BREAST IMPLANT ILLNESS (BII)
Breast Implant Illness (BII) is a term that originated from a group of women who became ill after undergoing breast augmentation surgery. This illness is represented by a series of symptoms attributed to breast implants and can vary from patient to patient with different clinical manifestations. These symptoms are all related to autoimmune processes and are also present in many autoimmune conditions.
The first thing that needs to be clarified is that there are still many unanswered questions regarding the pathophysiology and etiology of this condition and, although several theories have been proposed, there is still no clear understanding of why some women develop these symptoms.
THE ADJUVANT THEORY
A breast implant is a foreign body that for years the medical community considered biocompatible with the human body. Although some patients developed capsular contractures, which are clear evidence of the body's reaction to the implant, the medical community continued to consider these devices safe.
An adjuvant is a particle that stimulates the immune response to a foreign body, or what is called an antigen. There is a good chance that implants may contain substances that act as adjuvants, which in some women trigger a chronic systemic immunological response, that is, an inflammatory response, which causes the immune system to attack various tissues in the body. These foreign bodies are seen by the immune system as antigens and cause the symptoms suffered by these patients.
There are many substances that can act as adjuvants. Several articles have been published suggesting that some of these present in breast implants may cause autoimmunity, and this possibility was overlooked years ago in the studies that authorized the safe use of breast implants.
The first report of this problem dates back 50 years as a syndrome called adjuvant-induced illness. Although the placement of breast implants is now routine with excellent results and high satisfaction rates, a small percentage of patients may have a sort of predisposition to develop an autoimmune response to breast implants, recently named Breast Implant Illness (BII). This does not happen only with breast implants, but adjuvants present in some vaccines, certain infections such as Lyme disease, some proteins in foods, and even some metals are capable of triggering and aggravating an immune response that leads to syndromes very similar to those described, with almost identical symptoms. These include, among others, ASIA syndrome and silicone incompatibility syndrome. The autoimmune syndrome induced by adjuvants, known as ASIA syndrome, refers to autoimmune syndromes induced by adjuvants.
The etiology of autoimmune syndromes, such as fibromyalgia, Sjogren's, systemic lupus erythematosus, rheumatoid arthritis, chronic fatigue syndrome, etc., has been categorized as idiopathic, which is the medical term used for "The cause is not known".
It is known that some autoantibodies and some inflammatory proteins become positive, but the reality is that we do not know why. It seems that suddenly our immune system decides to start fighting our own body. It is very interesting to observe how some of these syndromes have such similar onsets and symptoms. It is hard not to wonder if they could potentially be triggered by adjuvants, just as is happening in some individuals with vaccines, silicone implants, and some infectious diseases.
The symptomatology includes many different physical signs, but all are related to some kind of inflammation affecting various systems and tissues in our body. Dr. Yehuda Shoenfeld published in his article on ASIA syndrome that the removal of the "triggering agent" helps with improvement. This fact is in line with the Maastricht cohort study, in which symptom improvement occurred in 50% of patients, and in another study conducted by Peters, in which patients experienced a 58% improvement after explantation of the prostheses, and 74% of patients stated that "they felt better and that their quality of life had improved." There is no information regarding what type of capsular removal was used, but in the past, it was not common practice to completely remove the capsules.
In the literature, patients undergoing Enbloc removal (complete removal of the implant and the surrounding biological capsule) show a complete remission rate of symptoms at 6 months close to 75% and an improvement of symptoms in 85% of cases.
The difference in results could be related to the type of capsular removal performed. Tissue analysis by pathologists has shown that many implants present groups of macrophages with clear inclusions in the cytoplasm, which correspond to silicone leakage, even if their shells are intact. According to reports, some patients had silicone particles in the axillary lymph nodes, others had positive analyses for silicone particles at the systemic level, which could explain why patients do not experience remission, but only improvement, even if an Enbloc resection was performed.
It is very difficult to know whether these patients are not also experiencing these problems due to another adjuvant present in their bodies, and it is still unclear why some patients develop the problem and others do not, just as happens with autoimmune diseases.
Important concepts TO KEEP IN MIND:
Not everyone with a breast implant will develop Breast Implant Illness (BII). There are many patients who have had implants for years without developing any symptoms, so it is thought that there must be an immunological predisposition to developing ASIA/BII, just as happens with autoimmune syndromes. It is very important to raise awareness in the medical community that the possibility of women developing these symptoms is real, as most patients presenting with these issues are ignored by their caregivers. According to several patients, it is very frustrating to consult doctors who do not take them seriously. It would be good practice to inform patients requesting breast augmentation for aesthetic or reconstructive purposes that, just as there is a possible correlation between anaplastic large cell lymphoma (ALCL) and breast implants, there could be the possibility of developing BII. Both should be mentioned as possible risks.
It is EXTREMELY important to perform a complete removal of the capsule and not just the breast implants, as the particles that act as adjuvants can remain in the capsule and continue to trigger the chronic immunological stimulus.
Currently, BII is underdiagnosed also due to the lack of widespread information within the medical community, and many women are treated for autoimmune syndromes, depression, etc., without realizing that there is an actual BII syndrome behind it.
REMOVAL OF BREAST IMPLANTS
A total capsulectomy will be performed if it is not possible to perform an en bloc removal. The capsule may contain bacteria or pieces of silicone that should not be left inside the body.
What is an en bloc removal?
Following the insertion of an implant into the body, the latter forms a capsule around the prosthesis to contain and isolate it. An en bloc removal means that the implant and the surrounding tissue are removed together as a single piece. It is a difficult procedure to perform, especially when separating the capsule from the chest wall when the implants are under the muscle. The capsule tends to adhere to the ribs and intercostal muscles near the lungs. A proper en bloc removal requires a surgeon with experience in the procedure and in chest wall reconstruction.
Why is an en bloc removal important in breast implant illness?
Many of the adjuvants contained in breast implants could potentially remain in the biological capsule generated by the body around the breast implant. Failure to completely remove this capsule could perpetuate the exacerbated immunological response in these patients.
What is total capsulectomy?
Total capsulectomy is when the surgeon removes 100% of the capsule that is in the body, in the thoracic cavity.
Why do some doctors not believe that breast implant illness is real?
This is simple. Currently, the scientific evidence that breast implants make women sick is insufficient. The symptoms experienced by patients with BII are varied. Some patients experience different symptoms from others.
In the absence of widespread information regarding these different clinical presentations, it is easy to misdiagnose the problem or attribute these symptoms to depression, fibromyalgia, other medical conditions or, even worse, to assume that there is nothing pathological.
Do all breast implants lead to BII?
This is probably one of the most frequently asked questions. Many patients seem to have no problems with breast implants and do not develop any apparent symptoms. However, in the same way, just as with capsular contracture, we do not know whether or not they will develop problems in the future.