Breast Implant Herniation Mimicking Coronary Artery Disease in a Postmenopausal Woman
According to the American Society of Plastic Surgeons, breast augmentation is the most common cosmetic surgery in the United States. In 2011, 307,000 Americans underwent breast augmentation procedures, which represents a 4% increase from the rates observed in 2010.1 In addition to being used cosmetically, breast implants are used to reconstruct the breasts after mastectomy for breast cancer, which contributes to the high prevalence of these procedures. Because the incidence of breast augmentation has increased in the last decade, the number of older women with breast implants is rising, including those with preexisting implants and those who receive them as older adults after a mastectomy for breast cancer, a disease that increases in prevalence with age. Today’s elders, the fastest growing segment of the American population, may include some of the first users of breast implants, which have been commercially available since the 1960s. Although breast implants have been around for almost half a century and the use of implants is increasing, the prevalence of late-life complications of implants is unknown, and no prospective studies have been performed to evaluate the late onset of complications and symptoms from breast implants in elders who received them when younger. In addition, various types of breast implants have been developed and used over the years, adding to the conundrum in older patients. Currently, the three most commonly used breast implants are silicone implants (these are filled with silicone gel), saline implants (these have a silicone outer shell, but are filled with saline), and double lumen silicone implants (these have two chambers, one filled with saline and the other with silicone gel).
The presence of breast implants in older women raises several questions. Does an implant affect the ability of mammography to detect breast cancer, the most common non–skin cancer in women aged 65 years or older? Does an implant influence false-positive rates of screening mammography? Does the impact of age-related changes on the musculoskeletal system affect the integrity and viability of saline and silicone implants? Does an implant alter the clinical presentation of cardiopulmonary diseases in postmenopausal women? More specifically, what is the impact of breast implants on the risk and presentation of coronary artery disease (CAD) in older women? There is little evidence in the literature to help answer these questions. Knowing the bidirectional interaction between age-related changes and the presence of a breast implant may help guide clinical decision-making for the increasing number of older women living with breast implants. Because postmenopausal women already have a higher risk of CAD than premenopausal women,2 it is particularly important not to confuse symptoms of breast implant complications with symptoms of acute coronary syndromes and angina. Breast implant herniation symptoms range from mild firmness and mild chest discomfort to severe angina-like chest pain precipitated by physical activity or movement of the implant. In this report, we discuss the first case of herniation of a left breast implant presenting as angina in a postmenopausal patient.
Case Report
An obese 69-year-old white woman presented with a 3- to 4-year history of intermittent left-sided chest pressure, which she described as moderate heaviness that lasted for a few minutes on the left side of the chest and radiated to her back. The pressure mainly occurred at night, although it had also occurred during the day, and was not related to any specific activity. There was no associated shortness of breath, palpitations, headache, lightheadedness, diaphoresis, reflux, heartburn, or dyspepsia. The patient reported receiving mild pain relief with over-the-counter acetaminophen. In addition to her weight (body mass index, 32 kg/m2), her medical history was significant for hyperlipidemia and a bilateral breast augmentation performed in 1990. The patient had a dobutamine stress test performed in 2007 for her chest pressure, but it was negative; however, her symptoms had recently became exacerbated.
Results of the physical examination were relatively benign. The patient had a regular heartbeat, with no evidence of murmur, and her lungs were clear to bilateral auscultation. Her breasts were normal in size, symmetry, and skin color. On palpation, there were no masses, nodules, axillary adenopathy, or breast implant abnormalities, and no breast tenderness was elicited. Her extremities were normal, with no edema or tenderness to palpation of the intercostal spaces on the left side of the chest wall. A dobutamine stress test was performed, which showed a normal ejection fraction of 55% and was negative for inducible ischemia or wall motion abnormalities. A mammogram was undertaken, which showed the patient’s bilateral breast implants and medial herniation of the left implant (Figure). The patient was evaluated by a plastic surgeon and subsequently underwent bilateral breast implant removal and bilateral capsulectomy. Pathologic findings of the excised capsule showed benign fibro-adipose tissue with fibrosis, granulomatous inflammation, and synovial metaplasia.
