Seroma as a Late Complication after Breast Augmentation

Abstract

This report with late seromas occurring in the periprosthetic cavity. This complication is a rare development after breast augmentation. From 1996 to 2009, the authors performed 568 initial breast augmentation procedures. During this period, they observed late seromas in six cases. In five of the six cases, the initial operations were performed by the authors (0.88% of all breast augmentation operations performed at the authors’ center during the respective period). In one case, the operation had been performed in another clinic. Late seromas occurred at various intervals 2 to 10 years after the initial breast augmentation. In five of the six reported cases, revision surgery was required. In one case, conservative treatment was applied. An implant rupture was observed in only one case. In the remaining five cases, the implants were intact. In the authors’ opinion, seromas may occur when any sliding surfaces are present and as a result of micromotion of implants in cavities. The inner surface of a capsule with a synovial metaplasia becomes a target for chronic infections.

As breast augmentation with silicone implants becomes increasingly popular, we observe a larger number of very rare complications directly related to the presence of a foreign object (i.e, a silicone implant) in the body. A seroma in the periprosthetic cavity occurring with a substantial delay after the initial surgery is one such rare complication.

Several cases of late seroma development are described in the literature [9, 10, 14]. To date, the reasons for the development of late seromas (the so-called breast autoinflation) have not been studied sufficiently. Possible etiologic factors include a chronic infection, an allergic reaction, a hormonal imbalance, lymphorrhea (exudation) from the damaged surface of the connective tissue capsule, and implant rupture.

Patients and Methods

During 1996–2009, we performed 568 breast augmentation procedures. Of the 568 operations, 306 were performed with retropectoral (partially subpectoral or fully submuscular) implant placement, and 262 were performed with retromammary (subglandular or subfascial) placement. In all cases, anatomically shaped or round textured implants were used [1]. The patients wore compressing underwear up to 2 months after surgery. During this period we observed late seromas in six patients.

In five cases, the initial operations were performed by us and represented 0.88% of the all the breast augmentations performed at our center. In one case, the initial operation was performed at another institution.

Late seromas occurred at various intervals 2 to 10 years after the initial breast augmentation. In five of the reported cases, revision surgery was required. In one case, conservative treatment was applied.

Case 1

On 26 November 1997, patient P, a 35-year-old woman, had a breast augmentation with subfascial placement of McGhan 110 st 240-cm³ implants (Arklow, Ireland) through the inframammary approach. In late August 2007, she returned with enlargement and discomfort in her left breast that followed a week after an onset of a minor cold. Together with breast enlargement, the patient reported general weakness and a temperature increase up to 38.5°C. The patient experienced no pain and took Augmentin (GlaxoSmithKline, Brentford, UK). Breast asymmetry was obvious, as was a swelling of the upper pole of the left breast. The breast was firm and sensitive to palpation (Fig. 1a).

Fig. 1

Case 1. a Left-side seroma 10 years after submammary breast augmentation with McGhan 110 st 240-cm³ implants. b Computed tomography (CT) scan before the paracentesis showing fluid in the cavity around the deformed left implant. c Serous fluid (120 ml) drained through the paracentesis. d Aesthetic appearance directly after the paracentesis

The blood analysis showed a minor shift of the leucocytic curve to the left. Ultrasound scanning and mammography indicated fluid in the cavity around the left implant. The breast tissue was normal, and the regional lymph nodes were not enlarged. Computed tomography (CT) showed fluid around the left implant and thickening of the capsule that deformed the implant (Fig. 1b).

On 1 September 2007, about 120 ml of serous fluid was drained through the paracentesis (Fig. 1c). Due to the observed breast asymmetry and the remaining deformation of the left implant (as shown in the control CT scan performed 1 month after the paracentesis; Fig. 2b), on 3 October 2007, a repeat partial subpectoral breast augmentation with a new McGhan 410 MX 290-cm³ implant was performed (Fig. 2). The removed implants were both intact. The capsule around the implants had the appearance of cartilaginous tissue (Fig. 3). At removal of the capsule, the implant fully recovered its original shape. At 1 year after the revision surgery, the patient had no complaints. The breasts were symmetric, and the implants were soft.

