Keywords
silicone breast injection - silicone pneumonitis - deep inferior epigastric perforator
flap
Introduction
Silicones were studied and classified for a hypothetic industrial use by the English
chemist, Frederich Stanley Kipping in 1940.[1] At the beginning, they were harangued as “sticky messes” and it was believed there
would be no practical uses for these materials. Since that time, many things changed
and now silicone is one of the most used materials in medical industry. Despite being
especially used in its solid form, it is still injected as a filler for aesthetic
purposes in many countries. Here, we present a rare case of a woman with silicone
pneumonitis after breast silicone injection.
Case Report
A nonsmoker 55-year-old woman was admitted in our hospital for dyspnea associated
with intermittent fever up to 38°C. These symptoms had been present for a few months
during effort, then also at rest. Her medical history consisted of primary hyperparathyroidism
under pharmacological therapy and no allergies. Besides she reported many breast silicone
injections for aesthetic purposes ~25 years before.
The clinical examination of the thorax showed the presence of an extended breast scarring
bilaterally, a complete deformity of the breast cone with nipple-areola complex herniation
and a hard-full-thickness scar tissue with many subcutaneous nodules, observed through
palpation of the remaining breast tissues ([Fig. 1]).
Fig. 1 Breast tissues condition with presence of an extended hard-full-thickness scar with
many subcutaneous nodules bilaterally and a complete deformity of the breast cone
with nipple-areola complex herniation.
Spirometry exam showed values compatible with a pulmonary restrictive syndrome. Chest
X-ray investigation did not reveal any abnormality. The subsequent computer tomography
scan excluded any sign of pulmonary embolism or infectious pneumonitis but it showed
an interstitial lung disease, with a reticular fibrosis pattern, and several traction
bronchiectasis. No lymphadenopathies or pleural effusion was noticed. Breast tissues
showed an important and dishomogeneous increase in thickness with presence of hyperdense
nodules of silicone ([Fig. 2]). The ultrasound study of axillary nodes displayed a similar bilateral pattern with
lymph nodes fulfilled with foreign material. The bronchoscopy procedure with analysis
of the bronchoalveolar fluid showed the presence of alveolar macrophages with intracytoplasmatic
deposits of foreign particulate material, birefringent in polarized light. Subsequent
immunologic tests excluded any autoimmune disease.
Fig. 2 Computer tomography scan showing an important and dishomogeneous increase in thickness
of breast tissues with the presence of hyperdense nodules of silicone.
The patient was then treated for 10 days with oxygen therapy, beclomethasone, salbutamol,
and broad-spectrum antibiotic therapy. In agreement with pulmonologists' diagnosis
of a restrictive syndrome due to the thoracic extensive scarring tissue and the high
demand of oxygen therapy, we planned an extensive surgical removal of the scarring
tissue. We also planned a simultaneous reconstruction with a deep inferior epigastric
perforator flap ([Fig. 3]) because of the wide bilateral involved area and the possibility of sternal exposure.
The debridement was performed involving also part of the muscular plane that was broadly
filled with liquid silicone ([Fig. 4]). The flap was harvested bilaterally based on a preoperative computed tomography
angiography to determine the exact position of perforators ([Figs. 5A]
[5B]). The deep inferior epigastric artery was anastomized with the thoracodorsal artery,
the same for the two comitantes veins. During the operation, we observed venous congestion.
Therefore, we decided to perform two additional anastomoses between the superficial
epigastric and the lateral thoracic veins. At the end of the procedure, four drains
were positioned: two in the donor site and one for each breast. The patient was transferred
in the intensive care unit department for the first 48 postoperative hours and a heater
lamp was applied above the flap. The flap was monitored through handheld Doppler every
hour and observing capillary refill and temperature. Low molecular weight heparin
and broad-spectrum antibiotic medication (cefazolin 1 g thrice daily [TID]) were administered
for the first 10 days. Analgesic covering was reached using paracetamol 1 g TID and
ketoprofen 10 mg twice daily. After 48 hours, the patient was transferred to the plastic
surgery department where she was maintained at rest until the fifth postoperative
day. Drains were removed completely after 8 days with a fluid output lower than 20cc
each. The patient was discharged 10 days after the procedure. A compressive abdominal
girdle was applied and physical activity was avoided for 6 weeks ([Fig. 6]).
Fig. 3 Preoperative planning of scar removal and reconstruction with bilateral deep inferior
epigastric perforator flap. Perforators are marked with.
Fig. 4 The debridement was carried out involving also the muscular fascia and part of the
muscular superficial plane that was broadly filled with liquid silicone.
