JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Volume 94 March 2001
Silicone in the sputum after rupture of a calf implant
SE James mb BSc FRCS
G Tarr mbbs
MS Butterworth MB frcs (Plast)
J McCarthy mb PhD1
P E Butler frcs
JR Soc Med 2001,94:133-134
Silicone-filled prostheses have been used as medical
implants for nearly 40 years, but the systemic consequences
of rupture remain uncertain.
CASE HISTORY
An otherwise healthy woman aged 27 sought advice 5 years
after having bilateral calf implants inserted in Brazil for
cosmetic augmentation of thin calfs. Each implant contained
about 175 mL of silicone gel. For the past eighteen months
the patient had experienced right calf swelling and pain,
with difficulty putting her foot flat on the floor. She
attributed various non-specific symptoms such as lethargy,
gastritis and backache to the implants and also reported that
she intermittently coughed up a lumpy and sticky substance,
a sample of which she provided. This had an unusual
gelatinous appearance and was sent for histological,
electronmicroscopical and chemical analysis. There were
no symptoms or signs of lung disease; chest X-ray and
computed tomographic scan were normal, as were liver
ultrasound and blood indices. Ultrasound indicated leakage
from the right implant, and magnetic resonance imaging
revealed a surrounding fluid-filled pseudocapsule. After
removal under general anaesthesia both implants proved to
be ruptured, and the presence of altered blood throughout
the right implant suggested perforation at the time of
insertion. Electronmicroscopy of the sputum revealed near-
uniform granular deposits about 2 ìm across (Figure 1),
corresponding morphologically to silicon oxide and
identical to a sample from the explanted prosthesis. On
evaluation by energy dispersive analysis of X-rays (EDAX),
the silicone in sputum exactly matched that from the
prosthesis (Figure 2) and was contained within an
amorphous background material high in sulphates and
phosphates suggestive of tissue origin.
Departments of Plastic and Reconstructive Surgery and 1Histopathology, Royal
Free Hospital, London NW3 20G, UK
Correspondence to: Mr PE Butler frcs, Department of Plastic and Recon-
structive Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK
Figure 1 Electronmicrograph of sputum sample. Insert (arrow) shows silicone oxide granules
COMMENT
Much of the concern about silicone-gel-filled prostheses
relates to breast implants1. The systemic effects of silicone
gel released by rupture are uncertain2, but an alleged excess
of connective tissue diseases has not been confirmed3. Wear
debris from silastic finger joints has been associated with
axillary lymphadenopathy and malignant lymphoma4,5.
After rupture of breast implants, silicone has seemingly
gained entry to the nipple ducts, axillary nodes, pleura,
chest wall and upper arm6. The early practice of direct
injection of silicone was abandoned because of widespread
adverse effects.
There are nine reported cases of pneumonitis or acute
lung injury following the accidental direct intravascular
injection of silicone fluid7. In some of these cases silicone
was detected within macrophages after bronchoalveolar
lavage, and the mechanism of lung damage was thought
similar to that after fat embolism in which microvascular
occlusion, followed by local serotonin release, platelet
adherence to emboli and degranulation, can produce acute
lung injury. Factors implicated in the rupture of breast
implants are implant age, trauma to the breast (including
closed capsulotomy, in which manual pressure is used to
break up local fibrous tissue around an implant) and
mammography. Implants positioned within the calf are
under greater mechanical forces which could possibly lead
to early rupture with extrusion of silicone gel locally.
Figure 2 EDAX analysis of silicone particles in sputum sample (above) and from right calf implant (below)
We think this is the first reported case of silicone
expectoration after rupture of a silicone-gel filled implant.
The mechanism of migration is unclear. We speculate that
the gel, extruded under high pressure, gained entry to the
vasculature and embolized in the lungs.
Acknowledgment We thank Mrs Jackie Lewin for
valuable assistance with electronmicroscopy.
REFERENCES
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3 Silverman BG, Brown SI, Bright RA, Kaczmarek RG, Arrowsmith-
Lowe JB, Kessler DM. Reported complications of silicone gel breast
implants: an epidemiological review. Ann Intern Med 1996;124:744-56
4 Benjamin E, Ahmed A, Rashid AT, Wright DH. Silicone
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