Peters Walter, Fornasier Victor
Division of Plastic Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario.
Can J Plast Surg. 2007 Spring;15(1):19-28. doi: 10.1177/229255030701500107.
Late unilateral breast enlargement after the insertion of silicone gel breast implants is a very rare phenomenon. The present study reports five women who presented with this finding over the past 20 years. Three of these patients presented with late unilateral hematomas, which developed nine, 12 and 14 years, respectively, after initial breast augmentation, in the absence of any known trauma. These patients presented for treatment one, four and 12 months, respectively, after their breast enlargements initially appeared. Two of these patients had developed chronic expanding hematomas. Extensive histopathological analyses of the capsules of all three patients provided explanations for the etiologies and progressions of the findings in these patients. In each of the three patients, the etiology of the hematoma was consistent with erosion of a capsular artery. Numerous large vessels were seen within the wall of the capsules. In each case, there was a class IV capsular contracture, which could have increased the friction of the intact implant against the capsule, and there was both old (hemosiderin deposits) and new bleeding into the pocket from the capsules. This supports the concept that numerous episodes of bleeding had occurred in each case. Histopathology also demonstrated the progression of the hematomas. After four weeks, only liquefied hematoma was present, while after four months, there were both liquefied hematoma and blood clotting. The hematoma on the surface of the capsule was becoming organized peripherally, but not centrally. After 12 months, the hematoma was becoming very well organized compared with the hematoma at four months. In one of the two remaining cases, late infection was the cause of the breast enlargement. Histopathology of this capsule showed that the involved capsule was six times as thick as the other side. It also showed edema and infiltration by scattered mononuclear cells, polymorphonuclear cells, and irregular crenated and degenerating nuclei. In the final patient, chronic inflammation appeared to be the cause of the breast enlargement. The histopathology of this capsule was unique. Its inner surface showed re-epithelialization and metaplasia of the ductal epithelium to form stratified squamous epithelium with early surface keratinization. These findings are consistent with synovial metaplasia. Several areas of the fibrous portion of the capsule showed patchy loss of cellular staining with loss of nuclei, indicative of necrosis. This produced a 'washed out' staining appearance. This tissue was paucivascular and fibrotic, and showed areas of fibrinoid necrosis, suggestive of mechanical abrasion and increased pressure.
硅胶乳房植入术后出现晚期单侧乳房增大是一种非常罕见的现象。本研究报告了过去20年中出现这一情况的5名女性。其中3例患者出现晚期单侧血肿，分别在初次隆胸后9年、12年和14年发生，且无任何已知外伤史。这些患者在乳房增大最初出现后分别于1个月、4个月和12个月前来接受治疗。其中2例患者形成了慢性扩展性血肿。对所有3例患者的包膜进行广泛的组织病理学分析，为这些患者的病因及病情进展提供了解释。在这3例患者中，每例血肿的病因均与包膜动脉侵蚀一致。在包膜壁内可见大量大血管。在每例病例中，均存在IV级包膜挛缩，这可能增加了完整植入物与包膜之间的摩擦力，并且既有陈旧性出血（含铁血黄素沉积），也有来自包膜的新出血进入腔隙。这支持了每例病例均发生过多次出血的观点。组织病理学也显示了血肿的进展情况。四周后，仅存在液化血肿，而四个月后，既有液化血肿又有血凝块。包膜表面的血肿在周边开始机化，但中央未机化。12个月后，与四个月时的血肿相比，血肿的机化程度更好。其余2例病例中的1例，晚期感染是乳房增大的原因。该包膜的组织病理学显示，受累包膜比另一侧厚6倍。还显示有水肿以及散在的单核细胞、多形核细胞浸润，以及细胞核不规则皱缩和退变。在最后1例患者中，慢性炎症似乎是乳房增大的原因。该包膜的组织病理学很独特。其内表面显示复层上皮化以及导管上皮化生，形成早期表面角化的复层鳞状上皮。这些发现与滑膜化生一致。包膜纤维部分的几个区域显示细胞染色呈斑片状缺失且细胞核消失，提示坏死。这产生了一种“褪色”的染色外观。该组织血管稀少且纤维化，并显示有纤维蛋白样坏死区域，提示机械性磨损和压力增加。
