http://www.revmaterialeplastice.ro MATERIALE PLASTICE ♦56♦No. 1 ♦2019 71Textured Breast Implants and Anaplastic Large Cell Lymphoma CRISTINA-NICOLETA… [613850]

http://www.revmaterialeplastice.ro MATERIALE PLASTICE ♦56♦No. 1 ♦2019 71Textured Breast Implants and Anaplastic Large Cell Lymphoma
CRISTINA-NICOLETA COZMA1,2, ADELAIDA AVINO1*, ANDRA-ELENA BALCANGIU-STROESCU3,4, DANIELA GABRIELA BALAN3,
MARIA-DANIELA TANASESCU5,6 , DELIA TIMOFTE4,7, DIANA RUXANDRA SINESCU2,8, SILVIA MARIA STOICESCU9,
DORIN IONESCU5,6
1 Prof.Dr.Agrippa Ionescu Clinical Emergency Hospital, Department of Plastic and Reconstructive Surgery, 7 Arh Ion Mincu Str.,
011356, Bucharest, Romania
2Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Discipline of Plastic and Reconstructive Surgery, 37
Dionisie Lupu Str., 020021, Bucharest, Romania
3Carol Davila University of Medicine and Pharmacy , Faculty of Dental Medicine, Discipline of Physiology, 37 Dionisie Lupu Str.,
020021., Bucharest, Romania
4Emergency University Hospital Bucharest, Department of Dialysis, 169 Spaiul Independentei, 050098, Bucharest, Romania
5Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Semiology, Discipline of
Internal Medicine I and Nephrology, 37 Dionisie Lupu Str., 020021, Bucharest, Romania
6Emergency University Hospital Bucharest, Department of Nephrology, 169 Splaiul Independenei, 050098, Bucharest, Romania
7Dialysis Center Sema Parc Bucharest, 319 Splaiul Independenei, 060044, Bucharest, Romania
8Elias Clinical Emergency Hospital, Department of Plastic and Reconstructive Surgery, Bucharest, 17 Marasti Blvd., 011461,
Bucharest, Romania
9Carol Davila University of Medicine and Pharmacy, Faculty of General Medicine, Discipline of Obstetrics-Gynecology, 38-52 Gh.
Polizu Str., 011062, Bucharest, Romania
Breast implants are nowadays used in breast augmentation and reconstruction. These can have a silicone
or saline filling and a textured or smooth surface. Textured implants have been more frequently used due to
their capacity of impairing moving and developing capsular contracture. Breast associated anaplastic large
cell lymphoma has been correlated with the presence of textured implants even if the pathogenesis is not
entirely understood and other factors might be involved.
Keywords: Textured implants, anaplastic large cell lymphoma, silicone
Breast implants are largely used not only in esthetic
breast augmentation, but also in breast reconstruction aftermastectomies and for correcting different congenital
breast deformities [1,2]. Breast implants have been
invented in 1961 by two American plastic surgeons,Thomas Cronin and Frank Gerow, and were first used for a
breast augmentation in 1962. These were made of a
silicone fill with a shell made of a silicone elastomer [3].The elastomer was produced by extensive cross-linking of
the silicone gel and had a higher consistency [4]. The
silicone used for breast implants is a polymer that containsnumerous chains of polydimethyl siloxane monomers
which gives stability and flexibility [4]. In 1964, in France,
saline implants were invented and were made of a siliconeshell and filed with a saline solution [5]. These were used
as a second–choice prosthesis due to frequent leakage,
having a 2-3% yearly deflation rate [5].
Besides implant filling, the implant cover became also
an issue in implant development. In the beginning, adjacent
to the silicone shell a new polyurethane cover of 1.2-2mmwas realized in order to increase fixation and decrease
capsular contracture by realizing an inflammation that
decrease formation of a fibrous collagen capsule aroundthe implant [6], but due to its slowly deterioration and risk
of implant rupture has been withdrawn from market in
1991 [4]. In order to maintain the benefits of polyurethanecoat through decreasing capsular contracture rate but to
increase shell strength, textured implants were developed
[4].
Breast implant characteristics
Nowadays, breast implants are divided in the same two
categories according to their filling: silicone or saline, their
shell being made of silicone elastomer. The surface texture
can be textured or smooth and the shape round oranatomic [6].
* email: adelaida.avino@gmail.com All the authors contributed equally to the present work and thus are main authorsSilicone breast implants are considered to be gold
standard for breast augmentation and reconstruction,
having a better breast like consistency than saline implants
with less rippling, less malposition and a more natural look[2]. These can be used also in immediate breast
reconstruction by using an additional mesh for covering
[7], having a great role in decreasing postoperativedepression symptoms [8]. The disadvantage might be the
necessity of a larger incision, gentle handling by the surgeon
and long term evaluation due to risk of rupture and gelmigration in the surrounding tissues [4].
