Abstract
Breast augmentation with implants is one of the most popular cosmetic surgery operations performed worldwide. Complications of breast implants are well recognized, and include capsular contracture, implant rupture, and infrequently distant migration of silicone, resulting in siliconoma. Distant migration of silicone can present many years after implantation with a wide variety of signs and symptoms.
The aim of this study was to describe the authors’ experience of orbital silicone migration and to review the literature describing documented cases of distant silicon migration from breast implants, both ocular and nonocular.
In January 2022, a case of breast implant augmentation presented with silicone migration into the right orbit. This rare case was monitored and diagnosed with ocular muscle palsy and diplopia. Here, the authors present the patient's presenting complaint, symptomatology, working investigations, and outcomes. A comprehensive report of all available cases of distant silicone migration is presented along with their associated complications and more specifically ocular silicone migration.
Systemic migration of silicone from breast implants to the orbital region is extremely rare: a total of 4 previous cases of ocular silicone migration from breast implants have been described previously; the authors describe the fifth case herein.
Silicone implant rupture can present with a wide variety of clinical symptoms that may mimic different clinical pathologies. In every patient with a history of breast augmentation with silicone implants, the possibility of silicone migration should be always taken into consideration during the differential diagnosis process.
Breast augmentation with implants is one of the most popular cosmetic surgery operations performed worldwide.1 The first attempts of breast augmentation for cosmetic purposes were described in the second half of the 19th century,2 while silicone implants were first used in the 1960s.3 Both techniques and the quality of the implants have evolved over the years, leading to the development of 5 generations of breast implants. With each generation, due to constant progress in technology and research, the quality of the products has improved, lowering the risk of complications such as capsular contracture, rippling, implant rupture, malposition, and extrusion.4 A variety of implants are available on the market and new industrial processes have made them more durable and safer over time. However, the majority of patients requiring change of implants do not have latest-generation implants but rather devices that were introduced 20 years ago.
As a general consideration, we are all aware that the risk of implant rupture is directly proportional to the age of the implant, with the average implant lifetime estimated as being between 10 and 16 years.5–7 Although it is difficult both from clinical examination and imaging to detect whether an implant has ruptured,8,9 in many cases the decision to undergo an implant replacement procedure is taken for other reasons, ie, capsular contracture, malposition, and cosmetic desires. Therefore, breakage and subsequent silicone leakage is discovered in most cases only accidentally. Distant silicon migration due to implant rupture has seldom been reported in the literature and is considered to be a rare event. We describe a case of silicone migration from implant into the right orbit, resulting in ocular muscle palsy and diplopia, and review previously reported cases of distant silicon migration from breast implants, both ocular and nonocular.
METHODS
In January 2022, a case of breast implant augmentation presented with silicone migration into the right orbit. This rare case was monitored and diagnosed with ocular muscle palsy and diplopia. In this report we present the patient's presenting complaint, symptomatology, working investigations, and outcomes up to January 2023. Furthermore, a comprehensive report of all available cases of distant silicone migration are presented along with their associated complications and more specifically ocular silicone migration.
RESULTS
A 58-year-old female presented to the hospital with a “change in the shape” of her right eye and double vision. Ophthalmologic examination revealed muscle paralysis of the right eye on upward gaze and proptosis (Figures 1, 2). The patient had no past medical history but reported having undergone a breast augmentation with form-stable textured silicone breast implants 11 years previously. She denied receiving any kind of injection of silicone or filler into the face, or any previous facial procedures. Breast examination revealed bilateral Baker IV capsular contracture but no clinical signs of implant rupture (Figure 3).
Forward gaze of the 58-year-old female subject.
Upward gaze with right-sided palsy of the 58-year-old female subject.
Photographs of the 58-year-old female's breasts with Baker IV capsular contracture: (A) frontal view; (B) right-sided lateral view.
Following a surgical review, exploration of the right internal orbit was undertaken, which found “tissues infiltrated by a white homogeneous component” and biopsies were taken from the lacrimal gland, inferior oblique muscle, and inferior fornix. Histopathologic analysis subsequently reported the presence of a silicone granuloma in the right orbit. The case was discussed at a multidisciplinary meeting with rheumatology, neurology, ophthalmology, and plastic surgery. Further imaging was performed, which revealed a suspected silicon granuloma in the right carotid artery. This was treated medically with antiplatelets and corticosteroids.
Despite magnetic resonance and ultrasound imaging of the breasts indicating no signs of implant rupture, surgical intervention was arranged. The right breast implant was found to be intact, but the left implant had ruptured with massive silicon leakage. Bilateral total capsulectomy was performed and the capsule on the left side was sent for pathologic analysis, which was negative for silicone infiltration, reporting “scar tissue capsule surrounding breast implants with no atypical findings.”
