Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e598ee599

CORRESPONDENCE AND COMMUNICATION

A peculiar case of spontaneousbilateral mammary implantcapsule detachment

Communication

The most common local complication in patients with siliconemammary implants (SMIs) is excessive peri-SMI connectivetissue capsule formation and its subsequent contracture. Inother cases breast prosthesis itself breaks down. Traumaticrupture of the surrounding fibrous capsule without disruptionof the prosthetic envelope has been reported.1 In all cases ofsilicone breast implant complications, at surgical explorationthe capsule is so firmly sticking to the chest wall that, in somecases, it is difficult to carry out a complete capsulectomy.

We describe an uncommon and peculiar case of spon-taneous and complete mammary capsule detachment fromthe chest wall and free-flowing prosthesis within theseroma of the mammary pocket.

A 37-year-old Caucasian woman was referred to ourdepartment for a sudden and quick swelling of the rightbreast, together with discomfort and severe pain, butwithout systemic symptoms, such as redness, local warmth,fever and alteration of blood tests (Figure 1 left).

The patient underwent bilateral retro-glandular breastaugmentation for cosmetic reasons two years before.

Patient clinical history had no report of either previousallergic reactions, or connective tissue disorders, orprevious traumas.

Ultrasonography imaging showed no signs of prosthesisrupture2, a wide quantity of periprosthetic fluid anda reactive nonspecific axillary lymph-adenopathy.

Surgicalexploration revealed600 mlof clearhaematicfluid;breast implant and its fibrous capsule appeared completelydetached from the chest wall, free-flowing within the cavity.

An accurate check of the cavity showed no sign ofcapsule adhesion to the chest wall and to the mammarygland. Mammary implant (Silimed� round prosthesis 360 cc)was surprisingly intact inside the capsule that appeared tobe thin and with some sign of blood leak (Figure 1 right).

We supposed that a micro trauma produced a haema-toma in the extracapsular space, increasing up to thedetachment of the fibrous capsule.

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Post-op recovery was uneventful and the patient couldbe discharged three days later.

While the patient was waiting for a new prosthesisimplantation, 14-days later the problem occurred again, inthe same fashion, on the controlateral side. Without anysystemic sign, the breast volume increased twice so much,so that the patient came back to our department to gettreated again. A new ultrasonograpy imaging showeda great volume of liquid around the prosthesis. Again weperformed then an implant removal.

The implant appeared neither broken nor damaged freeflowing in 800 cc of clear sero-haematic fluid andcompletely surrounded by its periprosthesic capsule,detached from the chest wall and from the gland. Nobleeding from the periprosthetic pocket was observed.Post-operatory recovery was uneventful.

As the patient didn’t remember or report any trauma atthe breast level, we carried out several examinations.Bacteriological examination of the fluid did not reveal anygrowth. Histological assessment of the latter did revealneither an alteration of the collagen structure, nor animmunologic reaction, but only stratified blood leaks on thesurface and ordinary scattered chronic inflammatory cells(Figure 2).

Cytological analysis of the clear haematic fluid revealedonly the presence of histiocyte and lysing cells, withoutlymphocytes neither eosinophils to indicate an immuno-logical resuming.

Furthermore, serological and immunological analyseswere negative for the presence of antibodies (ANA, n-DNA,ENA, IgA, IgG, IgM, AIb, C3).

Allergologycal analyses weren’t necessary because ofthe lack of other clinical and laboratory indications.

The patient was then discharged with the diagnosis ofbreast prosthesis capsule detachment.

This represents the first reported case of spontaneouscapsule detachment from the chest wall.

At the beginning we supposed that a micro trauma couldhave produced a haematoma in the extra capsular space,increasing more and more until detaching the peri-prosthesic capsule. But when it recurred after 14-days onthe other side, since this was the first reported case ofcapsule detachment, we carried out histological, cytolog-ical, serological and immunological analysis, but they allresulted to be negative for alterations.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 2 Left: A fibrous capsule is present around the breast implant. Fibrinous-haematic material is stratified on the innersurface of the capsule (H&E, 25x total magnification). Right: Some scattered chronic inflammatory cells are present in the thicknessof the fibrous capsule; the subtle filaments of fibrin are evident on the inner surface (H&E, 163x total magnification).

Figure 1 Left: Pre-operative view showing the swelling of the right breast. Right: Intra-operative Mammary implant view showingthe completely intact prosthesis inside the capsule that appears to be thin and with some sign of blood extravasations. The capsuleholes were caused by the surgical handling.

Correspondence and communication e599

Furthermore, the review of the literature showed that thereare not scientific basis for any association between implantrupture and well-defined connective tissue disease or undefinedor atypical connective tissue diseases.3 Even if a set of param-eters (CIC, procollagen III, APA, sICAM-1) in serum that correlatewithfibrosisdevelopmentand thedurationof the implants couldbe found according to some authors,4 the sensitivity and speci-ficity of these parameters have to be established yet.

Despite all the tests performed and the literaturereview, the mechanism of such a peculiar and suddenprosthesis detachment still remains unknown. The patientrefuses to have breast implantation any more.

Conflict of interest

None.

Funding

None.

References

1. Springer HA. Bilateral accidental rupture of the fibrous capsulessurrounding mammary prosthesis. Case report. Plast ReconstrSurg 1976 Aug;58:230e1.

2. Di Benedetto G, Cecchini S, Grassetti L, et al. Comparativestudy of breast implant rupture using mammography,

sonography and magnetic resonance imaging: correlation withsurgical findings. Breast J 2008 NoveDec;14:532e7.

3. Holmich LR, Lipworth L, McLaughlin JK, et al. Breast implantrupture and connective tissue disease: a review of the litera-ture. Plast Reconstr Surg 2007 Dec;120:62Se69S.

4. Wolfram D, Oberreiter B, Mayerl C, et al. Altered systemicserologic parameters in patients with silicone mammaryimplants. Immunol Lett. 2008 Jun 15;118:96e100.

Giovanni Di BenedettoAntonio Stanizzi

Department of Plastic and Reconstructive Surgery,Marche Polytechnic University Medical School, Via Conca,

1-60020 Ancona, ItalyE-mail addresses: dibenplast@hotmail.com,

lucagrassetti2000@yahoo.it

Alfredo SantinelliDepartment of Pathology,

Marche Polytechnic University Medical School,Ancona, Italy

Davide TaleviLuca Grassetti

Department of Plastic and Reconstructive Surgery,Marche Polytechnic University Medical School,

Ancona, Italy