This work was supported by the National Research Foundation of Korea (NRF) grant funded by The Ministry of Education (NRF-2021R1I1A1A01049056).
This article was presented at the PRS KOREA 2021 on July 10–11, 2021
Spontaneous inflation of saline breast implants is a rare phenomenon. In this case report, we share our experience treating a patient who complained of asymmetric breasts from what appeared to be a straightforward case of capsular contracture. Spontaneous autoinflation of the right breast implant was subsequently found to be the cause of breast asymmetry and hardness. The presentation, diagnostic challenge, management, and mechanism of this rare phenomenon are presented here.
Controversy over the safety of silicone gel-filled implants led to the temporary popularity of saline-filled implants in the 1990s. During that time, saline-filled mammary implants had lower complication rates than silicone breast implants, which had presented with complications such as capsular contracture, rupture, gel bleed, and migration [
We report a case of autoinflation, an unusual complication in a saline implant, which was initially thought to be a straightforward case of capsular contracture because of their similar properties (i.e., hardening, pain, and spherical enlargement of the breast).
A 58-year-old patient presented to our institution complaining of gradual breast hardening and asymmetry. She had received bilateral breast augmentation with permanent implants 15 years earlier. She did not recall the type or model of the implants.
On physical examination, the right breast was harder than the left breast, and upper pole fullness was evident on the right breast when compared to the left breast. The patient complained of stretching pain on the right side. The right nipple-areolar complex was drawn cranially (
Under general anesthesia, a bilateral inframammary crease incision was utilized. Contrary to our expectation, a thin layer of capsule was noted around the right implant. Total capsulectomy was possible on both sides without violation of the capsule or rupture of the implants. After unviolated total capsulectomy, the remnant right breast pocket was intact without signs of infection or fibrosis. However, as a precautionary measure, the explanted breast pockets were thoroughly irrigated with triple-antibiotic solution and closed in the usual fashion with negative suction drains. The patient preferred not to have new implants after explantation.
After removal of the implants, it was confirmed that both left and right implants were of the same model and volume (190 cc, textured, saline filled). However, the implant on the right was significantly larger and spherical in shape rather than the normal dome shape (
The internal fluid from both implants was evacuated. The total aspiration volume of the autoinflated implant was 275 cc, compared to 180 cc in the contralateral implant, corresponding to a 40% inflation from the native volume. The gross appearance of the fluid was also different. The aspirate from the autoinflated implant showed a yellowish discoloration (
Chemical analysis of the aspirated fluids from both the normal and the autoinflated implants was performed (
Autoinflation of breast implants is a rare phenomenon that has been documented only in saline-filled breast implants. In the early 1990s, the safety of silicone-filled implants was questioned and saline implants gained popularity. Saline implants were considered less toxic, with a lower incidence of capsular contracture, as well as a lower rate of gel bleeding and migration [
Botti and Villedieu [
The mechanism of implant autoinflation has not been clearly elucidated. However, there are two hypotheses for the phenomenon. The most straightforward hypothesis suggests that a defect in the valve integrity is responsible for autoinflation. The faulty inflation valve, which is designed to permanently seal off after the initial instillation of the normal saline, becomes leaky and might act as a check valve [
A peculiar feature of our case is the time to diagnosis of autoinflation after augmentation. A literature search showed that time to patient presentation ranged from 6 to 120 months (
It should be pointed out that autoinflated implants can mimic high-grade capsular contracture in terms of upward migration, spherical deformation, stiffness, and pain. The impression of autoinflation is further confounded because most patients do not recall the model or material properties of their implants. In our case, we were not able to obtain an implant-related history from the patient or from the previous hospital and therefore presumed that the patient had developed capsular contracture, a common and reasonable explanation for the patient’s symptoms. Routine mammograms were not enough to evaluate the degree of capsular contracture. In retrospect, performing an ultrasound or magnetic resonance imaging examination might have differentiated autoinflation from capsular contracture. However, we did not feel it was necessary to perform a costly examination since the findings were very similar to high-grade capsular contracture, and the prosthesis was old enough to consider explantation. The medical history and physical examination provided more than sufficient findings to think that capsulectomy and implant removal were indicated for the patient.
Although seldom used in current practice, previously inserted saline implants require follow-up care. In this context, we think that the rare phenomenon of autoinflation in a saline implant is noteworthy.
No potential conflict of interest relevant to this article was reported.
This study was approved by the Institutional Review Board of The Catholic University of Korea College of Medicine (IRB No. KC22- ZASI0221).
The patient provided written informed consent for publication of the case and the use of her images.
Patient at initial presentation. A larger breast is noted on the right side.
Explanted implant, capsule, and aspirated fluid from inside the implant. (A) Total capsulectomy was performed without violating the implant integrity. Both implants were textured saline implants of the same volume. The capsulectomy specimen was nonspecific and did not show a high degree of contracture. (B) Although the two implants were of the same model, overinflation is noted in one implant (on the left). (C) The color and turbidity of the aspirate are deeper yellow and viscous (left syringe) compared to the normal aspirate (right syringe).
Chemical analysis of the fluid inside an autoinflated saline implant compared to an unaffected saline implant
Measurement | Autoinflated side (right) | Normal side (left) |
---|---|---|
Total protein (µg/mL) | 1,119.5 | 1.8 |
Albumin (g/dL) | 0.91 | <0.1 |
pH | 7.6 | 7.2 |
Color | Yellow | Colorless |
Specific gravity (g/cm3) | 1.012 | 1.005 |
White blood cell count (/µL) | 605 |
1 |
Red blood cell count (/µL) | 1,200 | 0 |
Chloride (mEq/L) | 130 | 153 |
Glucose (mg/dL) | <10 | <10 |
Osmolality (mOsm/kg) | 299 | 293 |
Lactate dehydrogenase (IU/L) | <50 | <50 |
Lymphocytes 5%, macrophages 95%.
Summary of previous literature reporting autoinflation of saline implants
No. of subjects | Lumen | Texture | Interval to symptom occurrence (mo), range | Gross description of implant fluid | Increase of volume (%), range | Chemical analysis | Reference |
---|---|---|---|---|---|---|---|
1 | Double | Textured | 6 | Brown colored, thick | NA | NA | [ |
2 | Single | Textured | 8 | Brown colored, thick, or clear | 15 | Negative bacterial culture | [ |
3 | NA | Smooth | 45-87 | Brown colored, thick | 45-87 | Hyperosmolar, high in sodium and chloride, positive bacterial culture | [ |
3 | Single | Smooth | 86-108 | Highly viscous | 15-114 | High protein content, hyperosmolar | [ |
1 | Single | Smooth | 120 | Dark yellow, more viscous | NA | Electrophoresis results similar to patient’s serum | [ |
NA, not available.