The patient experienced no complications during or after the surgery, and her left-sided chest pain resolved. She remained free of chest pain at her 1-month postoperative follow-up examination.
Discussion
In the literature, several general complications have been reported with breast implants, including capsular contracture, rupture, leakage, and infection (Table).3,4 Our case report illustrates that breast implants can also cause atypical complications and symptoms in elderly patients, such as breast implant herniation mimicking CAD. Because older adults are the fastest-growing population in 
America and include individuals who had breast implants inserted when younger or older for cosmetic reasons or to reconstruct the breasts following a mastectomy, it is especially important for clinicians not to mistake breast implant complications in elderly patients for other chronic conditions. Although our patient’s medical history and symptoms raised a high suspicion of heart disease, as demonstrated by performance of a dobutamine stress test several years before her current presentation, her angina-like symptoms were ultimately found to be related to her herniating left breast implant. Since cardiovascular disease remains the leading cause of death in women, with nearly half of all deaths in women older than 50 years attributable to some form of cardiovascular disease,2 acute coronary events are a top consideration in older women with implants who present with chest pain. However, if the results of a stress test and other cardiac tests are negative, as they were in our patient’s case, breast implant herniation should be considered as part of the differential diagnosis of chest pain in an older woman with implants.
Possible Causes of Chest Pain
There are two main types of chest pain: typical and atypical. Typical chest pain, described as heaviness or pressure under the sternum, usually occurs with exertion or emotion and is relieved with rest or nitroglycerin. Associated symptoms often include shortness of breath, dyspnea on exertion, nausea, vomiting, diaphoresis, dizziness, fatigue, heartburn, dyspepsia, and palpitations. Atypical chest pain, often described as sharp and intermittent, is localized to the left side of the chest or occurs in the abdomen, back, or arms; is not related to exercise; and is not relieved by rest or nitroglycerin. It is more common in women.
The differential diagnosis of chest pain is broad. Well-established etiologies include musculoskeletal causes, such as costochondritis; ischemic chest pain from CAD, which encompasses a spectrum of presentations, such as stable angina pectoris, unstable angina, non–ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction; aortic dissection; valvular heart disease; pericarditis; myocarditis; gastrointestinal causes, such as gastroesophageal reflux disease, peptic ulcer disease, or esophagitis; achalasia; pulmonary causes, such as pulmonary embolism, pneumonia, pleuritis, and pleural effusion; and psychogenic causes, such as anxiety. Our case report now adds another potential cause of chest pain: herniation of a breast implant.
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Complications of Breast Implants
The overall risk of complications following breast implant surgery is 27.6%, with 23.1% of patients requiring reoperation for deflation or capsular contracture in one study.5 The Table summarizes the complications from breast implant surgery reported in several studies.3,4 What follows is a more detailed overview of some of the most commonly reported early and late complications, which are similar for all implant types.
Early Complications. Early complications are generally considered to be those that occur within 1 month of the operation. The following early complications have been reported3,4:
1. Hypertrophic scarring: A hypertrophic scar is a thick, raised red scar that develops after surgery. Hypertrophic scarring occurs in 2% to 5% of patients.
2. Hematoma: A hematoma is a pocket of blood inside the wound. It occurs in 1% to 6% of patients, usually within 2 to 3 days after surgery.
3. Seroma: In the days or weeks following the operation, fluid can leak from vessels damaged during surgery and collect around the implant, similar to the leakage of blood that forms a hematoma. This collection of “blister fluid” is called a seroma, and it can cause pain or swelling.
4. Wound separation (dehiscence): A relatively rare complication within the first 2 weeks after surgery, dehiscence occurs when the edges of the wound separate, resulting in an open wound or possible exposure of the implant.
