Case Report

A white female patient underwent breast augmentation in 2010. At the time, she was 22 years old, weighing 64 kg, and measuring 1.71 m in height, with complaints of hypomastia. Physical examination revealed hypoplastic, symmetrical breasts with good upper breast coverage. Each breast received a 275 mL, round, textured implant. The approach was at the inframammary fold, and implant placement occurred in the subfascial plane.

In the immediate postoperative period, the patient found her breasts somewhat small. However, she reported subsequent acceptance. In 2018, at age 30, with the same weight and height, and asymptomatic, the patient underwent a routine ultrasound. The test revealed rupture of the right implantand a nodule (0.7 cm) at the quadrant junction of the left breast, which was biopsied and diagnosed as fibroadenoma.

The patient opted for permanent explantation, removing the implants and their capsules using the same incision in the inferior mammary fold, but 2 cm larger than the original one. Each breast received a 100 mL fat graft, both peripherally and subcutaneously, preserving the intact mammary gland. Breast tissue remodeling was performed through an internal asterisk plication in the center of both breasts, starting behind the nipple-areola complex (NAC) region to reconstruct breast projection. After the plication, the internal projection of the NAC was fixed to the chest wall to minimize subsequent breast ptosis (►Fig. 1,3). At a follow-up visit 1 year later, the patient reported satisfaction with the projection and shape of her breasts (►Fig. 2).

Fig. 1 - Operative times.

Fig. 1 - Operative times.

Fig. 2 - Preand postoperative aspects.

Fig. 2 - Preand postoperative aspects.

Fig. 3 - Sequence for the performance of a asterisk suture.

Fig. 3 - Sequence for the performance of a asterisk suture.

Results

Fat grafting and breast assembly with asterisk, concentric sutures in the breast parenchyma resulted in proper NAC projection, with its position fixed in the pectoral fascia to prevent residual ptosis. The case progressed satisfactorily with no outcome loss during the follow-up.

Discussion

The emergence of new questions about the effects of silicone implants and the information disseminated on social media increased the demand for removal. Social media describes a myriad of symptoms attributed to silicone, including malaise, fatigue, fibromyalgia, and headaches. To date, no study has demonstrated a cause-and-effect relationship with the so-called silicone disease. A theory links the disease to an overstimulation of the immune system, potentially representing a type of allergic response, but this is conjecture.^5,6,8

Explant planning requires thorough history taking and physical examination. The desired breast volume and shape after explantation, as well as the acceptance of additional scars, are discussed in detail. The degree of ptosis, amount of breast tissue, areola size, volume, implant type and position, and degree of skin elasticity are assessed.^1,9 Procedures such as mastopexy and fat grafting are often necessary to achieve satisfactory outcomes.⁴

Some authors recommend capsule removal for the same reason as prosthesis removal, since it can be intact in selected asymptomaticcases.Theyalsorecommendpartial or complete capsulectomy for grade-III and -IV contractures.⁵ Histopathological analyses of resected capsules may reveal evidence of silicone, even in intact implants from asymptomatic patients.¹⁰ Studies differ on the recurrence of systemic symptoms and capsular contracture after implant replacement.^4,5,7,8

The indication for en bloc capsulectomy, that is, implant and capsule removal in a single anatomical piece, occurs only when BIA-ALCL cannot be ruled out, as capsule fragments may result in lesion recurrence and impact patients’ survival.³

We performed a permanent removal of the implants and complete removal of capsules in the subglandular plane. Fat grafting and breast assembly with fan-shaped, concentric sutures in the breast parenchyma resulted in proper NAC projection, with its position fixed in the pectoral fascia to prevent residual ptosis. The case progressed satisfactorily, with no outcome loss at follow-up.

Conclusion

This case highlights an asymptomatic patient with a ruptured implant who requested removal without prosthetic replacement. It is worth emphasizing that achieving satisfactory results is easier with a correct diagnosis and aligned expectations before surgery. The simple technique of fat grafting and breast remodeling should be in the arsenal of anyone performing explants. Clear guidance regarding the surgical limitations and results is essential for these procedures, which require extensive discussion in academic circles as they become increasingly common.