never underwent TKA were enrolled as control cohort. Covariates were matched via propensity score matching. Risk of RA in TKA patients were valuated under various follow-up time and sensitivity models. Results: Under 1-year, 3-year and 5-year of follow-up, TKA patients were associated with significantly elevated risk of RA, especially under 1-year follow-up (HR=1.74; 95% CI, 1.39-2.18). Subgroup analysis demonstrated a significant increase in the risk of RA following TKA in the female subgroup (HR=1.42; 95% CI, 1.24-1.63), the subgroup aged 18-64 years (HR=1.48; 95% CI, 1.11-1.97), and the subgroup aged greater than 65 years old (HR=1.38; 95% CI, 1.21-1.58) based on 5-year follow-up. Conclusion: Clinicians should be concerned about uncharted association between TKA and RA reported our current study. Additional prospective studies and in-depth mechanistic inquiries were warranted to determine the causation.

Consulting the Digital Doctor: Google Versus ChatGPT as Sources of Information on Breast Implant-Associated Anaplastic Large Cell Lymphoma and Breast Implant Illness

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare complication associated with the use of breast implants. Breast implant illness (BII) is another potentially concerning issue related to breast implants. This study aims to assess the quality of ChatGPT as a potential source of patient education by comparing the answers to frequently asked questions on BIA-ALCL and BII provided by ChatGPT and Google.

METHODS

The Google and ChatGPT answers to the 10 most frequently asked questions on the search terms "breast implant associated anaplastic large cell lymphoma" and "breast implant illness" were recorded. Five blinded breast plastic surgeons were then asked to grade the quality of the answers according to the Global Quality Score (GQS). A Wilcoxon paired t-test was performed to evaluate the difference in GQS ratings for Google and ChatGPT answers. The sources provided by Google and ChatGPT were also categorized and assessed.

RESULTS

In a comparison of answers provided by Google and ChatGPT on BIA-ALCL and BII, ChatGPT significantly outperformed Google. For BIA-ALCL, Google's average score was 2.72 ± 1.44, whereas ChatGPT scored an average of 4.18 ± 1.04 (p < 0.01). For BII, Google's average score was 2.66 ± 1.24, while ChatGPT scored an average of 4.28 ± 0.97 (p < 0.01). The superiority of ChatGPT's responses was attributed to their comprehensive nature and recognition of existing knowledge gaps. However, some of ChatGPT's answers had inaccessible sources.

CONCLUSION

ChatGPT outperforms Google in providing high-quality answers to commonly asked questions on BIA-ALCL and BII, highlighting the potential of AI technologies in patient education.

LEVEL OF EVIDENCE

Level III, comparative study 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 .

Biofilm-derived oxylipin 10-HOME mediated immune response in women with breast implants

Breast implant illness (BII) is a poorly understood disease in which patients develop symptoms typical of autoimmune conditions following breast implantation. There is no known underlying cause, and patients often resort to breast implant removal and capsulectomy to alleviate symptoms. In this issue of the JCI, Khan and colleagues examined 86 breast explants from patients that reported BII symptoms and 55 control explants. The BII group showed a disproportionally high degree of biofilm, which was associated with oxylipin (10-HOME) on the implant surfaces. Injections of 10-HOME in the mammary fat pad of a murine model recapitulated BII symptoms and increased Th1 cell populations. Notably, macrophages in the periprosthetic tissue from BII patients were more likely to exhibit a proinflammatory phenotype, and naive T cells exposed to 10-HOME caused naive macrophages to differentiate to a proinflammatory phenotype. This work provides a pathophysiologic mechanism for a currently understudied and poorly characterized disease.

The Problem of Diagnostic Criteria of Breast Implant Illness in Women After Breast Reconstruction: Review and Discussion of a Case

INTRODUCTION

There has been a rising trend in the use of silicone breast implants for breast reconstructions after breast cancer treatment, as well as in the aesthetic breast procedures. A cluster of non-specific symptoms related to the presence of silicone implant has been called breast implant illness (BII). However, there are no strict criteria of BII which would specifically define this term. The increasing interest in BII among patients and physicians urges verifying own cases of "on-demand" explantations.

MATERIAL AND METHODS

In this paper, we discussed a case of a patient with initial BII diagnosis, after breast reconstruction, and reviewed the literature on the BII symptoms and aetiology. A decision for aesthetic revision, not explantation, was made as the diagnosis of BII was questioned, and somatisation due to dissatisfaction with the aesthetic result of breast reconstruction was diagnosed.

RESULTS

Improving aesthetics by implant exchange and contralateral mastopexy caused a full recovery from patient's symptoms.

CONCLUSION

Based on our case, we point on the fact that BII diagnosis in patients after breast reconstruction is challenging. We suggest that while considering such a diagnosis and further proceedings, e.g. explantation, especially in patients after breast reconstruction, some exclusion criteria should be considered. Dissatisfaction with the result of the surgery can also lead to somatisation and the presence of real clinical symptoms, which should not be confused with the possible autoimmune reaction to silicone particles.

LEVEL OF EVIDENCE IV

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 .

Updated trends of breast implant surgeries: An Israeli analysis

INTRODUCTION

Breast augmentation remains one of the most prevalent procedures in plastic surgery. While most patients experience high satisfaction with the outcomes, a subset may encounter various complications or dissatisfaction with achieved results necessitating subsequent surgical intervention including implant removal or exchange.