5. Infection (cellulitis): Cellulitis occurs in 2% to 4% of patients, usually from bacteria that normally live on the skin. Symptoms of infection include pain, redness, swelling, and fever.
6. Mondor’s disease: Occurring in about 1% of patients, Mondor’s disease is an inflammation of the blood vessels that run under the surface of the breast.
Late Complications. Late complications are generally considered those that occur 1 month or more following the operation. They include the following:
1. Asymmetry: Breast asymmetry is a difference between the left and right breasts in size or shape.
2. Contour problems: Contour problems may be seen before or after breast augmentation. Although implants usually improve breast shape, contour irregularities may persist or worsen postoperatively, requiring additional surgery to correct them.
3. Capsular contracture and breast implant herniation: Connective tissue, or the fibrous capsule, is responsible for keeping the implant in place. This capsule, for reasons that are poorly understood, can sometimes thicken and contract. This condition, which can lead to breast implant herniation, is described in greater detail later in this article.
4. Altered sensation or feeling: Most women experience a decrease in breast or nipple sensation after surgery, although feeling often returns after 6 to 12 months.
5. Deflation or rupture of the implant: A rate of implant deflation of 8.3% was reported in one large, well-
controlled study.
6. Anaplastic large cell lymphoma (ALCL): The US Food and Drug Administration reports that women with breast implants may have a very low but increased risk of developing ALCL adjacent to the breast implant.
A literature review identified 60 unique cases of ALCL in women with breast implants worldwide.3
Capsular Contracture and Breast Implant Herniation
Early and late complications following placement of breast implants are uncommon, but do occur with all types of prostheses, with the most common late complications being capsular contracture and herniation. Herniation can develop early or late in capsule formation. When a hernia first develops, it cannot be observed unless the breast is pressed. Later, it manifests as a visible protrusion in the breast.6
After an implant has been placed, fibroblasts produce scar tissue surrounding the surface of the implant. This occurs around any implant in the body, including artificial joints, pacemakers, or shunts. The scar tissue forms connective tissue, or the fibrous capsule, that keeps the implant in place. When this capsule thickens and contracts, it squeezes the implant, causing shape changes, hardening, pain, or a combination of these sympoms.
Since the introduction of breast implants, capsular contracture has been the most common cause of reoperation after breast augmentation.7 Warning signs of capsular contracture include deformed, misshapen, and painful breasts, or breasts that are firmer than when first implanted.8 The four levels of capsular contracture are as follows3:
• Grade I: The breast is soft and looks natural.
• Grade II: The breast is slightly firm, but looks normal.
• Grade III: The breast is firm and looks abnormal.
• Grade IV: The breast is hard, painful, and looks abnormal.
Effects of Aging on Breast Implants in Elders
According to Colakoglu and colleagues,9 a significant predictor of an increased risk of complications after breast implantation is older age (>45 years). All implants can have deleterious effects on the breast because they exert pressure on the skin, subcutaneous tissue, breast parenchyma, muscles, and bones. The physical characteristics of breast implants differ from those of adjacent soft tissue. Although both have a fixed volume and are compressible, soft tissues are elastic, whereas implants are not. The insertion of an implant results in immediate compression of both the implant and the surrounding muscle and parenchyma, among other effects. Over time, these effects tend to subside and stabilize as a result of creep and stress relaxation.10 However, physiological changes that occur with age may alter the stability of the relationship between the implant and the surrounding tissue. Cellular changes in the skin include thinning of the epidermis with a reduced mitotic rate in epidermal basal cells, a decrease in skin collagen concentration, and a decrease in subcutaneous fat. The loss of skin elasticity from increased collagen cross-links and decreased elastin leads to skin sagging and wrinkling.11
With increasing age, lean body mass decreases, caused in part by loss of muscle tissue. Muscle changes often begin in women at the age of 40. Lipofuscin and fat are deposited in muscle tissue; at the same time, muscle fibers shrink. Together, these changes lead to reduced muscle tone.11 The additional fat deposition in the breast gland can distort the anatomy of the mammary gland, shifting the breast implant and leading to late complications.12-14
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Conclusion
Our patient had chest pain secondary to a herniated breast implant, but presented with several misleading features of CAD. The negative results of the workup for CAD prompted us to look at the integrity of the breast implants, which led to the correct diagnosis and guided intervention. As our case report demonstrates, late complications of breast implants should be considered in the differential diagnosis of any patient who presents with chest pain or symptoms of CAD and has breast implants. However, since CAD is much more common in elders than a breast implant complication such as herniation, it should remain the primary consideration, and all cardiac causes must be ruled out before a patient’s symptoms are solely attributed to a breast implant or other noncardiac problem. This is especially critical when the patient has important risk factors for CAD, such as older age, smoking history, obesity, and diabetes.
