Breast Implant Illness: Capsulectomy and Implant Removal

In This Article

Abstract and Introduction

Abstract

Background: Breast implant illness (BII) is extramammary systemic symptoms that are caused by breast implants. The emergence of this controversial topic has spurred patients with breast implants who are experiencing these symptoms to seek implant removal, hoping to feel better. This article presents novel outcomes and suggestions for plastic surgeons in managing BII using total capsulectomy and breast implant removal.

Methods: In this retrospective cohort study conducted between 2016 and 2020, medical records of all patients undergoing breast implant removal were reviewed. Inclusion criteria consisted of all patients with history of breast implant placement presenting with mastodynia and capsular contracture on physical examination. Patients with history of implant-based reconstruction following mastectomy and patients who underwent implant exchange were excluded. All patients underwent bilateral implant removal and total capsulectomies.

Results: A total of 200 patients who fulfilled the inclusion criteria were identified. Average age was 45.5 (range: 29–73) years and average body mass index was 26.28 (range: 19–36.8), with an average follow-up time of 5 months postoperatively. Of patients with a presentation of BII, 96% reported improved or complete resolution of their systemic symptoms after implant removal and total capsulectomy. A positive microbial culture was found in 68.5% of patients, and all culture-positive patients reported improvement post-treatment. The most common organisms found were Propionibacterium acnes (49.6%). There were no associations between implant characteristics and rate of positive microbiology findings.

Conclusions: Our study shows that implant removal with capsulectomy drastically improves BII symptoms. Further large prospective cohort studies are needed to better understand this entity.

Introduction

Breast implant illness (BII) refers to symptoms that develop after breast reconstruction or augmentation with any type of breast implants (saline-filled, silicone gel–filled, textured surface, smooth surface, round, or teardrop-shaped). Symptoms of BII first appeared in women in the 1980s, and there were large concerns of connective tissue diseases being linked to newly implanted silicone breast implants. These symptoms were especially prevalent in Japanese women during World War II.^[1,2] After years of further study, the Food and Drug Administration (FDA) approved modified breast implants to be introduced to the market.^[3] Unfortunately, BII is still prevalent today and impacts individuals in many unique ways including but not limited to the symptoms shown in Table 1. Symptoms may appear at any time post-breast implant surgery.

Currently, there is a lack of literature on cohort study outcomes after implant removal surgery for BII patients. A study of 100 patients concluded that 89% of patients who had capsulectomy and implant removal had symptom improvement within 3 months of surgery.^[4] These symptoms included cognitive problems, fatigue, burning pain in the breast and chest wall, dry eyes, anxiety, and joint pain. Researchers in the Netherlands studied 80 women with implants and found that symptoms improved in 69% of patients after surgery.^[5]

Clearly, breast implant removal improves or completely resolves the BII symptoms. However, BII is not accepted as an official medical diagnosis. It is poorly understood, and there are limited studies because it is a unique condition. BII appears to be a cluster of symptoms that do not align with other classic diagnosis. It can worsen over time and is different in its presentation even for patients with similar implants. As of now, the incidence and prevalence of BII is increasing.

To our knowledge, there is a lack of Level I cohort studies of women with breast implants who subsequently develop BII. In our novel retrospective study, we review the outcomes in managing BII using total capsulectomy and breast implant removal. Additionally, we discuss the details of BII and what patients should do if BII is suspected.

Table 1. Common symptoms of BII
BII Common Symptoms
• joint and muscle pain	• swollen and tender lymph nodes in the breast area, axilla, supraclavicular, and cervical
• chronic fatigue	• premature aging
• memory and concentration problems	• bouts of dehydration for no reason
• breathing problems	• frequent urination
• sleep disturbance	• numbness/tingling around implant and underarm
• rashes and skin problems	• optic neuritis
• dry mouth and dry eyes	• hypo/hyperthyroidism
• dry skin and dry hair	• liver/kidney dysfunction
• anxiety	• hypo/hyper adrenal symptoms
• depression	• cramping
• headaches	• hormonal imbalance
• hair loss	• toxic shock symptoms
• gastrointestinal problems	• panic attacks
• slow muscle recovery after activity	• symptoms or diagnosis of fibromyalgia
• easy bruising	• symptoms or diagnosis of lyme disease
• fever and night sweats	• symptoms or diagnosis of autoimmune disease or connective tissue disorders (ie, lupus, Hashimoto's thyroiditis, rheumatoid arthritis, scleroderma)
• brain fog (cognitive dysfunction)	• delayed wound healing
• heart palpitations, changes in heart rate, heart pain	• GERD
• sore hip joints, aching backbone and sore feet	• vertigo
• new and persistent viral and bacterial illnesses	• dysphagia and digestive disorders
• symptoms or diagnosis of BIA- ALCL	• fungal infection
• tinnitus	• food allergies
• food intolerance

Table 2. Characteristics of patients with reported BII symptoms
Age at surgery: average (range), years		45.5 (29–73)
BMI, average (range)		26.3 (19–36.8)
Textured implant–to–smooth implant ratio		1:5
Placement of implants, %
	Subpectoral plane	59
	Subglandular plane	41
Follow-up time: average (range), months		5.0 (0.5–20)
Patient diagnosis, %
	Baker-Gordon Grade I capsular contracture	0
	Baker-Gordon Grade II capsular contracture	0
	Baker-Gordon Grade III capsular contracture	75.5
	Baker-Gordon Grade IV capsular contracture	14.5
Comorbidities/past medical history, %
	Hyperthroidism/Hypothyroidism	34.7
	Fibromyalgia	16.3
	Hyperlipemia	14.3
	Mental Disorder/Depression/Anxiety	14.3
	Hypertension	8.1
	GERD	6.1
	Diabetes Mellitus	6.1
	Asthma	4.0
	Migraine	4.0
	Lupus	2.0
	Atrial Fibrillation	2.0
	Inflammatory Arthritis	2.0
	COPD	2.0
	Osteoarthritis	2.0
	Raynaud's Disease	2.0
	Hepatitis C Virus	2.0
	Obstructive Sleep Apnea	2.0
	Osteopenia	2.0
	Achalasia	2.0
	Pulmonary Embolism	2.0
	Erythema Nodosum	2.0

Table 3. Ten most common self-reported symptoms of BII in study cohort
Symptom	Patients, % (n = 200)
Mastodynia	100
Capsular contracture	90.0
Fatigue	82.5
Loss of concentration during activities	81.5
Joint pain or arthralgia	57.5
Muscle pain	51.5
Rash or other skin disorder	37.5
Ocular compliant	23.5
Memory loss	18.0
Autoimmune diagnosis	10.5

Table 4. Pathologic examination of culture on removed specimens
Organism	Patients, % (n = 137)
Propionibacterium acnes	49.6
Staphylococcus epidermidis	26.2
Propionibacterium granulosum	16.8
Alpha-hemolytic Streptococcus species	8.7
Bacillus species*	2.5
Escherichia coli	0.7
Mycobacterium chelonae	0.7
Mycobacterium fortuitum	0.7
Mycobacterium avium-intracellulare	0.7
Candida albicans	0.7
Aspergillus fumigatus	0.7
Positive culture for more than 1 organism	10.2
Positive culture for more than 3 organisms	2.2