High cohesive silicone gel breast implants, introduced in Europe in 1993, are composed of a textured silicone elastomer shell and are filled with high cohesive silicone gel. High cohesive gel is formed by increasing the number of crosslinks between gel molecules, which results in an implant that has better retention of shape and that is less likely to fold or collapse, especially in the upper pole.2
It has also been claimed that in the event of rupture of an implant, the high cohesive silicone will not leak into the surrounding tissues and will be unlikely to spread elsewhere.1 We present a case of rupture of high cohesive gel silicone implants with locoregional silicone spread to axillary lymph nodes.
A 24-year-old woman developed several masses in both axillas. She underwent bilateral cosmetic breast augmentation with textured shell high cohesive gel silicone round profile breast implants (Poly Implant Prostheses, Seyne-sur-Mer, France) placed in the subglandular position 6 years previously (in December of 1999).
In May of 2005, she was referred to our department because she had noticed a sensitive swelling in her left axilla associated with the palpation of some hard, resilient, slightly painful masses. On clinical examination, no other masses were found, neither breast was red or painful, both breasts felt smooth (Baker grade I), and there was no nodularity or nipple secretions.
She performed all required tests to exclude an infectious or lymphomatous lymphadenopathy. Results from all of them were negative.
Ultrasound examination revealed in both armpits multiple conglobated nodular hypoechoic lesions with anterior reinforcement and loss of posterior definition (“snowstorm”) consistent with silicone masses. Fine-needle aspiration cytology of axillary masses was performed, which showed a picture of chronic inflammation from a foreign body. The rupture of both prostheses was diagnosed by magnetic resonance imaging, which showed the linguine sign in both breasts.
Surgical removal of both implants was performed through a periareolar incision. At operation, it was noticed that the right implant had a large tear along the junction of the back wall with the rest of the shell (Fig. 1) and the left implant was completely collapsed.
We removed the ruptured shells, and after an accurate intraoperative inspection of the residual cavity, two textured saline prostheses were implanted. We also performed an open biopsy of the axillary masses in both armpits with intraoperative ultrasound help to isolate 51 hypertrophic lymph nodes (Fig. 2). Histologic evaluation confirmed the presence of lymph node hypertrophy caused by inflammation from a foreign body.
Our experience with this patient illustrates the fact that even high cohesive gel implants may not be as safe as is commonly believed. Once ruptured, most of the silicone gel may retain its memory and stay within or close to the capsule, but there still may be a significant risk of some silicone spread and its consequences. Moreover, as most of the gel retains its shape, the diagnosis of rupture may be more difficult, and normal breast findings do not exclude a rupture of the implant. We recommend that, irrespective of the degree of cohesiveness of the silicone filler gel, all suspected implant ruptures should be investigated thoroughly, remembering that breast augmentation is not a “once-in-a lifetime” operation.
Antonello Accurso, M.D.
Nicola Rocco, M.D.
Cosimo Feleppa, M.D.
Alessio Palumbo, M.D.
Department of General, Geriatric, Oncologic Surgery and Advanced Technologies
Faculty of Medicine and Surgery
University Federico II of Naples
Francesco D’Andrea, M.D.
Department of Orthopaedic, Rehabilitative-Traumatologic and Plastic-Reconstructive Sciences
Faculty of Medicine and Surgery
Second University of Naples
1. Heden, P., Jernbeck, J., and Hober, M. Breast augmentation with anatomical cohesive gel implants: The world’s largest current experience. Clin. Plast. Surg.
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2. Tebbetts J. B. The other side of the story (Reply). Plast. Reconstr. Surg.
101: 875, 1994.
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