What are the treatment options for a female patient experiencing breast implant illness with symptoms such as fatigue, joint pain, and skin rashes after breast augmentation surgery?

Treatment of Breast Implant Illness

For patients experiencing systemic symptoms attributed to breast implants (fatigue, joint pain, skin rashes), the definitive treatment is complete implant removal with total capsulectomy, which results in symptom improvement or complete resolution in 81-96% of patients. 1, 2, 3

Initial Diagnostic Considerations

Before proceeding with explantation, you must first rule out breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), which is a distinct clinical entity from BII:

• BIA-ALCL presents with late-onset seroma (>1 year post-implantation), typically 8-10 years after placement, and requires CD30 positivity for diagnosis. 4, 5
• If the patient has new breast swelling, asymmetry, fullness, or pain occurring >1 year after implantation, perform ultrasound examination first. 5
• If ANY fluid collection is detected on ultrasound (even minimal), proceed immediately to ultrasound-guided aspiration for cytology with CD30 immunohistochemistry and flow cytometry. 5, 6
• BII symptoms do not correlate with implant type (saline vs. silicone), surface texture, fill material, or duration of implantation, distinguishing it from BIA-ALCL. 4

Definitive Surgical Treatment

Once BIA-ALCL is excluded, proceed with surgical management:

Surgical Technique

• Perform bilateral implant removal with complete total capsulectomy (en bloc resection when possible). 1, 2, 7
• En bloc resection involves removing the intact capsule containing the implant to assess margins and extent of any pathology. 8
• Send all explanted implants and capsular tissue for histology and microbiological culture. 1, 7

Expected Outcomes

• 96% of patients report improved or complete resolution of systemic symptoms after implant removal with total capsulectomy. 1
• Average symptom score reduction of 1.6 points (on a 1-5 scale), with elimination of an average of 2.8 symptoms per patient. 2
• The most commonly improved symptoms are fatigue (58.3% prevalence), joint pain (51%), and muscle pain (44%). 3

Microbiological and Pathological Findings

Understanding the underlying pathology helps explain symptom resolution:

• Positive microbial cultures are found in 35-68.5% of BII patients, with Propionibacterium acnes being the most common organism (49.6%). 1, 7, 3
• All culture-positive patients report symptom improvement post-treatment. 1
• Capsular inflammation is present in 58.4% of cases, and synoviocyte metaplasia occurs at significantly higher rates than in asymptomatic controls. 7, 3
• There is no association between implant characteristics and rate of positive microbiology findings. 1

Special Considerations

Radiation History

• In patients with a history of chest wall radiation, tissue expanders/implants are relatively contraindicated due to significantly increased risk of capsular contracture, malposition, poor cosmesis, and implant exposure. 6
• If the patient received radiation after initial implant reconstruction, conversion to autologous tissue flap reconstruction should be strongly considered rather than repeat implant-based surgery. 6

Screening for Comorbidities

• Screen for autoimmune conditions (20.7% prevalence), fibromyalgia (12% prevalence), and psychiatric illness (16.5% prevalence) as these may coexist with BII. 3
• ANA positivity prevalence is estimated at 24% in BII patients. 3

Common Pitfalls to Avoid

• Do not dismiss patients as psychosomatic—BII is a genuine clinical entity with objective microbiological and histological abnormalities in a significant proportion of patients. 7
• Do not perform implant exchange—removal without replacement is the appropriate treatment, as 84-100% of patients would not consider having breast implants again after experiencing BII. 7
• Do not perform partial capsulectomy—total capsulectomy is essential for optimal symptom resolution. 1, 2
• Do not rely solely on imaging to exclude BIA-ALCL—if clinical suspicion remains high despite negative imaging, consider proceeding to capsulectomy with complete pathologic examination. 5