Introduction
BII refers to an array of non-specific symptoms attributed to breast implantation. These symptoms include fatigue, hair loss, headache, memory loss, rashes, chills, depression, sleep disturbances, and many more. Patients may decide to retain their implants or can undergo procedures to remove implants under the care of a board-certified plastic surgeon.
BII is also referred to as:
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Silicone implant disease.
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Autoimmune or inflammatory syndrome induced by adjuvants (ASIA).
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Breast implant disease.
Symptoms may occur immediately after implantation or may develop later on. In most cases, the removal of implants can make the symptoms disappear.
What Are the Signs and Symptoms of BII?
About half of the patients with BII have local symptoms like breast pain, tenderness, and burning sensation. Patients also develop changes in breast shape, symmetry, size, and firmness. In addition, BII patients experience systemic symptoms called chronic fatigue syndrome/myalgic encephalomyelitis(CFS/ME). BII is a form of autoimmune or autoinflammatory syndrome. BII includes neurological/musculoskeletal, vascular, and or immunological manifestations and is induced by adjuvants.
These include:
1.Sleep Disturbances:
The patient experiences difficulty falling asleep and also staying asleep. These sleep disturbances further increase fatigue.
2.Cognitive Impairment:
Cognitive impairment symptoms result in memory impairment (Alzheimer-light), absent-mindedness, difficulties in word-finding, and poor attention span.
3.Arthralgia/Myalgia:
Most patients report myalgia or muscle weakness. About 90% of patients fulfill the classification criteria for fibromyalgia. The weakness can be severe in some cases making the patient bedridden. About two third of patients reported pyrexia (elevated body temperature) and night sweats.
4.Sicca Symptoms:
About 75% of patients have severely dry eyes, mouth, and impaired tear production. Dry mouth problems may lead to swallowing difficulties, gum problems, and tooth decay. Sjogren (Sjogren’s syndrome is an autoimmune disorder characterized by dry eyes and mouth) like dry eyes and mouth are seen. In addition, headache, blurred vision, and or keratitis sicca (desiccation of conjunctiva due to decreased tear production) are also seen.
5. Atopic Symptoms:
Atopic (a type of allergy) symptoms include sneezing, runny nose, itchy eyes, red eyes, nasal congestion, and post-nasal drip (a condition in which mucous accumulates at the back of the throat). In some cases where allergies preexist, there is a worsening of the symptoms with implants.
6. Shortness of Breath:
Shortness of breath may occur due to severe asthma, interstitial lung disease, or pulmonary silicone embolism.
7. Pregnancy and Breast Implants:
It was found that around 79% can breastfeed at least one child with implants. But in 20% of cases, a decreased milk production was reported.
8. Breast Implant and Cancer:
Studies confirm that there is no association between breast cancer and implant. But breast implants affect the accuracy of mammographic tests used for cancer screening. In addition, studies suggest implants affect visualization in such cases. This, in turn, delays breast cancer’s early diagnosis and can worsen its prognosis. In addition, recent studies show a link between textured silicone breast implants and a rare form of anaplastic large cell lymphoma(ALCL).
What Are the Diagnostic Tests for BII?
Most cases show normal CRP(C-reactive proteins) levels. In 50 % of patients, Angiotensin- Converting enzyme and soluble Interleukin-2 receptor levels increase. Antinuclear antibodies are detected in 20 % of patients. Other antibodies like SSA/SSB, anti-ds DNA, anti-cardiolipin, IgM- rheumatoid factor, ANCA(anti-neutrophil cytoplasmic antibody), and cryoglobulin may also be detected. Vitamin D insufficiency and or deficiency is found in some cases. IgG levels are decreased in some patients.
For screening implant rupture, periodic imaging( ultrasound or MRI ) is done. MRI (Magnetic Resonance Imaging) is the test of choice in such cases. Mammograms are contraindicated, as compression may result in or exacerbate intracapsular rupture. MRI investigation can also detect capsular contracture, seroma, anaplastic large cell lymphoma (ALCL), and silicone-induced granuloma of the breast. MRI also detects silicone-containing granuloma in the lymph nodes. In ultrasound imaging, silicone lymphadenopathy shows a ‘snowstorm sign’(free silicone droplets mixed with breast tissue).
Pathophysiology of BII
Following implantation, there is an attraction of proteins and phagocytes. Rupture of the implant or leakage results in silicone leakage, leading to increased apoptosis or cell necrosis. Further, antigen-presenting cells get activated. This results in T-cell activation and granuloma(aggregation of immune cells in response to inflammation) formation. All these cellular mechanisms result in lymphadenopathy(the enlargement of lymph nodes) and autoantibody production. Clinical manifestations occur in the form of fatigue and arthralgia.
What Are the Treatment Options of BII?
Breast implant removal is dependent on the individual’s choice.
There are varying degree of implant explantation(removal of the implant) which includes:
En Bloc Explantation:
In this type, the capsule(scar tissue formed around the implant) and implant are removed as a single unit leaving the capsule tissue intact. Surgeons use an inframammary fold incision for this procedure.
Explant With Total Capsulectomy:
This procedure removes the implant and all capsule tissue, but not as a single unit.
Explant With Partial Capsulectomy:
In this technique, the surgeon removes the implant and some capsular tissue.
Open Capsulotomy:
In this method, the capsule or scar tissue surrounding the implant is surgically released and left in the patient’s body. Electrocautery is used for scoring the tissue. In the case of patients where the capsules are adherent to the chest wall, great care should be taken while doing en-bloc and capsule removal. Any injury to the underlying structures can pose a high risk, and there is even a chance for the development of pneumothorax (lung collapse due to air leakage into space between the lung and chest wall). So, the procedures of capsule removal and implant should always be performed by a skilled surgeon.
Conclusion
Breast implantation is one of the most popular cosmetic surgeries done worldwide. Unfortunately, some women develop a constellation of symptoms following breast implants, collectively called BII. Some of these symptoms can even be systemic and involve connective-tissue disorders. BII is an area that needs further research and studies. Most cases of BII subside by removing the implant, which is the most effective treatment option.
