Late Seroma Formation after Breast Surgery with Textured Silicone Implants: A Problem Worth Bearing in Mind

Abstract

Sir: In mammary implantation surgery, when breast enlargement occurs, physicians should first exclude infection and then investigate the presence of friction irritation or a true allergic response.1 Late hematoma and seroma are rare complications with an unknown incidence; current theories on their cause are as yet unproven. Several authors have suggested that microtrauma of the textured surface on the capsule causes the formation of granular tissue with neovessels that with rupture may lead to hematoma formation.2–4 In fact, cases of late hematoma and seroma unrelated to macroscopic trauma have been strictly associated with textured or polyurethane implants.3,5 We report a series of eight late seromas (five subglandular and three submuscular) accounting for a 1.84 percent incidence in our series. Patients presented a progressive monolateral breast enlargement (Figs. 1 and 2), but just four reported that a trauma had occurred a few days before. Ultrasound-guided needle aspiration of the fluid permitted us to exclude infection after aspirate culture. All patients experienced seroma recurrence and underwent reoperation with prosthesis removal. Removed implants did not present macroscopic signs of rupture. Immediate implant replacement was performed only if a new submuscular pocket could be created after capsulectomy. Otherwise, the implant was reintroduced into the same submuscular pocket after a period of 6 months. No seroma recurrence was observed at 1-year follow-up.Fig. 1.: Clinical photograph of a patient who underwent bilateral subglandular breast augmentation and developed a right late seroma (frontal view).Fig. 2.: Echographic image showing the intracapsular late seroma.Textured-surface and polyurethane implants have been preferred because of their lower rates of capsular contraction than smooth-surface implants in the subglandular compartment. However, it is noteworthy that reports of late seromas started only after the introduction of textured implants; indeed, late seromas are not mentioned in earlier studies investigating complications associated with smooth implants. The majority of reports of late seromas are associated with textured implants. Moreover, all reports of late seromas and hematomas related to smooth implants are associated with additional factors believed to be the cause.3 Lastly, unbroken textured or polyurethane implants have been associated with late seromas and hematoma in the absence of any apparent causative factor.2–4 Thus, the assumption that textured breast implants may cause late seroma seems to be correct. The incidence of these complications may be higher than believed because most reports are presented as single cases and not as part of wider, long-term studies. On the basis of our findings and the data reported concerning the etiopathogenetic mechanisms of late hematomas and seromas, we probably should consider changing the type of the implant from textured to smooth whenever a prosthesis needs to be replaced after these complications occur. Indeed, the smooth implant eliminates the risk of the friction irritation caused by the textured implant. Although we did not replace in our patients any of the textured implants with smooth ones to preserve implant symmetry and, also, any recurrence, we would seriously consider the possibility of doing so should any other cases of late seroma come to our attention. The inclusion of these complications in the informed consent form may be worth considering. Long-term studies designed to investigate the underlying causes of late intracapsular seroma and hematoma are warranted to prevent these complications. Marco Mazzocchi, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Perugia, Italy Luca A. Dessy, M.D., Ph.D. Bruno Carlesimo, M.D. Francesco Marchetti, M.D. Nicolò Scuderi, M.D. Department of Plastic and Reconstructive Surgery University “La Sapienza” Rome, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.