DISCUSSION
Safety of silicone implants was first debated after a case of silicone pneumonitis described in 1976.10 Silicone migrating outside a breast implant can present in different locations and can be divided into 3 categories: intracapsular, extracapsular, or leakage (sometimes referred as “gel bleed”). Intracapsular rupture is defined by the breakage of the implant shell, with silicone still located within the fibrous capsule surrounding the implant. Extracapsular rupture occurs when macroscopic silicone material can be found external to the fibrous capsule around the implant. When silicone molecules are observed permeating through the intact shell of the implant, the condition is termed leakage.11 Leakage of silicon can occur from both ruptured and intact implants,12 and may present with local symptoms including breast pain, skin wrinkling, asymmetry, capsular contraction, and (rarely) infection.11,13 The rupture may also be asymptomatic, known as a “silent” rupture.14
In rare cases, silicon can migrate beyond the localized area of the breast and its surrounding tissue and infiltrate other organ systems, resulting in vague, insidious symptoms which may mimic other pathologies—leading to a challenging differential diagnosis. It has been hypothesized that systemic silicon deposition primarily occurs through both hematogenous and lymphatic routes,11 leading to systemic complications. These complications are the result of an inflammatory foreign body reaction and the formation of silicone granulomas or “siliconomas.”9 The most common systemic complication resulting from distant migration or embolization of silicone is silicone lymphadenopathy in the axillary or cervical lymph nodes.5,15 This is described as silicone in 1 or more lymph nodes, normally a late and incidental finding, usually discovered between 6 and 30 years after breast implantation.16,17 Reports of distant silicon migration mimicking breast cancer, pneumonitis, pulmonary embolism, sarcoidosis, dermatomyositis, and hepatic congestion have all been reported in the literature, and are summarized in Table 1.5,9,10,15,16,18–23 Due to the rarity of these complications, the literature is limited to unfiltered case reports and case series. Although notable in their findings, the evidence presented is low quality and must be treated accordingly. These sequelae are rare but can result in extensive investigations, misdiagnosis, and serious harm. For this reason, it is important that plastic surgeons counsel their patients appropriately regarding the potential long-term risks of breast augmentation.
Reported Complications Associated With Distant Silicone Migration From Breast Implants
| Author (year) | Complications |
|---|---|
| Khakbaz et al (2021)5 | Chronic silicone pulmonary embolism as a complication of saline implants with silicone shell |
| Hadfield et al (2020)9 | Siliconoma mimicking a locally invasive fungating breast malignancy |
| Azeem et al (2019)15 | Fibrosing pneumonitis and pulmonary embolism—leading to death of 1 patient |
| Ryu et al (2018)16 | Silicone pneumonitis and hypercalcemia |
| Hernández et al (2016)10 | Subacute silicone pneumonitis |
| Tanaka et al (2015)22 | Siliconoma mimicking malignant pleural mesothelioma |
| Mcgivern and Teoh (2012)20 | Silicone granuloma mimicking lung cancer |
| Dragu et al (2009)19 | Intrapulmonary siliconoma after silent silicone breast implant failure |
| Grubstein et al (2007)21 | Siliconoma mimicking sarcoidosis |
| Meyer et al (1998)18 | Siliconoma and dermatomyositis—causing bilateral chronic eyelid edema |
| Pfleiderer and Garrido (1995)23 | Accumulation of silicone in the liver |
| Author (year) | Complications |
|---|---|
| Khakbaz et al (2021)5 | Chronic silicone pulmonary embolism as a complication of saline implants with silicone shell |
| Hadfield et al (2020)9 | Siliconoma mimicking a locally invasive fungating breast malignancy |
| Azeem et al (2019)15 | Fibrosing pneumonitis and pulmonary embolism—leading to death of 1 patient |
| Ryu et al (2018)16 | Silicone pneumonitis and hypercalcemia |
| Hernández et al (2016)10 | Subacute silicone pneumonitis |
| Tanaka et al (2015)22 | Siliconoma mimicking malignant pleural mesothelioma |
| Mcgivern and Teoh (2012)20 | Silicone granuloma mimicking lung cancer |
| Dragu et al (2009)19 | Intrapulmonary siliconoma after silent silicone breast implant failure |
| Grubstein et al (2007)21 | Siliconoma mimicking sarcoidosis |
| Meyer et al (1998)18 | Siliconoma and dermatomyositis—causing bilateral chronic eyelid edema |