Acknowledgments
Dr. Andrade was supported in part by a Hispanic Center of Excellence Medical Careers Diversity Program Grant from the Health Resources and Services Administration, US Department of Health and Human Services. The sponsor had no role in the design, method, or preparation of the manuscript. The authors thank Sarah Toombs Smith, PhD, ELS, for her editorial assistance with this manuscript.
The other authors report no relevant financial relationships.
References
1. American Society of Plastic Surgeons. 2011 top five cosmetic surgical procedures. www.plasticsurgery.org/Documents/news-resources/statistics/2011-statistics/2011-top-5-cosmetic-procedures-statistics.pdf. Accessed April 26, 2012.
2. Matthews KA, Meilahn E, Kuller LH, Kelsey SF, Caggiula AW, Wing RR. Menopause and risk factors for coronary heart disease. N Engl J Med. 1989;321(10):641-646.
3. US Food and Drug Administration. Breast implants: local complications and adverse outcomes. 2011. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm259296.htm. Accessed April 2, 2012.
4. US Food and Drug Administration. FDA update on the safety of silicone gel-filled breast implants, June 2011. http://bit.ly/BreastImplantSafety. Accessed May 1, 2012.
5. Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr Surg. 2000;105(6):2143-2149.
6. Szemerey IB. The fasciocapsular flap in capsular herniation. Aesthetic Plast Surg. 2006;30(3):277-281.
7. Gabriel SE, Woods JE, O’Fallon WM, Beard CM, Kurland LT, Melton LJ. Complications leading to surgery after breast implantation. N Engl J Med. 1997;336(10):677-682.
8. Codner MA, Mejia JD, Locke MB, et al. A 15-year experience with primary breast augmentation. Plast Reconstr Surg. 2011;127(3):1300-1310.
9. Colakoglu S, Khansa I, Curtis MS, et al. Impact of complications on patient satisfaction in breast reconstruction. Plast Reconstr Surg. 2011;127(4):1428-1436.
10. Nahabedian MY. Discussion: high- and extra-high-projection breast implants: potential consequences for patients. Plast Reconstr Surg. 2010;126(6):2165-2167.
11. Pacala JT, Christmas C, Eleazer GP, Fabiny A, Lantz MS, Medina-Walpole A, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 7th ed. New York, NY: American Geriatrics Society; 2010.
12. American Cancer Society. Breast cancer facts & figures 2009-2010. Atlanta, GA: American Cancer Society. www.cancer.org/Research/CancerFactsFigures/BreastCancerFactsFigures/breast-cancer-facts--figures-2009-2010. Accessed April 2, 2012.
13. Pelosi MA 3rd, Pelosi MA 2nd. Breast augmentation. Obstet Gynecol Clin N Am. 2010;37(4):533–546, vii.
14. Rubin JP, Landfair AS, Shestak K, et al. Health characteristics of postmenopausal women with breast implants. Plast Reconstr Surg. 2010;125(3):799-810.