Silicone has been used for many years in cosmetic and reconstructive breast surgery. When first introduced, it was thought to be relatively inert and to cause minimal tissue reaction. However, there have been several reports of foreign body reactions occurring in response to the presence of free silicone, both in animal experiments’ and in clinical practice [
7‐
12]. The histological features reported in these cases have shown mixed cellular infiltrate of histiocytes, lymphocytes, eosinophils, multinuclear giant cell granulomas, and macrophages with foamy cytoplasm. As in the case presented, after silicone implant rupture, free silicone may migrate throw areas of least resistance. The frequency of rupture of silicone breast implants is unknown but is a well-known occurrence, occurring at the time of insertion or during manual compression, after chest wall trauma or by iatrogenic causes. A minimum of 15% of modern implants can be expected to rupture between the third and tenth year after implantation [
13]. Brown et al. found that 77% of women with silicone breast implants, without regard to complaints or symptoms, had at least one breast implant rupture; median implant age at the time of rupture was 10.8 years [
14]. Extruded silicone, due to a breast implant failure, causes areas of inflammation, silicone granulomas, in the breast and surrounding tissues, including axillary lymph nodes, leading to the formation of pseudotumors [
15,
16].Diagnosis of ruptured implants is difficult and is performed with physical examination, mammography, breast ultrasound, CT, and MRI. None of these techniques can detect all ruptures; CT and MRI detect approximately 80% and 90%, respectively [
17,
18].
M.R. Stevens was the first author to report a pleural effusion occurring as a result of ruptured breast prostheses 5 years after implantation [
5]. The implant rupture was caused by a chest trauma, and the author treated the pleural effusion with a complete aspiration of pleural fluid obtaining complete resolution of the symptoms. Even Hirdmand et al., in 1994, treated a similar pleural effusion by aspiration through a thoracentesis defect [
19]. In this case, the implants were 20 years old (breast augmentation), and no clear etiology of migration was found. The patient only had capsulotomies 2 years after breast augmentation for capsular contracture. Breast implant failure associated to surgical procedures had instead been well documented in 1993, by Taupmann et al., that showed a singular case of silicone migration in pleural cavity due to a failed thoracocentesis under ultrasonic guidance. The breast prosthesis of a 13-year-old was nicked or traversed by the chest tube, allowing egress of silicone down the outside of the chest tube into pleural cavity [
20]. Rice et al. in 1995 reported on a post-surgical silicone pleural effusion due to a complication of tube thoracostomy in the presence of mammary implants positioned 15 years before [
21]. A tube thoracostomy was placed to drain a post-traumatic pleural effusion. Failure of this procedure nicked prosthesis integrity and developed a pleural effusion complicated by a
Staphylococcus aureus supra-infection. Clinical resolution was obtained by thoracotomy and pleural decortication, silicone evacuation, breast implant removal, and antibiotics [
22]. In 2005, Levine et al. and in 2015 Tanaka et al. described cases of fibrothorax, mimicking a mesothelioma, related to a breast implant rupture and silicone effusion during a cardiac-thoracic surgery procedure [
23,
24]. Moreover, in 2009, Dragu et al. and in 2012 Di Carlo et al. reported a similar intrapulmonary silicon effusion, for aesthetic and reconstructive breast implant failure, respectively, related to lobectomy procedure and remote thoracic scar, mimicking breast metastasis or primitives lung cancer [
6,
25]. A similar case was reported by Sykes in 2012 and Lehoux in 2013, but silicone effusion occurred through a remote scar of chest wall caused by a video-assisted thoracoscopic surgery (VATS) procedure [
26,
27]. Silicone effusion is not the only complication that may involve the chest cavity. In fact, a different pressure between intrathoracic cavity and extrathoracic tissues can lead to the complete migration of a breast implant through a chest wall interruption, elicited by physical exercise, compression, and implant liquidity [
28‐
30]. Chest wall interruption may have different etiologies like trauma, congenital conditions and iatrogenic, as report by Metha et al. [
31]. The authors describe a breast implant migration, 14 years later a breast augmentation, through a chest wall interruption due to thoracotomy for lung cancer. Another case of chest wall interruption after surgery was described in 2015 by Russel et al that shown an intrathoracic removal of breast implant following VATS procedure [
32]. Silicone implant failure may be clinically silent, and usually, it is more likely to be found in the “old generation” silicone prosthesis placed more than two decades ago. As biomaterial science has recently developed, thanks to multilayers implants and cohesive silicone gel implants, the risk of implant failure and free silicone diffusion is greatly reduced. In fact, a leakage is unlikely to happen with more modern cohesive silicone gel implants, so this kind of complication is likely to become even more rare. Apart from some exceptional circumstances, in fact, cohesive silicone will not easily spread to the surrounding tissue; however, silicone present in older generations of implants can be subject to wide dissemination. For these reasons, some authors suggest replacing all implants used before the era of double lumen and cohesive silicone gel implants with new and modern implants [
33,
34].We present a rare case of pleural silicone effusion through a chest wall defect with consequent granulomas, 18 years after a right breast reconstruction for breast cancer, treated with a multidisciplinary approach with thoracic surgeons and radiologists. We performed a breast implant removal, and fluid silicone was drained out of the breast cavity. Chest wall integrity was restored with a pectoralis major flap and a pre-pectoral breast reconstruction with the support of a biological membrane. To date, biomaterials evolution and surgical techniques evolution allow more accurate surgical treatments using breast implants with synthetic mesh and membrane [
35‐
38]. In our case, we performed a pre-pectoral breast reconstruction with breast implant and synthetic membrane, using pectoralis major muscle to cover thoracic gap and restore chest wall integrity and to allow implant placement. Reviewing the literature, thoracic effusion of silicon after breast implant rupture is a rare event. Nevertheless, in the majority of cases recorded, a previous surgical procedure involving chest wall is reported. This condition may cause the interruption in the chest wall as well as develop a “locus minoris resistencia” at the level of the scars, representing prerequisites for a silicon migration in cases of extracapsular implant ruptures. We are glad to present an original surgical procedure to treat, for the first time, thoracic silicone effusion after breast implant rupture with a pre-pectoral major reconstruction using breast implant and synthetic membrane. Chest wall suture and pectoralis major flap have guaranteed restoration of chest wall integrity by a hermetic fistula closure. Functional and cosmetic results gratified patient and surgeons. As reported in our case, the patient did not refer any respiratory symptoms. Nevertheless, thoracic cavity involvement may be either clinically silent or symptomatic, depending on the pulmonary enrollment. Lung compression or bronchial obstruction may determine respiratory distress syndrome or acute, and chronic, pneumonitis events. In this regard, even though this is a not very common event, it still represents a real potential complication that plastic surgeons should keep in mind when dealing with patients with breast implants who have experienced or are planning surgical thoracic procedures. No official guidelines for follow-up after breast prosthesis implantation are currently available, though targeted radiological protocols should be considered in all patients with suspected breast implants rupture, who underwent surgical procedures involving the chest wall [
33]. Cooperation among plastic surgeons, radiologists, and cardio-thoracic surgeons should be mandatory in order to manage such a complex clinical scenario.