BREAST IMPLANT ILLNESS (BII)
Understanding Breast Implant Illness (BII)
Breast Implant Illness (BII) is a term that originated from a group of women who experienced health issues following breast augmentation surgery. This condition is characterised by a range of symptoms attributed to breast implants, which can vary significantly among patients, manifesting in diverse clinical presentations. All these symptoms are linked to autoimmune processes, and they also appear in numerous autoimmune conditions.
It is crucial to clarify that many questions remain unanswered regarding the pathophysiology and aetiology of BII. Although various 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 the medical community has long considered biocompatible with the human body. While some patients have developed capsular contracture—clear evidence of the body’s reaction to the implant—the medical community has continued to regard these devices as safe.
An adjuvant is a particle that stimulates an immune response to a foreign body, or what is referred to as an antigen. There is a strong possibility that implants may contain substances that act as adjuvants, triggering a chronic systemic immune response in some women. This inflammatory response prompts the immune system to attack various tissues in the body. These foreign bodies are recognised by the immune system as antigens, resulting in the symptoms experienced by these patients.
Numerous substances can behave as adjuvants. Several studies have suggested that some of these present in breast implants may contribute to autoimmunity, a possibility that was overlooked years ago when studies endorsed the safe use of breast implants.
The initial reporting of this issue dates back 50 years to a syndrome known as adjuvant breast disease. Despite the routine placement of breast implants yielding excellent results and high satisfaction rates, a small percentage of patients may have a predisposition to developing an autoimmune response to breast implants, now termed Breast Implant Illness (BII). This phenomenon is not exclusive to breast implants; adjuvants found in certain vaccines, some infections like Lyme disease, specific food proteins, and even certain metals can trigger and exacerbate an immune response that leads to syndromes remarkably similar to those described in BII. These include, among others, ASIA syndrome and silicone incompatibility syndrome. The autoimmune syndrome induced by adjuvants, known as ASIA syndrome, refers to autoimmune syndromes triggered by these particles.
The aetiology of autoimmune syndromes, such as fibromyalgia, Sjögren’s syndrome, systemic lupus erythematosus, rheumatoid arthritis, and chronic fatigue syndrome, has often been categorised as idiopathic—meaning that the cause remains unknown.
Some autoantibodies and inflammatory proteins may test positive, but the reasons for this remain unclear. It appears as if the immune system suddenly decides to attack the body. It is intriguing to observe how some of these syndromes exhibit such similar onset and symptoms, leading to the question of whether they might be triggered by adjuvants, as seen in some individuals with vaccines, silicone implants, and specific infectious diseases.
The symptoms encompass a variety of physical signs, all linked to some form of inflammation affecting different systems and tissues in the body. Dr Yehuda Shoenfeld has published findings in his article on ASIA syndrome indicating that the removal of the "triggering agent" contributes to improvement. This aligns with the Maastricht cohort study, where 50% of patients reported symptom improvement, and another study by Peters, which found that 58% of patients experienced relief after implant explantation, with 74% reporting an enhanced quality of life. Details about the type of capsular removal performed were not provided, but historically, complete capsule removal was not a common practice.
In the literature, patients undergoing en bloc removal (complete removal of the implant and the surrounding biological capsule) demonstrate a near 75% rate of complete symptom remission at six months, with symptom improvement noted in 85% of cases.
The variation in outcomes may correlate with the type of capsular removal performed. Tissue analyses by pathologists have shown that many implants contain clusters of macrophages with clear silicone inclusions, even when their casings remain intact. Reports indicate that some patients had silicone particles in their axillary lymph nodes, while others tested positive for systemic silicone particles, which may explain why some patients do not experience complete remission but only improvement, even after en bloc resection.
Determining whether these patients are also facing issues due to another adjuvant in their bodies remains challenging. It is still unclear why some patients develop this issue while others do not, mirroring patterns observed in autoimmune diseases.
Important Concepts to Consider
Not all individuals with breast implants will develop Breast Implant Illness (BII). Many patients have had implants for years without any symptoms, suggesting that there may be an immunological predisposition to developing ASIA/BII, similar to what is observed in autoimmune syndromes. It is vital to raise awareness within the medical community regarding the genuine possibility of these symptoms developing, as many patients experiencing these issues are often dismissed by their healthcare providers. Numerous patients express frustration over consulting doctors who do not take their concerns seriously. It is advisable to inform patients seeking breast augmentation for cosmetic or reconstructive purposes that, just as there is a potential correlation between anaplastic large cell lymphoma (ALCL) and breast implants, there may also be a risk of developing BII. Both conditions should be mentioned as potential risks.
It is extremely important to perform complete capsule removal and not just the breast implants themselves, as particles that act as adjuvants may remain within the capsule and continue to provoke a chronic immune stimulus.
Currently, BII is underdiagnosed due to a lack of comprehensive information within the medical community, leading many women to be treated for autoimmune syndromes, depression, etc., without realising that a genuine BII syndrome underlies their symptoms.
Explantation of Breast Implants
A total capsulectomy will be performed if en bloc removal is not feasible. The capsule may contain bacteria or silicone fragments that should not remain within the body.
Following the insertion of an implant into the body, a capsule forms around the prosthesis to contain and isolate it. En bloc removal means that the implant and the surrounding tissue are excised together as a single unit. This procedure can be challenging, particularly when separating the capsule from the thoracic wall when implants are placed beneath the muscle. The capsule often adheres to the ribs and intercostal muscles near the lungs. Proper en bloc removal requires a surgeon experienced in the procedure and in reconstructing the thoracic wall.
Why is En Bloc Removal Important in Breast Implant Illness?
Many adjuvants present in breast implants could potentially remain within the biological capsule created by the body around the implant. Failure to completely remove this capsule may perpetuate the exacerbated immune response in these patients.
What is Total Capsulectomy?
Total capsulectomy involves the surgeon removing 100% of the capsule found in the body, within the thoracic cavity.
Why Do Some Doctors Doubt the Existence of Breast Implant Illness?
The answer is straightforward: current scientific evidence linking breast implants to illness in women is insufficient. The symptoms experienced by patients with BII are varied. Some patients report symptoms different from others.
In the absence of comprehensive information regarding these different clinical presentations, it is easy to misdiagnose the issue or attribute these symptoms to depression, fibromyalgia, other medical conditions, or, worse still, dismiss them as non-pathological.
Do All Breast Implants Lead to BII?
This is likely one of the most frequently asked questions. Many patients appear to have no problems with breast implants and do not exhibit any apparent symptoms. However, similarly to capsular contracture, it remains unknown whether they will develop issues in the future.