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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e3

CASE REPORT

Where the PIP is the implant? ´ a, Moira H.D. Bruintjes a, Corinne Schouten a, Jan Fabre Frits J. van den Wildenberg b, David S. Wijnberg a,* a Department of Plastic and Reconstructive Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands b Department of General Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands

Received 23 December 2013; accepted 26 January 2014

KEYWORDS PIP breast implant; Breast implant displacement; Breast augmentation; Thoracic surgery

Summary A 51-year-old woman, who had previous breast augmentation and a video-assisted thoracoscopic wedge resection of the lung, underwent breast implant replacement of Poly Implant Protheses (PIP) due to a loss of volume on the right side of the chest. During this procedure, no implant was found in the right subpectoral space; however, a large defect was observed in the fifth intercostal space. A computed tomography scan of the chest indicated a circular entity in the right pleural cavity, which was confirmed to be the lost implant during a subsequent video-assisted thoracoscopic surgery (VATS). ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Historically, breast augmentation with saline-filled implants has become a relatively safe procedure. Serious complications rarely occur. In this report, we describe a case in which a silicone breast implant migrated into the thoracic cavity after breast augmentation and subsequent thoracic surgery.

Case report A 51-year-old woman, with COPD Gold I, underwent a PIPimplant breast augmentation 20 years ago. Recently, she was treated for a suspicious lesion in the upper lobe of the right lung, with a video-assisted thoracoscopic surgery (VATS) wedge resection of the lung. Pathologic examination showed * Corresponding author. Canisius Wilhelmina Hospital Nijmegen, Department of Plastic and Reconstructive Surgery, 6532 SZ Nijmegen, The Netherlands. Tel.: þ31 24 365 82 35. E-mail addresses: [email protected] (M.H.D. Bruintjes), [email protected] (D.S. Wijnberg).

no malignant lesion, but a non-specific necrotising inflammation. During the post-operative period, she noted a loss of volume on the right side of the chest, for which she consulted her general practitioner, who referred her to the plastic surgeon for further investigation. Physical examination demonstrated an asymmetrical appearance of the breasts, the left one being bigger than the right. In the left breast, an implant could be palpated, whereas on the right side no implant was palpable. Subsequent mammography did not provide any additional information, whereas ultrasound showed remnants of the implant shell in the right axillary region. According to these results, the patient was considered to have a ruptured right implant and was therefore scheduled for a capsulectomy and implant exchange. The original inframammary scar was used. First, the implant capsule on the left side was opened and the retropectoral implant removed. After opening the implant capsule on the right side, however, no implant was found. Careful examination of the cavity showed a defect measuring 6  3 cm in the lateral

1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.035

Please cite this article in press as: Bruintjes MHD, et al., Where the PIP is the implant?, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.035

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Figure 1 A (left): CT image indicating a circular mass (red line) just above the diaphragm in the right pleural cavity. B (right): Coronal section of the CT scan showing the circular entity in the right chest.

portion of the cavity, which appeared to be in continuity with the intrathoracic cavity through the fifth intercostal space. Intra-operatively, the thoracic surgeon was consulted and advised to abort the procedure. Consequently, no new implants were placed. Post-operatively a computed tomography (CT) scan was made, indicating a circular mass just above the diaphragm in the right pleural cavity (Figure 1). Based on these findings, the patient was operated again in collaboration with the thoracic surgeon to remove the foreign body from the right pleural cavity via a VATS procedure. The original incisions from the previous VATS procedure were used and on exploration of the pleural cavity, a large defect measuring about 6  3 cm was observed in the fifth intercostal space. Through this defect, the pleural cavity was communicating with the implant cavity. The foreign body, which appeared to be the lost implant, was located in the posterior-medial aspect of the right pleural cavity. The implant was ruptured and surrounded by free silicone (Figure 2). No adhesions were seen with the pleura. The implant was removed and the pleural cavity thoroughly rinsed to eliminate the free silicone. Subsequently, the parietal pleura were scrubbed and a chest tube placed after which the defect of the chest wall was reinforced with the pectoralis major muscle. There were no complications during the post-operative period.

Discussion There have been a few reports on intrathoracic migration of breast implants.1e5 Sykes et al.1 reported a similar case of implant migration after VATS lobectomy. Mehta et al.2

described an intrathoracic migrated implant after a thoracotomy for lung cancer. Others reported migration of breast implants after mammoplasty, without any kind of thoracic surgery.3e5 It is assumed that the migration of these implants was due to chest wall injuries, post-operative breast massage or differences in intrathoracic and extrathoracic pressure. In our case, the thoracic defect combined with the negative pressure environment of the pleural space was sufficient to draw the implant through the chest wall and into the pleural space. Therefore, surgeons should be careful performing chest wall surgery on patients with a history of augmentation mammoplasty, as during chest surgery an iatrogenic connection between the subpectoral and pleural cavity can be created. Moreover, during breast augmentation surgeons should also be aware of the risk of injuring the pleural cavity. In case of pleural laceration, appropriate repair should be performed to avoid a communicating space between the implant capsule and pleural cavity. Despite the presence of an implant in the thorax, the patient did not experience any medical complaints resulting in a substantial delay. However, she did consult the plastic surgeon due to loss of projection of the right breast. Ultrasound confirmed implant rupture, but gave absolutely no indication of any implant dislocation into the chest cavity e misleading diagnostics galore.

Conclusion What you see, is what you feel, is what you get. If you do not feel the implant, it can be ruptured and diffused, but it can also be displaced. Therefore, use appropriate diagnostics, before you dive in.

Funding None.

Conflict of interest None.

References Figure 2 Intra-operative image showing the ruptured implant on the bottom of the right pleural cavity.

1. Sykes JB, Rosella PA. Intrathoracic migration of silicone breast implant 5 months after video-assisted thoracoscopic surgery. J Comput Assist Tomogr 2012;36:306e7.

Please cite this article in press as: Bruintjes MHD, et al., Where the PIP is the implant?, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.035

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Where the PIP is the implant? 2. Mehta AM, Bard MP, van Straten A, van Beijeren I, Rijna H. Intrathoracic migration of a breast prosthesis after thoracotomy. J Thorac Cardiovasc Surg 2008;135: 206e7. 3. Chen ZY, Wang ZG, Kuang RX, Wang BT, Su YP. Implant found in thoracic cavity after breast augmentation. Plast Reconstr Surg 2005;116:1826e7.

3 4. Kim H, Heo C, Baek R, Minn K, Kim S, Chun S. Breast implant migration into pleural cavity. J Plast Reconstr Aesthet Surg 2009;62:e89e90. 5. Lee JY, Kim HK, Kim WS, Park BY, Bae TH, Choe JW. Rupture and intrapleural migration of a cohesive silicone gel implant after augmentation mammoplasty. J Korean Soc Plast Reconstr Surg 2011;38:323e5.

Please cite this article in press as: Bruintjes MHD, et al., Where the PIP is the implant?, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.035

Where the PIP is the implant?

A 51-year-old woman, who had previous breast augmentation and a video-assisted thoracoscopic wedge resection of the lung, underwent breast implant rep...
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