Fig. 2

The same patient as in Fig. 1. a View 2 months after the paracentesis. b Computed tomography (CT) scan 1 month after the paracentesis showing deformation of the left implant. c Left implant removed together with the capsule. The bottom of the cavity was covered with folds and grooves, above which no capsule ingrowth into the membrane was observed. d View 1 year after the subtotal capsulectomy and repeat partial breast augmentation with McGhan 410 st MX 290-cm³ implants

Fig. 3

Aesthetic appearance of the left implant removed from the same patient as in Figs. 1 and 2 (see details in text)

Case 2

On 27 January 2004, patient M, a 32-year-old woman, had a breast augmentation by partial subpectoral placement of McGhan 410 MF 335-cm³ implants through the infra-areolar incision with a left circumareolar mastopexy. On 3 November 2008, the patient returned with enlargement of both breasts, which had occurred a week earlier (Fig. 4b). The symptom appeared to be accompanied by general weakness and temperature increases up to 38°C. The patient observed that similar, albeit very minor, breast enlargements were occurring in the past during common colds.

Fig. 4

Case 2. a The patient 3 weeks after the initial operation. The picture is from the archive. b The patient’s appearance in 4 years. Note the bilateral seroma. c Computed tomography (CT) scan showing fluid behind both implants. The implants are straightened. d The same patient 1 month after the conservative treatment

Both breasts were enlarged, as was apparent from a simple visual comparison with the pictures from the archive (Fig. 4a). Both breasts were somewhat firm, showing no pain at palpation, and had a homogeneous texture. The regional lymph nodes were not enlarged.

The blood analysis showed a minor shift of the leucocytic curve to the left and an increase in the erythrocyte sedimentation rate. Ultrasound diagnostics and mammography indicated fluid in the cavity around both implants. A CT scan showed fluid around the straightened, nondeformed implants (Fig. 4c).

Because the patient did not experience any pain or discomfort, had no symptoms of capsular contracture (CT scan showed the straightened implants), and improved after taking aciclovir (Darnitsa), we decided to apply a conservative treatment and monitor the patient. In 1 month, the patient recovered to her presymptom breast size (Fig. 4d).

Case 3

On 6 November 2007, patient К, a 40-year-old woman, had a breast augmentation with dual-plane placement of McGhan 120 st 260-cm³ implants through the inframammary approach. The rudimentary nipple in the right inframammary fold was left intact per the patient’s request. Minor inherent asymmetry (D > S) remained after the initial augmentation, although it did not disturb the patient.

In January 2008, the patient returned with blisters in the upper medial quadrant of the right breast. The diagnosis was herpes zoster, and the patient was prescribed aciclovir (Darnitsa) (Fig. 5). The symptoms of the herpetic infection disappeared in 1 week.

Fig. 5

Case 3. 3 months after the initial breast augmentation with the herpetic infection symptoms observed in the upper medial quadrant of the patient’s right breast

In June 2009, the patient returned with an enlarged right breast observed for 2 weeks. She noted that the onset of the disease happened during hypothermia and an acute respiratory viral infection. The woman was experiencing general weakness and temperature increases up to 38.5°C but no pain. The right breast was apparently enlarged and firm to palpation, whereas both implants were soft (Fig. 6a).

Fig. 6

Case 3. a At the moment of seroma formation. b Computed tomography (CT) scan showing fluid around the right implant. c The performance of capsulocentesis. d Serous-hemorrhagic fluid was evacuated. e The same patient 5 months after the capsulocentesis

The blood analysis results were normal. Ultrasound scanning and CT showed fluid around the right implant, a thickening of the capsule, and folds on the anterior surface of the implants (Fig. 6b). The glandular tissue was normal, and the regional lymph nodes were not enlarged.

