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96
aaps
Archives of
Aesthetic Plastic Surgery
CASE
REPORT
https://doi.org/10.14730/aaps.2017.23.2.96
Arch Aesthetic Plast Surg 2017;23(2):96-100
pISSN: 2234-0831 eISSN: 2288-9337
Late Capsular Hematoma after Prosthesis Removal
Following Aesthetic Breast Augmentation: A Case
Report
INTRODUCTION
Augmentation mammoplasty with prosthesis implantation may
cause several early and late complications. Among the early com-
plications, hematoma formation is common, with an incidence
ranging from 2% to 10.3%; it usually takes place approximately 3
days postoperatively [1]. Late hematoma formation is very rare,
and has only been reported in a few cases. Its incidence and etiolo-
gy are still unclear. The interval from surgery to the onset of late
hematoma has been reported to range from 6 months to 12 years
[1-4]. Herein, we report the first case of late capsular hematoma
formation because of newly started anticoagulation 10 years after
prosthesis removal, following augmentation mammoplasty that
was performed 20 years ago. After the patient underwent magnetic
resonance imaging (MRI), we carried out total excision of the cap-
sule. In this report, the clinical, radiological, gross examination,
and histological features of this case are presented.
CASE REPORT
A 70-year-old woman visited us complaining of discomfort due to
a 2-month history of a palpable mass on her left breast. She was
worried about the palpable mass being cancerous. The symptoms
started spontaneously, and no traumatic event had taken place.
The patient had undergone augmentation mammoplasty with im-
plants 20 years previously, and she had the implants removed be-
cause of capsular contracture 10 years ago. Moreover, she had a 15-
year history of diabetes mellitus and hyperlipidemia, which were
well controlled by oral medication. Her clinical history revealed
that she was taking 15 mg of rivaroxaban (a direct inhibitor of the
coagulation factor Xa) twice a day because of deep vein thrombo-
sis. She started taking the medicine after being diagnosed with deep
Si Hyun Park1, Eun Soo Park2,
Sang Gue Kang1
1Department of Plastic and
Reconstructive Surgery, Soonchunhyang
Seoul Hospital, Soonchunhyang
University College of Medicine, Seoul;
2Department of Plastic and
Reconstructive Surgery, Soonchunhyang
Bucheon Hospital, Soonchunhyang
University College of Medicine, Bucheon,
Korea
Late capsular hematoma formation after augmentation mammoplasty with an implant
is a very rare complication. Some mechanisms explaining late capsular hematoma for-
mation have been reported; it is thought to be associated with capsular contracture,
textured implants, and the use of corticosteroid and anticoagulant agents. However,
no reports of late capsular hematoma formation after prosthesis removal have been
published. Herein, we report a case of late capsular hematoma formation after the re-
moval of a prosthesis 10 years previously, following augmentation mammoplasty.
Keywords Anticoagulants, Breast implants, Hematoma, Postoperative complications
This work was supported by the Soonchun-
hyang University Research Fund.
No potential conflict of interest relevant to
this article was reported.
Received: Feb 13, 2017 Revised: Apr 9, 2017 Accepted: Apr 10, 2017
Correspondence: Sang Gue Kang Department of Plastic and Reconstructive
Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang
University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401,
Korea. E-mail: sgkang@schmc.ac.kr
Copyright © 2017 The Korean Society for Aesthetic Plastic Surgery.
This is an Open Access article distributed under the terms of the Creative Commons At-
tribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited. www.e-aaps.org
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Park SH et al. Late Capsular Hematoma
Fig. 1. Preoperative and postoperative photographs. The preopera-
tive photograph shows a bulged upper pole in the left breast caused
by a mass measuring 10 × 5 cm (A). Postoperative photograph taken
1 month after the operation (B).
A B
Fig. 2. Magnetic resonance imaging. A capsulated lesion measuring 8.8× 4.5 cm, between the pectoralis muscle and the anterior chest wall;
the inside of the lesion showed high signal intensity on a T1-weighted image (WI) (A) and a T2-WI (B). The presence of low signal intensity in-
side the lesion in T2-WI (water-suppressed) imaging (C) indicates that most of the lesion was filled with fluid. Several areas with low signal in-
tensity within the lesion in T2-WI (fat-suppressed) imaging (D) indicate the presence of focal fat components.
A
C
B
D
Fig. 3. Intraoperative findings. The lesion was covered by the pecto-
ralis muscle (A), and the dissection of this muscle revealed an en-
capsulated lesion (B).
A B
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Fig. 4. Gross findings of the capsular hematoma. The cyst consisted of reddish-brown soft tissue, weighing 68 g and measuring 10 × 8 × 1.2 cm
(A). The cyst was opened with a blade, and multiple fragments of brown soft tissue were found inside (B).
A B
vein thrombosis 4 months before presenting to our clinic. The pal-
pable mass measured 10× 5 cm in size and was ovoid, nontender,
soft, and movable. No bruise, discoloration, erythema, or signs of
inflammation on the covering skin were observed (Fig. 1). In order
to evaluate the mass, we performed breast MRI with contrast en-
hancement. No abnormally enhancing mass was observed in the
breast parenchyma, but a capsulated lesion measuring 8.8 × 4.5 cm
was seen between the pectoralis muscle and the anterior chest wall.
The inside of the lesion showed high signal intensity on a T1-weight-
ed image (WI) and a T2-WI. The radiologist concluded that the le-
sion was a the result of a foreign body reaction, and was composed
of water and a small amount of fat between the pectoralis muscle
and the left chest wall (Fig. 2). However, no lesion was observed on
a previous chest computed tomography (CT) scan of the patient,
which had been carried out 4 months previously when the patient
was diagnosed with a pulmonary embolism. The observed mass
was completely excised under general anesthesia. Intraoperative
findings revealed a cyst between the pectoralis major and the ante-
rior chest wall. No active bleeding or enlarged vessels were identi-
fied (Fig. 3). The gross findings of the cyst consisted of reddish-
brown soft tissue; it weighed 68 g and measured 10 × 8 × 1.2 cm.
