The “Clinda-Clumper” – A Quick and Efficient Method to Remove Free Silicone After a Breast Implant Rupture Using a Clindamycin Solution

© 2024 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.

A 51-year-old female with a past medical history of breast cancer status post-bilateral mastectomy with immediate subpectoral tissue expander-based reconstruction and subsequent 800-cc high-profile silicone implants presented 10 years post-reconstruction with unilateral capsular contracture due to a ruptured implant. The patient underwent removal and replacement of bilateral silicone implants in exchange for saline implants.

Inframammary incisions were used bilaterally. The left implant was removed and found to be intact. The capsule was released to allow appropriate expansion, and the pocket was irrigated with a triple antibiotic solution prior to placing an 800-cc saline implant. The right implant, which was predicted to be ruptured radiographically, was confirmed. A known method of using a clindamycin solution for assisting the removal of free silicone was utilized. The irrigation consisted of 1 g of clindamycin sulfate with 1 L of saline. This solution immediately reacted with the free silicone, causing a coagulative-like effect, allowing for an easier and quicker removal. The capsule was removed, and the pocket was similarly prepared with triple antibiotic solution and subsequent placement of a saline implant (Video).

Video. A demonstration of the quick and efficacious use of a clindamycin solution to congeal the silicone into clumps for easy removal.

In 2022, there were 1.6 million cosmetic surgical procedures performed in the United States, with 255,200 of those being breast augmentations.¹ In the same year, breast augmentation was the most common cosmetic surgical procedure for women worldwide, with approximately 2.1 million performed.¹ Currently, most implants are expected to last at least 20 years when properly manufactured and inserted according to instruction. However, rupture is a potential risk for breast implant procedures.

Ruptured implants can remain within the fibrous capsule (intracapsular) or further extravasate beyond the fibrous capsule (extracapsular) to invade the surrounding tissues of the breast and chest wall, often causing scar tissue and local inflammation. The probability of rupture escalates as the implant ages.² A review by Hillard et al in 2017 determined the rupture risk for modern silicone breast implants is 2% within the first 5 years, increasing to a 15% risk of rupture at the 10-year mark.² It is important to consider that the actual frequency of silicone breast implant ruptures might be understated, given that most instances are asymptomatic and go clinically undetected.³

Additionally, it is necessary to compare rates of implant rupture between newer versus earlier generations of breast implants. Newer generations of breast implants, termed cohesive implants, are more likely to remain consolidated without invading surrounding tissue due to a more effective design.² Therefore, risk of rupture with extracapsular extravasation is associated primarily with earlier generations of implants.

Most silicone implant ruptures are clinically unnoticeable or display minor changes in shape or firmness. Various imaging options for monitoring silicone breast implants exist, including magnetic resonance imaging (MRI), mammography, ultrasound, and computed tomography (CT). MRI has the highest sensitivity and reliability, allowing the detection of both intracapsular and extracapsular rupture.^2,4-6 While mammography and ultrasounds are the most utilized for breast imaging, both modalities lack the ability to adequately detect intracapsular ruptures.^2,4-6 Additionally, CT imaging is not useful for either intracapsular or extracapsular ruptures as the radiosensitivity between silicone and soft tissue is equivalent.⁶ Currently, the US Food and Drug Administration (FDA) recommends patients be screened by MRI or ultrasound within 5 to 6 years postoperatively and every 2 to 3 years thereafter.⁷

Standard of care dictates that for a silent, intracapsular rupture, removal of the implant is not necessary as there is only a 10% chance of it becoming extracapsular. Symptoms following silicone implant rupture include skin changes, asymmetry, and nipple discharge.⁸ It is recommended for extracapsular or symptomatic intracapsular ruptures that the breast implant, capsule, and any free silicone be removed to prevent further symptoms.² Multiple surgeries may be required to successfully remove all silicone, as the gel migrates to distinct sites in 11 to 23% of ruptured cases; however, it is not always necessary to completely remove the silicone.^4,6

Removing ruptured silicone implants often becomes a chore due to the extremely adherent nature, leading to possible contamination of the sterile field and requiring the surgical team to change drapes, gloves, and instruments.^9-12 While silicone gel is relatively inert, good practice dictates the removal of foreign substances in the breast capsule to avoid potential negative effects. In an ideal setting, the intact capsule containing the ruptured implant can be removed in its entirety.¹³ However, if the capsule has ruptured, removal of free silicone can be tedious since manually scrubbing the pocket can be time-consuming and inefficient.^9-11

For ruptured capsules, various methods have been used to extricate the free silicone using vacuum or suction devices.^9-12,14These methods are atraumatic, inexpensive, readily available, and allow for good retraction.^9-12,14Additionally, these methods reduce contamination of the sterile field with silicone and save time from having to manually scrub out the pocket. However, the high viscosity of silicone can make it difficult to suction, and the small incision makes it hard to confirm maximal removal of silicone from surrounding tissues.^14ß

Saline and povidone-iodine are commonly used solutions in the operating room to remove free silicone. Additionally, surgical surfactant cleansers, such as Shur-Clens (Shur-Clens Skin Wound Cleanser, ConvaTec) are widely available, inexpensive, and have a good safety profile. Specifically, Shur-Clens can be used to increase silicone removal from surrounding tissue after implant ruptures in comparison with iodine and saline.¹⁵ Surfactants are molecules that have hydrophobic and hydrophilic properties that allow the silicone gel to better mix with the surfactant solution and significantly increase the removal of silicone gel.¹⁵ Surgical surfactants are not antibacterial but do not activate immune responses or cause an infection.¹⁵

A third approach is to add a solution of normal saline or antibacterial solutions to the breast pocket.^15,16 In this case, 1 g of clindamycin sulfate in 1 L of saline was used to irrigate the pocket. The clindamycin clumps with the silicone gel and results in easy removal. Similar benefits have been noted with the use of chlorhexidine and gentamycin.¹⁶

The senior author’s clinical practice with patients who experienced silicone breast implant ruptures showed the superiority of the clindamycin solution. This solution maximized the removal of silicone with a small incision when paralleled to a suction device. Additionally, this solution congealed the silicone into clumps for more efficient removal when evaluated clinically against an iodine or saline solution. Lastly, the clindamycin solution is widely available, low cost, and has a good safety profile with the addition of antimicrobial activity when compared with the Shur-Clens solution. The mechanism of action for the clindamycin solution and silicone is unclear, but the chemical or physical process is highly effective. This mechanism produces a coagulative type of effect that clumps the silicone for easy removal. Further studies are needed to determine the mechanism and verify the efficacy of this process when compared with other commonly used solutions.

Free silicone has not been associated with significant long-term health risks such as cancer, connective tissue disease, or autoimmune disease.^{4,11,14,17-19} However, ruptures are important to monitor because free silicone can lead to local and disseminated granuloma formation, causing aesthetic and functional complications. Complications include soreness, swelling, nipple discharge, capsular contraction, skin changes, lumps, asymmetry, and infection.⁸ Although silicone is inert, it has been noted that silicone-induced granulomas can cause a natural host immune response against silicone.⁴ Additionally, these granulomas may be difficult to differentiate from malignancies. Not all silicone granulomas require removal, although surveillance is important for those that do remain.