On 3 July 2009, a right capsulocentesis of the periprosthetic cavity was performed. The fluid was removed through skin and glandular tissue incisions 1.5 cm long. The incision size was within the inframammary fold of the initial operation. The capsule around the implant was pulled up and cut with scissors. About 80 ml of serous hemorrhagic fluid was drained from the cavity (Fig. 6c, d). Vacuum drainage was kept for 24 h. Conservative treatment with cefazolin (Borshchahivskiy Chemical-Pharmaceutical Plant, Kiev, Ukraine), and aciclovir (Darnitsa) was prescribed. No complications were observed after the revision surgery. At the control visit in 5 months, the patient’s right breast was soft and flexible. Both implants had similar density (Fig. 6e).

Case 4

On 19 October 2005, patient M, a 33-year-old woman, had an initial breast augmentation with partial subpectoral placement of McGhan 410 FM 235-cm³ implants through the inframammary fold.

On 15 September 2009, the patient returned with discomfort and enlargement of her left breast. She explained that the symptoms had appeared a week earlier accompanied by temperature increases up to 38°C, general weakness, and transient loss of consciousness. Later, the right breast returned to the presymptom size, and the left breast remained enlarged. The left breast was firm and sensitive to palpation (Fig. 7).

Fig. 7

Case 4. The aesthetic appearance at the first visit. Note the left-side seroma

Blood analysis determined a shift of the leucocytic curve to the left and an increase in the erythrocyte sedimentation rate. Ultrasonic scanning and mammography indicated fluid in the cavity around the left implant. Magnetic resonance imaging (MRI) showed fluid around the implant, a thickened capsule, and a compressed multiple-fold implant (Fig. 8a). The glandular tissue was normal, and the regional lymph nodes were not enlarged.

Fig. 8

Case 4. a Magnetic resonance image (MRI) showing fluid around the left implant. b Intraoperative view at the moment the connective tissue capsule is incised. c Appearance of the implant after explantation. d Appearance after irrigation. The implant has no defects. e The same patient as in Fig. 7 after 3 months

On 24 September 2009, a revision breast augmentation was performed. The capsule surrounding the implant was incised using the original inframammary fold scar, and 150 ml of dark-yellow serous fluid was drained (Fig. 8b). The cavity contained the implant covered by a thin interior leaf of connective tissue capsule and freely sliding along the exterior leaf (Fig. 8c). The removed implant was intact (Fig. 8d).

A new implant of the same shape was placed into the same cavity after removal of the connective tissue capsule and irrigation of the cavity with an antiseptic solution. Vacuum draining of the periprosthetic cavity was kept for 2 days. Cefazolin (Borshchahivskiy Chemical-Pharmaceutical Plant) and aciclovir (Darnitsa) were prescribed. No complications were observed after the revision surgery. At the control visit 3 months later, the patient’s breasts were symmetric, soft, and flexible. The implant was soft (Fig. 8e).

Case 5

Patient B, a 28-year-old woman, had a breast augmentation with anatomically shaped Silimed 325 cm³ implants (Dieburg, Germany) placed subpectorally through the inframammary fold with circumareola mastopexy. The procedure had been performed at another institution 6 years earlier.

On 20 October 2009, the patient presented with an enlarged left breast and reported a general discomfort. The period from the onset of the first symptoms to the first visit was less than 2 months. The patient was taking antibiotics, but the seroma was rapidly progressing (Fig. 9a).

Fig. 9

Case 5. a At the moment of the patient’s visit to the institution. Note the right-side seroma. b Magnetic resonance image (MRI) of the breasts showing fluid in periprosthetic cavity at the right and rotation of the left implant. c Intraoperative view showing 420 ml of evacuated fluid

Physical examination showed breast asymmetry with a considerably larger right breast. The patient experienced no pain at palpation. The left breast felt firmer than the right breast. Ptosis of both breasts was observed. An MRI showed fluid around the right implant and a thickened capsule. The implant was turned by 180°. A compressed and deformed implant due to the thickened capsule was observed to the left of the capsular contracture (Fig. 9b). All laboratory examination results were normal.