We opened the cyst with a blade and found multiple fragments of
brown soft tissue inside (Fig. 4). The subpectoral space was irrigat-
ed and sutured with drain insertion. The operation was finished
after cutaneous repair and aseptic compressive dressing. Micro-
scopic findings revealed a cyst lined by fibrous tissue with a foreign
body reaction, chronic nonspecific inflammation, and fibrin depo-
sition consistent with a reaction to the implant and subsequent
hemorrhage. The patient underwent daily dressings until the re-
moval of the drain and all the stitches 7 days postoperatively. Al-
though she did not discontinue anticoagulant therapy at any time,
no recurrence was observed at a 2-month follow-up examination
(Fig. 1).
DISCUSSION
Several mechanisms of late capsular hematoma formation have
been suggested. Labadie and Glover [5] described the formation of
a late expanding hematoma caused by a chronic inflammatory re-
sponse and increased vascular permeability. Wang et al. [3] found
that in several cases, textured implants stimulated an aggressive
foreign body inflammatory reaction, resulting in prolonged high
vascularity. Georgiade et al. [1] found an actively bleeding medi-
um-sized vessel in their re-exploration surgery. They suggested
that the corticosteroid injected into the implant caused vessel ero-
sion directly. Marques et al. [6] suggested that a capsular microfrac-
ture was associated with the rigidity of the capsule, which may have
prevented constriction of the injured vessels, leading to bleeding.
In our case, the start of anticoagulant therapy 4 months ago was
noteworthy. Late hematomas have been reported secondary to an-
ticoagulant therapy with warfarin in spite of a well-controlled in-
ternational normalized ratio [7].
The treatment of capsular contracture after breast augmentation
is variable. Capsulectomy is the most effective method for remov-
ing a capsule, but it poses the risk of distortion of the overlying skin,
compromised cutaneous blood supply, bleeding, muscle injury,
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Park SH et al. Late Capsular Hematoma
and/or pneumothorax [8]. If a patient simply wants the implant to
be removed without reinsertion, the treatment of choice is the re-
moval of at least a portion of the capsule with simultaneous masto-
pexy for the reduction of redundant skin and soft tissue [9]. If there
is capsular calcification or implant rupture, capsulectomy is recom-
mended [8]. In our case, we were not able to obtain the previous
operative findings of the patient, including the severity of capsular
contracture, capsular calcification, and details regarding the rup-
ture of the inserted implant, because the patient underwent both
breast augmentation and implant removal surgery a very long time
ago in an aesthetic clinic that is now out of business. Judging from
the fact that there was no scar tissue on the skin or inside the opened
cyst, we suspect that only implant removal was performed, without
other procedures such as scoring and/or mastopexy.
With respect to the pathophysiology of our case, we believe that
the vessels of capsule did not shrink sufficiently because of the ri-
gidity of the capsule and the fact that the capsule was not removed
during the operation for prosthesis removal 10 years ago; the vessel
started to bleed again because of the newly taken anticoagulant. No
similar cases of late capsular hematoma at a long interval after im-
plant removal have been previously reported.
The most common symptom of patients with late capsular he-
matoma is painful swelling of the breast. Skin discoloration and si-
nus tract discharge are less common. Symptoms of infection are
rare. Moreover, if the mass is large, an asymmetry between the breasts
can be seen [2]. Our patient presented with a painless palpable mass,
and she was worried about the palpable mass being cancerous. Sev-
eral reports documenting an association between the presence of a
prosthesis and anaplastic large-cell lymphoma have been published
[10]. However, other studies have reported that women who un-
derwent breast augmentation with silicone implants had a relative-
ly low incidence of breast cancer [11]. Therefore, physicians must
consider the possibility of cancer even when the palpable mass is
clinically unlikely to be a malignancy.
CT, MRI, and ultrasonography are possible diagnostic tools for
such scenarios. Ultrasonography has the major advantage of being
able to differentiate among seroma, blood, and a clotted hematoma
[12]. MRI is regarded as the best diagnostic tool because of its abil-
ity to assess the integrity of the implant [13]. In this case, the pati-
ent underwent MRI, and we were able to evaluate the quality of the
intracapsular fluid using water-suppressed and fat-suppressed im-
ages.
In our case, the capsular hematoma was completely evacuated,
as the patient wanted the mass to be removed because of her anxi-
ety about the possibility of cancer and a recurrence of the cyst. Some
authors have reported carrying out a percutaneous drain guided by
ultrasonography; this is a safe and inexpensive procedure when
performed by an experienced physician, and has a minimal risk of
implant puncture [12]. Hsiao et al. [4] reported 2 cases in which an
endoscope was used to inspect the capsule after hematoma evacu-
ation and implant removal through a small incision.
In conclusion, when physicians evaluate patients with a palpable
breast mass, thorough history-taking and a physical examination
must be carried out, keeping in mind the possibility of cancer. There-
after, MRI can be useful for the differential diagnosis. When late
capsular hematoma is suspected on the basis of radiological find-
ings, complete excision of the cyst is recommended to eliminate
the possibility of relapse or capsule enlargement. Furthermore, in
order to reduce the possibility of capsular hematoma formation, if
patients want the implant to be removed without reinsertion, it is
necessary to remove at least a portion of the capsule via partial cap-
sulectomy or total capsulectomy.
PATIENT CONSENT
Patients provided written consent for the use of their images.
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