| Pfleiderer and Garrido (1995)23 | Accumulation of silicone in the liver |
Reported Complications Associated With Distant Silicone Migration From Breast Implants
| Author (year) | Complications |
|---|---|
| Khakbaz et al (2021)5 | Chronic silicone pulmonary embolism as a complication of saline implants with silicone shell |
| Hadfield et al (2020)9 | Siliconoma mimicking a locally invasive fungating breast malignancy |
| Azeem et al (2019)15 | Fibrosing pneumonitis and pulmonary embolism—leading to death of 1 patient |
| Ryu et al (2018)16 | Silicone pneumonitis and hypercalcemia |
| Hernández et al (2016)10 | Subacute silicone pneumonitis |
| Tanaka et al (2015)22 | Siliconoma mimicking malignant pleural mesothelioma |
| Mcgivern and Teoh (2012)20 | Silicone granuloma mimicking lung cancer |
| Dragu et al (2009)19 | Intrapulmonary siliconoma after silent silicone breast implant failure |
| Grubstein et al (2007)21 | Siliconoma mimicking sarcoidosis |
| Meyer et al (1998)18 | Siliconoma and dermatomyositis—causing bilateral chronic eyelid edema |
| Pfleiderer and Garrido (1995)23 | Accumulation of silicone in the liver |
| Author (year) | Complications |
|---|---|
| Khakbaz et al (2021)5 | Chronic silicone pulmonary embolism as a complication of saline implants with silicone shell |
| Hadfield et al (2020)9 | Siliconoma mimicking a locally invasive fungating breast malignancy |
| Azeem et al (2019)15 | Fibrosing pneumonitis and pulmonary embolism—leading to death of 1 patient |
| Ryu et al (2018)16 | Silicone pneumonitis and hypercalcemia |
| Hernández et al (2016)10 | Subacute silicone pneumonitis |
| Tanaka et al (2015)22 | Siliconoma mimicking malignant pleural mesothelioma |
| Mcgivern and Teoh (2012)20 | Silicone granuloma mimicking lung cancer |
| Dragu et al (2009)19 | Intrapulmonary siliconoma after silent silicone breast implant failure |
| Grubstein et al (2007)21 | Siliconoma mimicking sarcoidosis |
| Meyer et al (1998)18 | Siliconoma and dermatomyositis—causing bilateral chronic eyelid edema |
| Pfleiderer and Garrido (1995)23 | Accumulation of silicone in the liver |
Systemic migration of silicone from breast implants to the orbital region is extremely rare, and consequently very few cases have been described. A total of 4 previous cases of ocular silicone migration from breast implants are described—these are summarized in Table 2.18,24,25 These reports vary in presentation but 3 of the 5 cases (including the case described in the present article) were found to have bilateral silicone deposition. Notably, 4 out of 5 cases presented with skin or eyelid changes including erythema, nodules, oedema, and ectropion. This variation of symptoms that patients report demonstrates how diagnosis can be challenging, and emphasis should be placed on thorough history-taking including all previous surgeries.
Reports of Silicone Breast Implants With Ocular Silicone Migration
| Author (year) | Age (years) | Source (right, left or bilateral breast implant) | Ocular migration | Interval between implantation and migration (years) | Symptoms/signs |
|---|---|---|---|---|---|
| Montemurro et al (current study) | 58 | Left | Right orbit (lacrimal gland, inferior oblique muscle and inferior fornix) | 11 | Diplopia, proptosis, unilateral upward gaze muscle palsy |
| Neerukonda et al (2022)24 | 46 | Bilateral | Right upper eyelid | 4 | Recurrent right upper eyelid nodules |
| Neerukonda et al (2022)24 | 73 | Bilateral | Bilateral upper and lower eyelids | 40 | Ectropion, eyelid retraction |
| Meyer et al (1998)18 | 71 | Right | Right lower eyelid | 10 | Lower eyelid edema and erythema |
| Chen et al (2018)25 | 56 | Bilateral | Orbit and eyelids | 5 | Painful lumps in orbit, eyelids, breasts, arms, legs, face |
| Author (year) | Age (years) | Source (right, left or bilateral breast implant) | Ocular migration | Interval between implantation and migration (years) | Symptoms/signs |
|---|---|---|---|---|---|
| Montemurro et al (current study) | 58 | Left | Right orbit (lacrimal gland, inferior oblique muscle and inferior fornix) | 11 | Diplopia, proptosis, unilateral upward gaze muscle palsy |
| Neerukonda et al (2022)24 | 46 | Bilateral | Right upper eyelid | 4 | Recurrent right upper eyelid nodules |
| Neerukonda et al (2022)24 | 73 | Bilateral | Bilateral upper and lower eyelids | 40 | Ectropion, eyelid retraction |
| Meyer et al (1998)18 | 71 | Right | Right lower eyelid | 10 | Lower eyelid edema and erythema |
