Although reports of late hematoma after placement of breast implants are rare, there has been a noticeable increase in these reports in recent years. Various etiologies have been proposed, usually relating to history of trauma, anticoagulant use, or physical strain. In this case report, we describe a 61-year-old patient who slowly developed a unilateral intracapsular hematoma 2 years after breast reconstruction with Biocell (Natrelle; Allergan, Inc, Irvine, California) textured implants. This case is unique because of the intraoperative finding of 2 capsules surrounding the implant, with the hematoma between the 2 layers. We also discuss the possible pathophysiological mechanisms of this phenomenon.
Level of Evidence: 5
Early hematoma within the first 3 days of a breast implant procedure is a well-documented complication that occurs in 2% to 10% of patients.1 However, late hematoma (>6 months postoperatively) is much less common. Scattered reports have appeared within the past 30 years, with increasing frequency in the last 5 years. These reports mainly describe single cases rather than randomized groups or at-risk populations. To date, only 17 patients have been described who have had a late hematoma after a reconstructive implant procedure2–8 and 31 who have had the condition after cosmetic augmentation mammaplasty.2,9–20 In this report, we present a single case of progressive, slow swelling of the right breast due to an intracapsular hematoma. This pathology occurred 2 years after a bilateral, reconstructive breast implant procedure in which Biocell textured implants were placed (Natrelle; Allergan, Inc, Irvine, California).
A 61-year-old woman with a 7-year medical history of treated hypertension, recurrent gastritis, and obesity (body mass index, 30.7) presented in May 2010 with ductal infiltrating breast cancer. In June 2010, the patient underwent a bilateral skin-reducing mastectomy and reconstruction with anatomically shaped Biocell textured implants. Twenty months later (February 2012), she noticed a progressive but painless increase in right breast volume along with generalized discomfort and a feeling of chest constriction. In March 2012, she visited our breast clinic, at which time regional ultrasounds (US) were completed. At this visit, an enlarged right breast and a lesser left armpit seroma were noted. On physical examination, the patient showed a deformity in breast contour; tense, thin, and inflamed skin with telangiectasias; implant profiles that were nonpalpable; lack of masses; and empty axilla because of prior lymphadenectomy (Figure 1). Regional US was repeated and magnetic resonance imaging (MRI) obtained. Both demonstrated a right breast seroma without signs of implant rupture. At admission, the patient's routine laboratory and complete blood count were within normal limits.
During the surgical dissection of the implant pocket, which occurred through the previous equatorial breast scar, a 300-mL hematoma was drained and a capsular small-sized arterial vessel was cauterized. Interestingly, the breast implant was intact and surrounded by a double capsule (Figure 2). The outer capsule was strongly adherent to the surrounding tissues (pectoralis major muscle, subcutaneous fat, and thoracic wall), while the inner capsule was adherent to the implant. The hematoma occurred between the 2 capsules in a virtual wide cavity. After capsulectomy, a new Allergan Natrelle 410-ST-MF-525gr implant was inserted into the pocket. The specimens were sent to pathology, the results of which showed an outer, dense hyaline fibrous capsule with hemosiderin pigment and aspecific inflammation of the inner capsule. Healing was uneventful with no further complications at a 4-month follow-up (Figure 3).
Previous authors have correlated delayed hematoma with direct trauma,3,11 clotting disorders,5,12 sexual intercourse,10 or use of corticosteroids at the time of implantation.13 Hematomas reported after these circumstances tend to present as a sudden onset of painful swelling of the breast.16 Our patient did not complain of pain in her breast. However, the implant was surrounded by a double capsule with a hematoma between the 2 layers. In addition, chronic capsular bleeding was identified.
