Iatrogenic intrathoracic encapsulated siliconoma from a ruptured breast implant
- 1 School of Medicine, California University of Science & Medicine, Colton, CA, USA
- 2 Division of Plastic Surgery, University of California, San Diego, San Diego, CA, USA
- 3 Surgery, Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, USA
- 4 Division of Plastic Surgery, Medical University of South Carolina, Charleston, SC, USA
- Correspondence to Ms Christina Shree Chopra; csc376@nyu.edu
Abstract
Our patient was a 57-year-old woman with a history of bilateral retropectoral silicone breast augmentation and axillary hyperhidrosis who underwent a bilateral thoracic sympathectomy via video-assisted thoracoscopic surgery by a surgeon at an outside hospital approximately 20 years ago. The left side required an open thoracotomy. Shortly after the surgery, she developed a left-sided Baker 4 capsular contracture and the left implant was noted to be ruptured. Both implants were exchanged. Several years later the patient began to experience progressive fatigue. Work-up revealed a left lung nodule and she underwent a biopsy that confirmed silicone granulomas. It was hypothesised that at the time of her initial thoracotomy the implant was violated resulting in silicone spillage into the thoracic cavity. The patient was referred to our institution for advanced management of her intrathoracic silicosis. The patient underwent bilateral removal of her silicone implants, total capsulectomy and needle-localised removal of her left thoracic silicone masses. She had an uneventful postoperative course with resolution of her fatigue.
Background
Silicone granulomas in the presence of ruptured silicone breast implants or after the injection of free silicone are well-described entities. Distant silicone migration from a ruptured implant is a rare and potentially serious complication that has been reported.1–5 Pulmonary manifestations in the form of effusions, pleural nodules and siliconomas are less common and their clinical presentation may remain elusive.5 There is a wide spectrum of symptoms associated with silicone implants and many of these symptoms are vague and non-specific.6 7 In patients with these symptoms removal of the implant and capsules may improve their symptom complex. We report on the first known case of intrathoracic silicone granuloma from iatrogenic implant rupture during a thoracotomy.
Case presentation
A 57-year-old woman presented to our hospital for removal of left-sided silicone granulomas. This patient was 25 years old when she underwent bilateral retropectoral silicone breast augmentation. Several years later she underwent bilateral sympathectomies for hyperhidrosis through bilateral video-assisted thoracoscopic surgery. The outside surgeon experienced exsanguinating haemorrhage from the descending aorta during the operation, which required emergent thoracotomy for control of bleeding. This resulted in a then-unknown rupture of the implant into the thoracic space on entry, leading to seeding the left hemithorax. After the procedure, the patient developed a capsular contracture of the left breast and the implant was noted to be ruptured. Both implants were exchanged. Several years later, the patient experienced progressive fatigue and subsequent work-up revealed thoracic granulomas. Biopsy revealed silicone material, and it was then determined the granulomas likely formed from unrecovered extravasated silicone from her implant rupture during her thoracotomy.
Investigations
Work-up included CT scan and lung biopsy. CT scan performed in June 2020 was significant for bilateral ruptured retropectoral silicone implants, with extensive high attenuation of the left-sided pleural nodularity and possible fistulous tract between the ruptured left breast implant and pleural space, compatible with pleural silicone granulomas (figure 1). The patient had multiple intrathoracic nodules on the left. The largest nodule measured 5.7×4.5 cm, with a smaller nodule medially posterior to the left breast implant. An augmented screening mammogram showed no radiographic evidence of malignancy.
CT image demonstrating intrathoracic silicone granuloma (arrow).
Physical examination demonstrated bilateral grade 4 capsular contracture with coning of the breast parenchyma superiorly, resulting in ptosis. Both implants appeared to be firm and well encapsulated. The patient endorsed pain on the left side on deep palpation.
Differential diagnosis
Differential diagnosis includes lung neoplasm and lung infection.
