Atypical Capsular Contracture with Delayed Intracapsular Hematoma After Breast Implantation for Reconstruction

Late spontaneous hematoma (> 6 months postoperatively) after breast reconstruction using implant is rare complication. We experienced a case of capsular contracture with a unique clinical form of intracapsular hematoma 13 years after implantation of smooth saline filled implants. This report presented the mechanism of complication examined through chart-review, histological morphological analysis, and literature review to help evaluation and treatment of various symptoms around the breast implant capsule. A 51-year-old woman underwent a unilateral breast reconstruction using tissue expander insertion in 2005, and underwent saline implant insertion after a year. A patient has been assessed through computed tomography (CT) and ultrasonography annually for cancer screening in General Surgery department, and in 14 years after implantation, she was referred to the Plastic Surgery department as a finding intracapsular multi-layering lesion around implant. She underwent implant removal and capsulectomy. The excised capsule was sent for histological evaluation. There were no trauma event, calcifications, or implant rupture. Symptoms of swelling and stiffness gradually developed. The etiology of late hematoma following implantation has been poorly characterized. There are opinions that delayed hematoma can be induced by capsule microfracture, which may be due to the rigidity of the contracted capsule, and that it may be caused by friction between the capsule and the implant when there is pathological contracture. It is thought to be an old hematoma capsule contracture that can be mistaken for tumor lesions, and it was concluded that our case corresponds.

A 51-year-old woman presented to the general surgery outpatient clinic with an itching sensation in the right nipple that began 3 months ago. The patient was diagnosed with right breast cancer (stage III) and axillary lymph node metastasis. In 2005, the patient underwent an immediate unilateral breast reconstruction using a tissue expander (550 cc) after undergoing a right modified radical mastectomy that was performed by the general surgery department. The patient was prescribed adjuvant radiation therapy (33 fractions of 180 cGy on the right breast; 25 fractions of 200 cGy on the right supraclavicular lymph nodes) and chemotherapy with taxotere that was administered four times. In addition, smooth, round, and moderate profile saline implant (mentor, 225 cc) was inserted after a year of tissue expander insertion.
After 13 years of the implantation, the patient was referred to our plastic surgery department after an intracapsular multi-layered lesion around implant was found (Fig. 1). The patient complained of shape deformation and hardness of the reconstructed breast, but there was no pain or size change. The physical findings revealed a contracture compatible with the Baker grade III-IV. Thick capsules were observed in the chest CT scan, whereas no evidence of capsule invasion into the surrounding tissues and implant rupture were observed. Since saline-filled implants were used, materials with different density than the saline were observed around the intracapsular space of the implant (Fig. 2). After referring to the ultrasound finding, we were slightly suspicious of the presence of certain solid substances, rather than liquids, in the breast. Clinical findings were inconsistent with Evidence Based Medicine (EBM) level V lymphoma, which has recently gained a lot of interest, and it was difficult to establish a correlation with breast cancer. Therefore, it was decided that all the implants and capsules would be removed for further diagnosis and treatment, and total capsulectomy and implant removal were performed. The patient wanted to remove the implants; hence, no new reconstruction was performed. For accurate diagnosis, the excised capsule was sent to the pathology department for histological evaluation.
The 17 × 13 × 7 cm, thick, firm, and stable fibrous capsule was observed in the capsule; however, there was no bloody or serous fluids in the capsule. The capsule was filled with huge debris that crumbled toward the end and grew from the inner surface of the capsule (Fig. 3). Pathologic sectioning revealed that the inner surface was papillary and granular in pattern. Moreover, microscopic results showed fibrinoinflammatory exudates in the inner surface and fibrosis in the wall of the capsule without any premalignant or tumorous lesion on the surface (Fig. 4).

Discussion
In this case, there was no event of trauma, calcification, or implant rupture, and symptoms of swelling and stiffness developed gradually. The patient had comorbid severe fibrosis due to postoperative radiation therapy, and the possibility of fibrosis progression as a risk factor for the development of the capsule in this condition cannot be ruled out. However, the patient had delayed hematoma on the inner surface of the capsule that might have contributed to the development of late capsular contracture.
Late hematoma has been reported very rarely after breast implant surgery. For this reason, etiology of late hematoma following implantation has been poorly characterized [1][2][3][4]. We hypothesized that the capsules and inflexible surrounding soft tissues that formed around the implant may have caused the development of early hematoma. It was suspected that the continuous friction between the capsule and implant, microfracture of the capsule due to the patient's movement, and repeated capillary bleeding caused continuous inflammation. Due to the nature of the fibrous thick capsule, a complex action such as obstruction of retraction of the eroded vessels was considered the most reasonable pathological mechanism. It is assumed that the progression to Baker grade III-IV led to a vicious cycle in which symptoms occurred repetitively [5,6]. Late hematoma often presents as a swelling or mass-like protrusion in the breast; therefore, the main approaches used for diagnosis are CT and magnetic resonance imaging. In our case, it was difficult to establish a confirmed diagnosis when the patient first visited the hospital because the patient was referred for abnormal findings in ultrasonography rather than symptoms such as swelling, enlargement, or presence of abnormal mass. Ultrasound and CT findings were combined, and the possibility of malignancy was judged as low. It was difficulty to perform fine needle aspiration biopsy in the presence of implants; therefore, a biopsy was performed by diagnostic capsulectomy. If the implants are to be reconstructed, a biopsy should also be considered prior to the surgery. In the case of breast implantation surgery, the possibility of epithelial malignancy of the capsule lining, such as the atypical large cell lymphoma issue or squamous cell carcinoma which were rarely reported but are being frequently reported now [7], and potential tumor conditions should be considered while examination and treatment planning. . The microscopic results showed fibrinoinflammatory exudates in the inner surface and fibrosis (asterisk) in the wall of the capsule without any premalignant or tumorous lesion on the surface. Cross sections of blood vessels (yellow arrows) were formed in parts in the middle of the fibrous inner wall, and a layer that appeared to be bleeding was observed in the innermost part of the inner wall Data Availability Available on request.

Ethics Approval
The study was approved by the Institutional Review Board of Daegu Catholic University Medical Center (IRB No. CR-22-057). This article does not contain any studies with human participants or animals performed by any of the authors.
Informed Consent For this type of study, informed consent is not required.

Conflict of Interest
The authors declare no competing interests.
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