| Chen et al (2018)25 | 56 | Bilateral | Orbit and eyelids | 5 | Painful lumps in orbit, eyelids, breasts, arms, legs, face |
Reports of Silicone Breast Implants With Ocular Silicone Migration
| Author (year) | Age (years) | Source (right, left or bilateral breast implant) | Ocular migration | Interval between implantation and migration (years) | Symptoms/signs |
|---|---|---|---|---|---|
| Montemurro et al (current study) | 58 | Left | Right orbit (lacrimal gland, inferior oblique muscle and inferior fornix) | 11 | Diplopia, proptosis, unilateral upward gaze muscle palsy |
| Neerukonda et al (2022)24 | 46 | Bilateral | Right upper eyelid | 4 | Recurrent right upper eyelid nodules |
| Neerukonda et al (2022)24 | 73 | Bilateral | Bilateral upper and lower eyelids | 40 | Ectropion, eyelid retraction |
| Meyer et al (1998)18 | 71 | Right | Right lower eyelid | 10 | Lower eyelid edema and erythema |
| Chen et al (2018)25 | 56 | Bilateral | Orbit and eyelids | 5 | Painful lumps in orbit, eyelids, breasts, arms, legs, face |
| Author (year) | Age (years) | Source (right, left or bilateral breast implant) | Ocular migration | Interval between implantation and migration (years) | Symptoms/signs |
|---|---|---|---|---|---|
| Montemurro et al (current study) | 58 | Left | Right orbit (lacrimal gland, inferior oblique muscle and inferior fornix) | 11 | Diplopia, proptosis, unilateral upward gaze muscle palsy |
| Neerukonda et al (2022)24 | 46 | Bilateral | Right upper eyelid | 4 | Recurrent right upper eyelid nodules |
| Neerukonda et al (2022)24 | 73 | Bilateral | Bilateral upper and lower eyelids | 40 | Ectropion, eyelid retraction |
| Meyer et al (1998)18 | 71 | Right | Right lower eyelid | 10 | Lower eyelid edema and erythema |
| Chen et al (2018)25 | 56 | Bilateral | Orbit and eyelids | 5 | Painful lumps in orbit, eyelids, breasts, arms, legs, face |
The diagnosis of silicone leakage on imaging is also challenging, with a wide spectrum of appearances. Ultrasound, MRI, computed tomography, and positron emission tomography have been investigated to determine how best to image siliconoma in the body.21 However, in most cases, a biopsy is required to further characterize the image findings, given that a siliconoma can show significant fluorodeoxy-10 glucose uptake, which can result in a misdiagnosis of malignancy from a positron emission tomography scan.26,27 Prompt diagnosis is important given that silicone leakage in the body has led to adverse events such as pneumonitis, alveolar congestion, and acute respiratory distress syndrome.28
Surgical treatment of distant silicone migration includes removal of implants, but this may not be sufficient since the therapeutic effect of this procedure has not been confirmed in the literature.10,29 This may be related to the production of immunoglobulin G antibodies formed in response to the presence of silicone particles which could be responsible for persistent symptoms even after implant removal.10 Finally, symptoms related to the presence of siliconoma can persist several years after implant removal,5,18 suggesting that it is not sufficient to remove implants to avoid complications arising in the future.
CONCLUSIONS
In every patient with a history of breast augmentation with silicone implants, the possibility of silicone migration should always be taken into consideration during the differential diagnosis process. Symptoms can persist years after implants are removed—suggesting that simple removal of implants may not be sufficient to prevent complications. The case presented here is unique and its diagnosis took time, involving several medical/surgical specialties. For this reason, it is important to highlight the possibility of siliconoma in the orbit as a complication following rupture of silicone breast implants. Technological innovations may in the future help to identify both implant rupture and secondary silicone migration, thus helping physicians to detect the cause of symptoms early and allowing them to begin treatment promptly.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
REFERENCES
Author notes
Drs Montemurro is a plastic surgeons in private practice in Stockholm, Sweden.
Pellegatta is a plastic surgeons in private practice in Stockholm, Sweden.
Dr Burton is a plastic surgeon, Chelsea and Westminster Hospital, London, UK.
Dr Pafitanis is a plastic surgeon, Department of Plastic Surgery, Emergency Care and Trauma Division, The Royal London Hospital, Barts Health NHS Trust, London, UK.