Treatment
The patient was evaluated by a cardiothoracic surgeon and a surgical plan for a non-rib spreading incision with preoperative needle localization was made. Given the fact that she had ruptured implants, plastic surgery was asked to assist with the removal of the implant and silicone granulomas.
The operation was performed in three steps. First, the patient underwent hookwire localisation of the siliconoma under CT guidance in interventional radiology. Second, the patient was taken to the operating room and underwent a non-rib spreading 5 cm incision directly over the wires. Within the chest, the siliconoma was encapsulated with fibrous tissue that was adherent to the adjacent lung. The siliconoma and capsule were resected together and adjacent lung tissue preserved. Third, a Clagett procedure was done. This involves instilling antibiotics into the area in the chest where the siliconoma had been and then closing the chest. The patient also underwent bilateral removal of her silicone implants and total capsulectomies (see figures 2 and 3).
In situ intraoperative image of silicone granuloma.
Postoperative image of silicone granuloma.
Outcome and follow-up
Diagnosis of siliconoma was confirmed in a postoperative pathology report of the removed specimens (figure 4). The patient had an uneventful postoperative course and was followed for 6 months with complete resolution of her fatigue. The patient is now doing well.
(A) Low power image of the intrathoracic silicone implant capsule showing fibrosis, chronic inflammation, and histiocytes. (B) Hyalinized fibrous tissue with vacuolated histiocytes and empty spaces. (C and D) (D with flipped condenser), high power images showing clear, refractile, nonpolarizable material within cytoplasmic vacuoles of histiocytes and extracellular empty spaces consistent with silicone (arrow).
Discussion
Siliconomas are rarely documented sequelae to silicone implants. Existing cases include migrations to the lungs, pectoral muscle, skin, lower extremities and cervical lymph nodes.1–5 Associated symptoms have been reported; however, many are vague and non-specific and may be defined as breast implant illness.6 7 An incident of siliconoma cervical lymphadenopathy was described as a painless neck mass, and in the case of pectoral muscle involvement, painless muscle hypertrophy.1 2 With more distant migrations, as to the lower extremities, tender nodules with associated inflammatory changes have been described.
To our knowledge, this is the first report of an intrathoracic silicone granuloma that was due to an unrecognised iatrogenic violation of an intact silicone implant. Although it is a rare complication, we feel that its awareness and management should be appreciated. Pulmonary manifestations of intrathoracic silicone may be life-threatening. In any patient who has silicone breast implants with chest trauma or surgery, the presence of intrathoracic silicone granulomas should be entertained.
Patient’s perspective
I did want to say that the surgery I had changed my life. I no longer live in pain, fear, or embarrassment. The surgery was so smooth for me and such an easy recovery. I will forever be grateful for Drs. Suliman and especially Dr. Thistlewaite. She gave me such a huge gift with the removal of the silicone from my chest cavity. I no longer have the stress and worry of having that mass inside my body.
Learning points
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The surgeon operating in the thoracic cavity of a patient with silicone implants should be aware of the rare instance of intrathoracic siliconoma as a potential sequela of implant rupture.
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Plastic surgeons should conduct thorough preoperative and intraoperative evaluations of potential silicone extravasation prior to rupture replacement.
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Siliconoma should be added to the differential when evaluating fatigue not attributable to other medical conditions in breast implant patients.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to thank Dr Somaye Zare, UCSD Department of Pathology, for her expertise in analysing the pathological specimens.
Footnotes
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Contributors CSC: responsible for drafting the case report and conducting corresponding literature review on the clinical content discussed and gave final approval of the version to be published. PT: contributed to data collection and interpretation as a member of the patient’s clinical care team, conducted critical revisions of the article and gave final approval of the version to be published. FH: conducted critical revisions of the article and gave final approval of the version to be published. AS: responsible for conception and design of the work, as well as data collection and interpretation, conducted critical revisions of the article and gave final approval of the version to be published.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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