Characteristics

Categories

Score

1. Amount of the infiltrated substance

Less than 200 ml

From 200 to 499 ml

From 500 ml to 1 liter

More than 1 liter

1

2

3

4

2. Infiltrated areas

One infiltrated area

From 2 to 3 infiltrated areas

More than 3 infiltrated areas

1

2

3

3. Nature of the infiltrated substance

Silicones

Biopolymers or methacrylates

Oils (edible, mineral, industrial, etc.)

Combined substances

1

2

3

4

4. Symptoms

Local inflammation (pain, heat, erythema)

Fever and generally unwell (asthenia, adynamia and weight loss)

Autoimmune disease

Pneumopathy

1

1

1

1

5. Signs

Presence of nodules

Substance migration

Hyperpigmentation and stiffening of the skin

Ulceration or infection

1

1

1

1

6. Laboratory studies

Normal studies

Leukopenia

High C-reactive protein level

Increase in erythrocyte-sedimentation rate

Multiple organ failure (hepatic, renal, blood)

0

1

1

1

1

7. Magnetic resonance imaging

Skin and the subcutaneous tissue involvement

Muscle involvement

Involvement of other organs

1

1

1

The decision regarding what form or forms of treatment to offer must be adapted to each patient’s clinical stage, since the presenting clinical manifestations of disease produced by the injection of oils or silicones are usually insidious, with nonspecific clinical and serological alterations, an unpredictable clinical course, and alternating symptomatic and asymptomatic periods (Table 7.2).

We are particularly concerned about women who have injected silicones into their breasts, because of the inability to detect early breast cancer, which is why we have designed the following specific therapeutic algorithm for mammary siliconomas (Graph 7.1).

For the treatment of silicone-induced axillary lymphadenopathy, we have designed another axillary-specific therapeutic algorithm that will be discussed at length in Chap. 14.

We followed the same guidelines provided in Chap. 5, where we described the diverse presentations of disease caused by liquid silicone injections, organized using a logical sequence of tissue and systemic compromise: from the mildest forms through to the most serious forms of damage, where the patient’s disease seriously impacts their quality of life and poses risks to life itself.

We will now present the appropriate therapeutic approaches for each form of mammary siliconoma presentation. Rather than forcing readers to refer back to photographs used in Chap. 5, some of those same photographs will be used here.

Patients with No Mammary Cutaneous Involvement (Figs. 7.1, 7.2, 7.3, 7.4, 7.5, and 7.6)

Patients with no cutaneous involvement of the breast were offered adenomastectomy with skin preservation, employing a submammary approach, with immediate placement of partial, retromuscular silicone gel (dual-plane) breast implants (Figs. 7.1 and 7.2).

On physical examination of the patient in Fig. 7.3, a good cosmetic and only slight erythema had resulted from the silicone injection that she had been administered by a non-physician (Fig. 7.3a, f, h, j and l). The patient reported having been pleased with the immediate result post-injection. Upon palpation, multiple painful nodules of different sizes were identified distributed throughout the breast. A subcutaneous adenomastectomy was performed with immediate totally retromuscular placement of silicone gel implants (Fig. 7.3c–e). The postoperative result was considered satisfactory, since the patient’s symptomatology disappeared. However, the aesthetic appearance was inferior to how the breast had appeared preoperatively (Fig. 7.3a, b, c, g).

A 24-year-old patient with a very good cosmetic result post silicone injection consulted for multiple painful breast masses, without alterations in the skin (Fig. 7.4a). A subcutaneous adenomastectomy was performed with the immediate partially retromuscular placement of silicone gel implants. As with the previous patient, the surgical outcome was deemed satisfactory, due to the resolution of symptoms, but was aesthetically worse than preoperative appearance (Fig. 7.4b).

Patients Who Reject Reconstruction with Implants

Many patients reject reconstruction with breast prostheses for fear of replacing silicone with silicone or for economic reasons.

Patient 1: This 30-year-old woman consulted for erythema and painful multiple mammary masses (Fig. 7.5a, c). She underwent subcutaneous adenomastectomy, via the inferior periareolar pathway, without reconstruction. In Fig. 7.5b, d, and e, the aesthetic sequelae of adenomastectomy without reconstruction are apparent.

Patient 2: This patient presented with good breast volume and good abdominal structure, so adenomastectomy with skin conservation was performed through the inferior periareolar pathway, followed by immediate reconstruction with a bilateral de-epidermalized TRAM flap (Fig. 7.6). The result of treatment initially was considered good, with the disappearance of symptoms and very good aesthetic result achieved. However, the patient rapidly developed partial necrosis of the abdominal flap and areola-left nipple complex and symptoms of depression postoperatively, which required treatment by our mental health service. Given her depression, we elected to reject surgical repair of the necrotic section of the abdominal flap and to pursue medical treatment instead (Fig. 7.6b, d). One year after her depression resolved, we returned her to the operating room to perform cosmetic revision of the abdominal defect and achieved a good result.

Patients with Mammary Cutaneous Involvement

Involvement Limited to the Lower Breast Quadrant (Figs. 7.7 and 7.8)

• 
  

  Wise Pattern Involvement (move to the top of the next paragraph)

For these patients, we generally perform a mastectomy without preservation of the nipple-areola complex, combined with breast reduction (Wise’s pattern), modified depending on the extent of skin involvement (Fig. 7.7a ), accompanied by adenomastectomy of the rest of the breast with immediate placement of a partially retromuscular silicone gel breast prosthesis.

In these cases, it is particularly important to choose small (no more than 200 or 250 cc), round, smooth, and low or moderate profile implants, or, alternatively, breast expanders with the objective that the flaps can close without tension, since there is the potential for silicone remnants in the flaps, which will compromise the flap’s vascularity and flexibility and can result in necrosis , seromas, and wound dehiscence if any tension is present. The result is typically satisfactory, with symptom resolution and an aesthetically acceptable breast.

• 
  

  Cutaneous Involvement that Exceeds Wise’s Pattern but Remains Limited to the Breast

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