Taking into consideration the sufficient amount of glandular tissue and the patient’s request, the implants were removed, and a mastopexy was performed on 22 October 2009. In particular, examination of the right side showed an intracapsular exudate of 420 ml (Fig. 9c). The lower pole of the implant was in the upper section of the cavity, and the implant was drifting freely in the serous fluid. The capsule did not adhere to the implants.

A bilateral implant explantation and Ribeiro’s T-mastopexy were performed [13]. No complications were observed after the revision surgery. At the control visit 3 months later, both breasts were symmetric, soft, and flexible. No signs of seroma formation were observed.

Case 6

On 19 April 2006, after a full standard examination (including ultrasound scanning and mammography, neither of which showed abnormalities), patient B, a 36-year-old woman, had an initial breast augmentation with circumareolar dermathopexy of the right breast. McGhan 410 FM 310-cm³ implants were placed partially into the subpectoral cavity through the infra-areolar approach.

On 10 November 2009, the patient returned with an unexplained sudden enlargement of the left breast that began a week earlier. The patient experienced general weakness and temperature increases up to 37.5°C. The left breast was obviously larger and firmer than the right breast. Palpation indicated two painless nonmobile, smooth-surface round formations at the interior quadrant edges. The formations did not adhere to any surrounding tissues (Fig. 10a). The skin integument was unchanged and showed no signs of a trauma.

Fig. 10

Case 6. a The patient’s appearance at the moment of the first visit. Note the left-side seroma. b Magnetic resonance image (MRI) of the breasts showing fluid behind the left implant. The implant rupture area is indicated by an arrow, and fibroadenoma is indicated by the dashes. c Connective tissue adherence inside the implant. d The moment of fibroadenoma removal

The blood analysis results were normal. Ultrasound scanning showed fluid in the periprosthetic cavity and two fibroadenomas (0.8 cm and 1.5 cm, respectively), as well as signs of an implant rupture. An MRI also showed fluid in the periprosthetic cavity and a rupture of the left implant in the area closely adjoining the glandular tissues, where the fibroadenomas were localized (Fig. 10b).

Although only one implant was damaged, the decision was made to replace both implants with McGhan 510 FX 435-ml implants, taking into consideration a potential enlargement of the cavity after capsulectomy and the patient’s request. It should be noted that at the moment of revision surgery, 2 weeks after the patient’s visit, the left breast regained its initial shape without any conservative treatment.

On 26 November 2009, a revision breast augmentation was performed through the approach using the inframammary fold. The textured implant was bluntly dissected from the adherent capsule and explanted from the cavity. The cover of the left implant was ruptured at the medial edge at 9 to 10 o’clock of the imaginary clock. No implant gel was observed outside of the capsule. A 30 × 12 × 12-mm invaginative connective tissue formation ingrown into the implant cavity through the membrane rupture was observed, suggesting that a rupture had occurred at some delayed point in the past (Fig. 10c). The connective tissue capsule around the implant was thickened and split into two leaves along the posterior wall. A small amount of a serous fluid was observed in the area between the leaves. Fibroadenomas were enucleated (histologic findings indicated pericanalicular fibroadenomas of the left breast) (Fig. 10d).

Capsulectomy of the anterior and partially posterior wall of the cavity was performed. A new implant was placed. The capsule of the right breast was thin and adherent to the implant. No capsulectomy was performed. No complications were observed after the revision surgery.

