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Corresponding author: Gladys L. Giron, MD, St Luke's-Roosevelt Hospital Center, Division of Breast Surgery, 425 W 59th St, Suite 7A, New York, NY 10019 (e-mail: gladyslgiron{at}hotmail.com).

Arch Surg. 2004;139:342.

Answer: Silicone Mastitis With Abscess
Computed tomographic scan shows the right breast with an irregular, thick-walled collection measuring 11 x 4 cm extending to and causing thickening of the underlying pectoralis major muscle.

Injection of foreign materials directly into mammary parenchyma is widely described in the literature. A wide range of objects have been used, including paraffin waxes, beeswax, shellac, shredded fabric, spun glass, and silicone fluid.¹ The practice of injecting silicone fluid became fairly widespread in the 1960s and early 1970s. Although the US Federal Drug Administration, Rockville, Md, never approved its use for breast augmentation, the practice continued illicitly in the United States and most notably in Asia.² The findings in our patient reveal a right breast abscess superimposed on a background of silicone mastitis. The abscess was immediately addressed with ultrasound-guided percutaneous drainage, followed by prompt resolution of the erythema, asymmetry, and a low-grade fever that had developed.

Complications of silicone injections are secondary to a granulomatous inflammation, which may be a reaction to a silicone-associated antigen.³ Alternatively, this may be a reaction to the Sakura technique in which the fluid is adulterated with other materials such as oil to induce fibrosis and retard migration.⁴ Silicone mastitis is characterized by tenderness; hard masses at injection sites; erythema; skin edema; increased pigmentation; migration to form daughter masses in dependent positions; skin slough; contractures; and, in some cases, spontaneously draining sinuses, dermal blebs, and galactorrhea.^{2, 5} Death due to pulmonary edema after inadvertent intra-arterial injection has been reported.²

Most importantly, the breast becomes altered in its dermal and parenchymal architecture after injections.⁶ It then becomes virtually impossible to detect breast cancer in its early stages because diffuse nodularity, nipple retraction, skin edema, and lymph node enlargement may be encountered. The silicone leads to a "whiting out" of mammographic films or detection of multiple nodular densities. These patients may require subcutaneous or total mastectomy with reconstruction for relief of symptoms or to facilitate cancer detection in patients at high risk.⁵ No causal relationship between silicone fluid injections and breast cancer has been demonstrated.⁵ Squamous cell carcinoma of the breast has been reported to occur after such treatments, presumably in the background of chronic inflammation.⁷

Submissions Due to the overwhelmingly positive response to the "Image of the Month," the Archives of Surgery has temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid 2004. Thank you.

REFERENCES

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1. Symmers WS. Silicone mastitis in "topless" waitresses and some other varieties of forgein-body mastitis. Br Med J. 1968;3:19-22. 2. Wustrack KO, Zarem HA. Surgical management of silicone mastitis. Plast Reconstr Surg. 1979;63:224-229. PUBMED 3. Chen TH. Silicone injection granulomas of the breast: treatment by subcutaneous mastectomy and immediate subpectoral breast implant. Br J Plast Surg. 1995;48:71-76. FULL TEXT | PUBMED 4. Timberlake GA, Looney GR. Adenocarcinoma of the breast associated with silicone injections. J Surg Oncol. 1986;32:79-81. FULL TEXT | ISI | PUBMED 5. Morgenstern L, Gleischman SH, Michel SL, Rosenberg JE, Knight I, Goodman D. Relation of free silicone to human breast carcinoma. Arch Surg. 1985;120:573-574. ABSTRACT 6. Lewis CM. Inflammatory carcinoma of the breast following silicone injections. Plast Reconstr Surg. 1980;66:134-136. PUBMED 7. Talmor M, Rothaus KO, Shannahan E, Cortese AF, Hoffman LA. Squamous cell carcinoma of the breast after augmentation with liquid silicone injection. Ann Plast Surg. 1995;34:619-623. PUBMED

SECTION EDITOR: GRACE S. ROZYCKI, MD

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Image of the Month—Quiz Case
Gladys L. Giron and Paul I. Tartter
Arch Surg. 2004;139(3):341-342.
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