MATERIALS AND METHODS

We collected information from three pivotal private medical centers in Israel where a considerable number of breast surgeries are performed. We examined the number of breast augmentations, implant exchange and implant removal surgeries with or without breast lift that were performed on a biannual basis for each center for the period 2018-2022. Trends in surgery types were analyzed and compared to registries in other countries.

RESULTS

Between the years 2018 and 2022, 20,075 surgeries were done in three main private medical centers in Israel. Data show a gradual increase in implant removal surgeries from 2018 (n = 80, 2.9%) to 2019 (n = 269, 9.9%), followed by a significant increase in 2020 (n = 1436, 27.3%), and a gradual decline between 2021 (n = 1019, 22.8%) and 2022 (n = 916, 18.5%). The overall number of breast implant insertion procedures (breast augmentation procedures and exchange procedures) was 2659 in 2018 (97%), 2424 in 2019 (90.0%), 3816 in 2020 (72.6%), 3437 in 2021 (77.1%), and 4019 in 2022 (81.4%).

SUMMARY

We present updated trends in breast implant surgeries in Israel. 2020 was a key year in which the rate of explantations was the highest, and the percentage rate of implantations was the lowest and a year in which the trend changed. These patterns partly align with trends seen in other countries worldwide.

Biofilm-derived oxylipin 10-HOME-mediated immune response in women with breast implants

This study investigates a mechanistic link of bacterial biofilm-mediated host-pathogen interaction leading to immunological complications associated with breast implant illness (BII). Over 10 million women worldwide have breast implants. In recent years, women have described a constellation of immunological symptoms believed to be related to their breast implants. We report that periprosthetic breast tissue of participants with symptoms associated with BII had increased abundance of biofilm and biofilm-derived oxylipin 10-HOME compared with participants with implants who are without symptoms (non-BII) and participants without implants. S. epidermidis biofilm was observed to be higher in the BII group compared with the non-BII group and the normal tissue group. Oxylipin 10-HOME was found to be immunogenically capable of polarizing naive CD4+ T cells with a resulting Th1 subtype in vitro and in vivo. Consistently, an abundance of CD4+Th1 subtype was observed in the periprosthetic breast tissue and blood of people in the BII group. Mice injected with 10-HOME also had increased Th1 subtype in their blood, akin to patients with BII, and demonstrated fatigue-like symptoms. The identification of an oxylipin-mediated mechanism of immune activation induced by local bacterial biofilm provides insight into the possible pathogenesis of the implant-associated immune symptoms of BII.

A Case Report on Breast Implant Illness

In this case report, we discuss the case of a 64-year-old woman who presented with an unusual complaint of a chronic cough associated with pleuritic chest pain of 15 years following a saline-filled breast implant surgery. Initially, these were minimally abated by acid reflux medications. However, her cough worsened despite other interventions. In the work-up to determine the etiology of her complaints, the most common causes of a chronic cough were considered. The history ruled out post-nasal drip, and pulmonary function tests excluded asthma and chronic obstructive pulmonary disease (COPD), although she had a family history. An IgE allergy panel and an Aspergillus antibody test were also normal. However, an esophagram revealed a significant finding of mild to moderate Gastroesophageal reflux disease (GERD). Ultimately, the subsequent removal of the implants led to a dramatic resolution of her symptoms. It is worth noting that breast implants, like any other medical device, carry certain risks. Complications such as infections, implant rupture, capsular contracture, and changes in breast sensations are known risks associated with breast augmentation surgery.

Pleural Effusion as a Potential Complication of Foreign Body Reaction to Silicone Breast Implants: A Case Study

Breast augmentation surgery, like any other surgery, has potential complications, including the less common complication of pleural effusion. We present a unique case of a 44-year-old female who developed pleuritic chest pain and shortness of breath 10 days after her breast augmentation surgery, with no prior history of cardiac or autoimmune conditions. The temporal relationship between the surgery and the onset of symptoms suggested a possible direct link to the implants. Imaging showed a small- to moderate-sized left pleural effusion, and pleural fluid analysis revealed findings suggestive of a foreign body reaction (FBR), including evidence of mesothelial and inflammatory cells with a lymphocyte percentage of 44% and monocytes of 30%. The patient received intravenous steroids at a dose of 40 mg every eight hours for three days while hospitalized, followed by a tapered oral dose of steroids upon discharge, for over three weeks. Follow-up imaging studies showed complete resolution of the pleural effusion. The diagnosis of pleural effusion resulting from FBR to silicone gel-filled breast implants involves a clinical history, cytopathological examination, and the exclusion of other potential causes. This case highlights the importance of considering FBR as a potential cause of pleural effusion post-breast augmentation surgery.

Worsening of Primary Raynaud's Phenomenon During Episodes of Pyrexia and Rigors in SARS-CoV-2 Infection

Acute SARS-CoV-2 infection is associated with several cutaneous manifestations, including vasculitic digital ischemia. The reversal of digital ischemia in the primary Raynaud phenomenon (RP) arises from endothelial hypersensitivity to circulating adrenaline and noradrenaline and diminished vasodilatory innervation. SARS-CoV-2 can infect endothelial cells and be associated with raised adrenaline levels, reduced microvascular dilatory responses, and exaggerated clotting mechanisms. We report worsened RP in a patient with previously mild winter-time primary RP during the periods of fever and rigors from an acute SARS-CoV-2 infection contracted in a warm summer period. This reverted to the mild phenotype after recovery, and we discussed possible mechanisms for the brief exacerbation.