Results and Discussion

During a revision breast augmentation, a small amount of fluid similar to synovial metaplasia often is observed in the periprosthetic cavity. This fluid reduces friction and protects the sliding surfaces. Ahn et al. [1] reported a small amount of fluid in the periprosthetic cavity in 15% of cases (21 of 139) studied. Because the processes of the exudation and resorption are balanced, a small amount of fluid can be considered normal. Several preconditions usually are observed before the occurrence of the fluid:

• 1. Two surfaces sliding against each other. These may be a connective tissue capsule and the wall of an implant, which is more typical for smooth implants or textured implants with a noneffective structure. This also may be a dual capsule with two leaflets, which is typical for textured implants with surfaces tending to adherence.

• 2. Excessive movement of the breast together with an implant against the chest wall.

• 3. Cases in which the breast skin area is larger than its parenchyma area. The “anterior pull skin stretch” (APSS) test is greater than 4 cm [15].

Many authors argue that the occurrence of intracapsular fluid results from the micromotions of implants and irritation of surrounding tissues, leading to synovial metaplasia [2, 3, 8, 11, 12]. Hameed et al. [6] examined morphologic and immunohistologic properties of 15 connective tissue capsules sampled during revision breast augmentation surgeries. In 7 of the 15 cases, intracapsular papillary (villous) synovial metaplasia was found. The authors noted that the pathophysiologic properties of the metaplasias were similar to those of proliferative synovitis occurring around orthopedic implants.

Flassbeck et al. [4] pointed to an allergogenic effect of silicone gel ingredients. The authors argued that platinum used in the production of silicone gel-filled implants under certain circumstances can act as a powerful allergen.

Gonzales [5] described one case of large late bilateral seroma that occurred 2.5 years after a buttock augmentation with micropolyurethane implants. The total volume of fluid reached 1.5 l. According to the author, occurrence of late hematoma and late seroma is related to the textured surfaces of the implants.

We agree with the opinion of Khan [7], who argued that the development of seroma can be a marker of implant rupture. The author described five late seromas accompanied by implant ruptures in which some shell damage was found using only a microscope. Nevertheless, the reasons why in one case a seroma self-cured even when an implant was damaged (case 6) and yet in another case progressed when an implant was intact (case 5) still are not clear (Table 1).

Table 1 Case summary of late seromas after breast augmentation

The clinician should distinguish between a small amount of fluid similar to synovial metaplasia and a pathologic exudation to the periprosthetic cavity, which finally results in formation of seroma. Tatla et al. [14] described one case of a late seroma, which occurred at the background of a rupture of a textured gel-filled implant. Oliveira et al. [9], on the contrary, described a case of a late seroma after a breast augmentation using silicone implants without any rupture. The literature also describes examples of late seroma after surgical correction of Poland syndrome in male patients using textured silicone gel-filled implants with no implant membrane ruptures [10].

It is our opinion that late seromas may occur due to chronic infection agents, which are tropic to the endothelium of a connective tissue capsule when such infection agents get activated due to weak immune resistance. This hypothesis can explain temperature increases and general weakness in the majority of cases described.

We performed bacteriologic and cytologic examinations of serous fluid in which Staphylococcus epidermidis was observed (cases 4 and 5) (possibly originating from the skin surface) and a large amount of neutrophylic leucocytes. We tested whether the seroma development was associated with TORCH infections. Our tests (herpes zoster, cytomegalovirus, chlamydia) showed that at high immunoglobulin G (IgG) levels, we typically observed a normal IgM level, which indicated no acute infectious processes. However, aciclovir treatment in two cases was effective.

We can assume that any changes in a body (e.g., hormonal changes, hypothermia) that weaken an immune system may result in several adenoviral infection stems becoming tropic toward the endothelium of the connective tissue capsule around silicone implants and causing various inflammation processes, with excessive exudate of serous fluid similar to synovitis.

Conclusions

The reasons for seroma development require further examination. In our opinion, seromas occur due to the presence of sliding surfaces and implant movement inside the cavity, resulting in synovial metaplasia of a capsule’s internal surface. The inner surface of a capsule with a synovial metaplasia becomes a target for chronic infections.