Other authors have suggested capsular vessel erosion as a source of late hematoma in the absence of any of the aforementioned risk factors, with a slow onset over the course of several weeks.1,4,7,9,14,15 Peters and Fornasier15 listed several potential causes of bleeding, including the friction between the capsule and an implant fold in the presence of pathologic contracture, friction between the rough surface of a textured implant and the capsule, and/or infection. Increased capillary permeability due to prolonged inflammation7,20 or elicited by polyurethane coating,4,18 or extravasation of a small amount of blood after minimally invasive heart surgery,19 can sustain further bleeding, acting as an oncotic and inflammatory stimulant as described for neurosurgical chronic expanding hematomas.21 Other studies have related chronic bleeding to microfractures in a rigid periprosthetic capsule, preventing damaged vessel retraction.6,8
The presence of a double capsule surrounding a breast implant has been occasionally described in the literature in association with a recurrent seroma in Biocell implants,22 around rotated Biocell implants,23 or after minor trauma around anatomical implants and the implant-expander.24 Colville et al25 discussed a prolonged inflammatory reaction due to soyabean oil leakage in Trilucent breast implants (Lipomatrix Inc/Collagen Aesthetics International, Neuchatel, Switzerland) and the formation of a double capsule in 2 patients with Baker grade 2 and 4 capsular contracture, respectively.
In 2011, Hall-Findlay9 reported her experience with 626 breast implant procedures using varying implants and showed an incidence of 14 double capsules in Biocell textured surface implants, most of which were occasional findings at surgery except 1 late seroma and 2 late hematomas. These rare complications were related to a mechanical problem due to capsular adhesion to the Biocell textured implant, as seen in polyurethane implants. If separation occurs in the interface between the rough surface of the implant and the capsule, shear forces can cause chronic irritation with subsequent inflammatory response and increased capillarity permeability. Seroma fluid–containing cells that can seed and grow on the implant might be the origin of the inner capsule found in Biocell implants because of the aggressive open pore texturization.26
Another mechanical hypothesis of double capsule formation was proposed by Robinson,27 who reported 2 patients with similar findings around Biocell implants and spherical breast contracture. Double capsule formation was related to shearing forces separating the breast implant/capsule complex from the nearby tissue, with progressive formation of another capsule.
According to Collins and Verheyden,2 larger breast implant size is associated, nearly significantly, with hematoma incidence due to greater weight and mass and their propensity to exert tensile and shearing forces on the capsule neovasculature. Late hematoma onset after a breast implant procedure is still a rare complication, yet reports in the medical literature have increased since the introduction of aggressively textured breast implants.5,9,16,18,23 It seems reasonable that mechanical friction and subsequent “implant degloving” between the texturized implant surface and the inner capsule layer may be at the root of this phenomenon. Capsular contracture or pocket position (subpectoral vs subglandular) does not appear to be a causative factor in late hematoma onset.16
Magnetic resonance imaging and US are useful diagnostic aids to detect fluid collection surrounding the implant,16 but in our experience, both have failed to identify the double capsule and the nature of the fluid collection (eg, seroma or hematoma).
Percutaneous needle drainage of fluid collection visualized with imaging procedures is useful to distinguish between seroma and hematoma, and the aspirate can be sent to pathology to rule out malignancy or infection.28 However, late hematoma management is surgical and involves capsulectomy and breast implant replacement, possibly with a smooth device, or removal.16,28 Because our patient had an anatomical implant that was not available with a smooth shell, and because polyurethane implants were not accessible due to hospital restrictions, we elected to insert a new device that was similar to the implant we removed. Although this decision may raise criticism, in similar circumstances, others have replaced an aggressively textured implant with a similar implant without recurrence of this complication.16,28,29
Late hematoma remains a rare complication of breast implant procedures but is beginning to occur more frequently than in the past. The presence of a double capsule surrounding a breast implant may facilitate its formation, as demonstrated in our single case report. Further reports are needed to establish the frequency of this finding and to more clearly delineate the reasons for this increase in late hematoma formation.
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
The authors received no financial support for the research, authorship, and publication of this article.