Fig. 5 Intraoperative incision (A) and perforators and nutrient vessels dissection (B).
Fig. 6 Postoperative picture showing the patient after 3 months from the operation.
Discussion
The term “silicone” indicates a large family of long-chain synthetic polymers containing
silicon, methyl, and oxygen atoms. The degree of polymerization and the number of
cross-linked bonds determine its viscosity. It exists in solid, gel, or liquid form,
which is called polydimethylsiloxane. Polydimethylsiloxanes are water-repellent fluids
with a low surface tension. The interest of the medical world in silicone has grown
exponentially since the 1940s.[2] In some ways, silicone has an excellent biocompatibility profile: it is permanent,
noncarcinogenic, minimally antigenic, and would not seem to favor bacterial growth.
It can be easily sterilized and is able to maintain its state as the temperature changes.
If silicone has found fertile ground in breast reconstruction with prostheses, the
same cannot be said as a liquid filler. After more than 50 years, liquid silicone,
unlike its solid and gel forms, is no longer used as a filling filler almost all over
the world. Depending on the country, its use is forbidden or off-label. However, clinical
experience has shown how the different silicone formulations, depending on the inoculation
site, have different side effects. Classical minor complications including edema,
erythema, skin texture change, and granulomas are reported with a frequency between
1 and 2%.[3] Other complications, including recurrent cellulitis, ulcerations, migration, and
nodule formation, have also been reported with silicone injections.[3]
Silicone migration or embolization as a result of large-volume injections and sometimes
breast implant rupture are considered the worst complication, which do not allow encapsulation
of the material. The migration of silicone can reach the lungs with a picture of parenchymal
siliconosis.[4]
[5] This complication can occur both in acute form with embolic modality and acute respiratory
distress syndrome,[5]
[6] or chronically.[7] Respiratory symptoms are present within 72 hours after injection of higher dose
silicone, but a delayed reaction is normally described up to a year and a half after
injection.[5] In this scenario, the release of silicone emboli leads to occlusion of the microvasculature
and triggers the inflammatory response, resulting in pulmonary edema, hemorrhage,
and subsequent fibrosis. Diagnosis of pneumonitis due to silicone liquid injection
can be challenging due to a lack of an available specific algorithm and more diagnostic
procedures are usually needed to confirm the diagnosis. First of all, silicone pneumonitis
must be always suspected when a clinical history of silicone implant or injection
is present. The radiological pattern includes subpleural infiltrates and peripherally
distributed ground-glass opacities, and tissues biopsy shows histopathological features
of alveolar hemorrhage and nonrefractile vacuole-like structure within the alveoli.[8]
[9]
[10] Alternatively, the presence of alveolar macrophages with intracytoplasmic silicone
inclusions in bronchoalveolar lavage sample is useful in facilitating a diagnosis.[11]
The case presented here represents a possible scenario of a complex of tissue and
lung siliconosis after liquid silicone improper use. Despite the importance of medical
support therapy, in this case, the contribution of the plastic surgeon has been crucial
to improve the mechanism of thoracic expansion. We performed an accurate debridement
and asportation of the scarring tissue and granulomas. For the reconstruction, we
chose the deep inferior epigastric perforator flap. This flap is a good source of
soft tissue, with a similar skin texture compared with the thoracic one. The donor
site scar can be placed in an aesthetically acceptable location and could contribute
to improve resultant abdominal contouring. Another advantage of this kind of flap
is the possibility of double team working without changing patient’s position. Before
the procedure, in accordance with the patient and the anesthesiologist, we decided
not to perform an aesthetic breast reconstruction. This choice was made to reduce
the amount of tissue needed and to avoid longer operative times in a patient with
such a severe reduction in pulmonary compliance. We planned a subsequent expander
positioning, once the local and pulmonary situation were stable. We performed a postoperative
spirometry exam, which did not observe a significant improvement in pulmonary volumes
despite the patient being referred for a clinical reduction in respiratory and thoracic
impairment. This curious clinical–laboratory dissociation might be attributed to the
role played by the soft tissue scarring on thoracic expansion. We suppose that despite
not influencing pulmonary volumes, breast scarring mechanically impaired lungs expansion.
Its removal has probably contributed to eliminate one of the factors of the restrictive
syndrome and the feeling of thoracic constriction perceived by the patient.
Conclusion
There is no consensus on the treatment of the silicone-induced pneumonitis. Surgical
asportation of the silicone and scarring tissues is considered as high risk of adverse
effects and technically complex. However, after a collegial discussion with the pulmonologist
expertise, surgical debridement of the scarring tissue and reconstruction of the affected
area could sometimes help to improve the ventilatory mechanism.