The main advantage of saline implant is that it can be
inserted in a deflated mode through a small incision afterthat being filled with saline solution. Also these have a
safety profile if rupture happens and are easy to evaluate
[4].
Despite the shape and type of breast implants, one of
the most important characteristic that have a great
involvement in preventing or creating complications is theirtexture. According to this property, implants can be smooth
or textured [6]. Smooth implants have a natural movement,
but their disadvantage is the risk of rotation and of formingcapsular contracture [8]. Textured implants increase
stability and prevent rotation being especially used in
anatomic shape (fig. 1). Some studies showed also thathave a lower rate of capsular contracture when are placed
in a subglandular pocket [9,10], but this difference is not
present in all studies [11].
Breast implants are classified nowadays in 4 categories
according to their surface roughness macrotexture-puls,
macrotexture, microtexture, nanotexture/smooth [12].Their texturization is realized using a salt-loss technique
by adding salt crystal to the silicone and washing creating
small pores that adhere to adjacent tissues [6]. There arealso other techniques of producing a textured surface like

http://www.revmaterialeplastice.ro MATERIALE PLASTICE ♦56♦No. 1 ♦2019 72coating surface with an ammonium carbonate through
vulcanization or by pressing silicone mandrel intopolyurethane foam that produces pores of 70-150 m
diameter. The minimal textured models are considered to
be nanotextured with a pore dimension of 40-100 µm and
are realized through a method of negative imprinting [6].
Textured implants have been used mostly in 85%-90%
of the cases in comparison with smooth implants (10-15%)due to their stability and their lower rate of capsular
contracture [12]. These were mostly used for breast
reconstruction. Due to a recent discovery (2011) of adelayed complication called breast implant associated
anaplastic large cell lymphoma [BIA-ALCL], currently the
recommendation is to inform and avoid when possibletextured implant in order to lower the possibility of
developing this disease [14].
Breast implant associated anaplastic large cell lymphoma
Anaplastic large cell lymphoma [ALCL] is a type of a T
cell lymphoma, with a rare incidence, that appeared inpatients with previous implants [15]. Breast implant
associated anaplastic large cell lymphoma is a rare entity,
with an incidence of 0.1 to 0.3 per 100000 women withimplants, that involves the surrounding breast tissue and is
characterized by the presence of a late seroma (8 to 10
years after implant surgery) around the implant or thecapsule, a tumoral mass or even capsular contracture [16].
Other symptoms may include enlargement of the breast,
presence of palpable nodules, pain or inflammation and insome cases even rash and erythema[15]. Primary diagnosis
is realized through evaluation of seroma or breast tumoral
mass using an ultrasonography that permits aspiration ofthe fluid or biopsy from the mass. Fluid or tissue analysis is
very important and shows a high expression of CD30, a T-
cell marker, that is expressed in ALCL. If diagnosis isconfirmed, local surgical treatment is required and consists
in implants removal with excision of the capsule,
surrounding tumoral tissue and suspicious lymph nodes[16]. Surgical treatment is usually sufficient when lymph
nodes are not involved. In advanced cases, chemotherapy
is usually used and also radiotherapy in locally unresectabletumor [16].
Discussion
Pathogenesis of ALCL was not entirely discovered, but
chronic inflammation might be the promotor of this
pathology. There are multiple theories that imply the onsetof this local inflammation that include silicone implant
leaking, textured implants or the presence of the biofilm
[15].
Textured implants have been incriminated in producing
ALCL because all the cases diagnosed with this disease
had a textured implant. As could have been seen, texturedimplants are not the main cause, because not all women
with textured implants develop ALCL [12]. These could be
a trigger or a stimulator in women which have differentallergies or genetic predisposition, some women having
JAK1/STAT3 gene mutations [17,18].One of the main problem of textured implants, could be
the possibility of peeling of the silicone particles of the
implant that could lead to an inflammatory state thatincreases lymphocyte population [18].
Another characteristic of textured implants is the
increased surface that shelters more bacteria than smoothimplants (72 times more) and stimulates the immune
response producing numerous T cell lymphocytes, that
could induce development of ALCL [19]. This wassustained also by 2 authors that considered that biofilm is
the main factor that triggers the disease and this can be
prevented through reducing the intraoperative risk ofinfection [20,21].
Conclusions
Breast implant associated anaplastic large cell
lymphoma has a multifactorial pathogenesis that implies
implant characteristics, microbial factors and host factorslike genetic predisposition and immune response. Due to
the rare incidence, the epidemiological studies are difficult
to be realized in order to understand better its pathogenesis.Recent recommendation is informing any patient about
the risk of developing this disease and trying to take any
preventing measure as possible.
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Manuscript received: 6.12.2018Fig. 1. Textured implants