Introduction

Immediate breast reconstruction during surgery for breast cancer is gaining in popularity. An implantable tissue expander is often used during the procedure. A late complication with the implantation of breast prostheses, especially those filled with silicone, is the onset of fibrous capsular contraction [1, 2]. This can be debilitating for patients, and often necessitates revisional surgery. Whilst the aetiology of capsular contraction is unclear, its pathogenesis clearly involves a localised tissue reaction [3, 4].

We report a case of severe capsular contraction in association with intense methylene blue dye staining of a saline-filled prosthesis. This occurred following immediate reconstructive surgery for breast cancer, in which methylene blue dye was used to identify the sentinel lymph node. The known tissue reactive properties of methylene blue dye [4–6] suggest that it may have been implicated in the pathogenesis of the fibrous contracture.

Case Report

A 58-year-old woman presented to the Breast Unit with a 1.7 cm-sized screen-detected carcinoma of the left breast, located lateral to the nipple. After confirmation of the diagnosis by fine-needle aspiration cytology (FNAC), the patient underwent immediate breast reconstructive surgery.

Subdermal periareolar injection of 1.5 ml of 1 percent methylene blue dye was performed five minutes prior to definitive surgery, to facilitate identification of the sentinel lymph node. Two blue lymph nodes were subsequently found during the course of axillary dissection, and removed. A skin-sparing mastectomy and immediate reconstruction were then performed, using a Becker™ saline-filled tissue expander implant.

The postoperative course was uneventful, and the patient was discharged from hospital after 4 days.

Seven days after surgery, the patient returned to the Breast Unit with a seroma surrounding the prosthesis. This was aspirated twice under ultrasound guidance, revealing serous fluid content only. An ultrasound scan at eight weeks showed the fluid collection had completely resolved.

Nine months later, the patient developed a Baker Grade 4 capsular contracture [7], and consented for revisional surgery.

At surgery, a thick fibrous inflammatory capsule was found surrounding the implant, and on removal the prosthesis was noted to have an intense blue discolouration (Figure 1).

The patient was discharged five days after surgery, and was well at last follow-up.

figure 1

Figure 1

Conclusion

Methylene blue dye is used in a variety of operative procedures, including breast surgery, to allow delineation of anatomical structures [4, 8, 9].

Use of the dye however, has been associated with a number of local and systemic complications. These include localised eruptions and rashes [4, 6], subcutaneous tissue necrosis and abscess formation [8], methaemoglobinaemia [10], and anaphylaxis [11].

The tissue reaction to methylene blue dye is a foreign body – type reaction characterised by eosinophilic infiltration, fibrinoid necrosis with ischaemic ulceration [4].

Fibrous capsule formation occurs around any implanted device as part of normal healing. After implantation of a breast prosthesis this process can lead to deleterious clinical changes, ranging from imperceptible deformation of the implant, to significant distortion and firmness [7]. The latter changes are often accompanied by tenderness and discomfort for the patient, necessitating revisional surgery. Recent studies have estimated an incidence of between 2% to 33% of capsular contraction in patients undergoing breast augmentation with various types of prosthesis [1, 2]. The precise aetiology of capsular contraction is unclear, but may be related to factors such as infection, excessive bleeding at the time of surgery, or foreign body reactions [3].

Although subareolar intradermal injection of methylene blue dye to aid sentinel node localisation is described as a generally safe procedure [12], acute adverse events caused by the dye during breast surgery have been reported [11, 13].

In this patient, a Grade 4 capsular contracture occurred some time after surgery in the presence of an implant intensely discoloured by the blue dye.

Whilst absolute causality cannot be proven, the presence of inflammation around the implant, together with the known tissue-reactive properties of methylene blue dye suggest that this substance may have been involved in a local tissue reaction which facilitated the development of the condition.

Use of methylene blue dye to localise sentinel nodes during immediate breast reconstructive surgery must therefore be considered as a factor which may increase the risk of subsequent capsular contraction.