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the process of autoinflation is multifactorial, it has an responses etc. [19] These latter factors need to be investigated
inflammatory response resulting in sterile creamy pus like further using microbiological assessment of the serum
substance collection. Broken down PAAG products creates present in the intracapsular fluid along with the chemical
an osmotic gradient resulting in shift of body fluids into the analysis of blood and intracapsular fluid samples.
injected PAAG resulting in autoinflation of the breast. [16]
Malignant effusion of the intracapsular space secondary
Intracapsular or periprosthetic fluid collection to ALCL is the least common but most alarming cause of
presenting as autoinflation of the breast autoinflation of the breast. ALCL is a rare type of non-
Intracapsular or periprosthetic fluid collection can be Hodgkin lymphoma, which is distinctly different from
seen following augmentation mammoplasty, revision the primary breast lymphoma of breast. Primary breast
mammoplasty or breast reconstructive surgery using breast lymphomas are overwhelmingly of B-cell as opposed to
implants. The presence of fluid has been reported in 15% T-cell phenotype that is associated with breast implants. [21]
of the revision surgeries and the amount of fluid collected The incidence of primary breast lymphoma is less than 1%
ranged from 0.2 mL to 20 mL. The fluid can be thick, of all breast neoplasm as compared to an estimated 3 in 100
mucinous, blood stained or serous. [3,4] It is not surprising million women per year of ALCL reported. Implant related
that collection of fluid in intracapsular space leading to ALCL is reported in 34 cases out of estimated 5 to 10 million
[2]
autoinflation of the breast is the most common cause of the women with breast implants. These haemopoitic tumours
late autoinflation. Collection of thick mucinous creamy fluid, of T-cell origin is extremely rare and the common factor
resembling like pus but with out positive bacterial culture, appears to be the texturing of the implants suggesting a site
is uncommon and is possibly due to a chemical reaction in and material specific chronic inflammatory cause. Other
response to the leaked silicone. [11-13] This type of collection possible causes are genetic predisposition and Biofilm
is reported following PIP silicone and hydrogel implant organism that may play a contributory role. The condition
ruptures [11-13] and PAAG injections. [15,16] The cause is the is not related to the implant fill material. [22] Considering the
direct contact of the material with the body either through extreme rarity of ALCL, it is likely that most physicians will
a rupture or following implantation or injection of PAAG. never see a single case of ALCL in their career. [2]

Autoinflation of breast due to haematoma Following is the recommendations and algorithm as a
or blood stained fluid useful guide to manage late autoinflation of the breast from
This is not the most common form of intracapsular fluid Bengtson et al. [23] Step 1: conservative treatment. Infection
collection presenting as autoinflation of the breast. This type should be ruled out and antibiotics given when in doubt.
of collection is seen following the separation of the adhered Aspiration of fluid for culture and cytology when possible;
capsule from the textured surface of the implant following Step 2: imaging ultrasound or magnetic resonance imaging
a physical force or trauma. These late blood stained fluid (MRI). Ultrasound may also assist ultrasound-guided aspiration
or haematomas are especially reported following the use of fluid for culture and cytology; third step: if palpable or
of polyurethane coated implants, where disappearance MRI evidence of a mass present or in case of refractory or
of polyurethane coating results in inflammation and the recurrent seroma, surgical exploration is recommended. The
implant starts behaving like a textured implant with a procedure includes complete capsulectomy with or without
highly vascular internal lining of capsule rubbing against the implant replacement.
textured surface of the implant. [17]
In the author’s practice, the incidence of late seroma was
Autoinflation of breast due to late seromas noted in 0.05% which is much lower when compared to
The collection of serum in intracapsular space following 0.88% and 1.68% incidence reported in other series. [17,19] In
breast implant surgery is the most common form of the current series all three patients who presented with late
autoinflation. The causes can be mechanical, inflammatory, seromas were treated conservatively using antibiotics and
traumatic, hormonal and most importantly malignant compression bandages. All responded to the treatment and
(ALCL). Textured implants are more commonly involved and there was no recurrence of autoinflation. One of the patient
the possible mechanism is the separation of the capsule developed capsular contracture on the side of autoinflation
from the textured surface of the implant. The shearing of due to late seroma.
the textured surface of the implant on the raw internal
vascular surface of the capsular lining starts an inflammatory In conclusion, implant working group recommendations are
process resulting in exudation of the fluid that may lead to available and should be used a guideline for the treatment
autoinflation of breast. [17,18] of late autoinflation of the breast. Late autoinflation of
the breast on its own is uncommon and can be treated
Micro-movements between the micro-textured or smooth conservatively in the first instance.
implants and capsule can result in synovial metaplasia
of the capsular internal lining. The metaplastic lining Financial support and sponsorship
continuously rubbing against the implant surface can trigger Nil.
the process. [19,20] Other less well defined possibilities are the
presence of subclinical infection, biofilms, any generalised Conflicts of interest
condition leading to low immune response, allergic There are no conflicts of interest.
34 Plast Aesthet Res || Vol 3 || Issue 1 || Jan 15, 2016