Late Intracapsular Seroma in Subfascial Buttock Augmentation: A Case Report

Aesth. Plast. Surg. 30:599 604, 2006 DOI: 10.1007/s00266-005-0162-5

Case Reports

Late Intracapsular Seroma in Subfascial Buttock Augmentation: A Case Report

Raul Gonzalez, M.D.

Abstract. Late intracapsular seroma and hematoma have been described frequently as a complication of breast augmentation surgery. However, there are few reports of late intracapsular seroma in buttock augmentation. Textured and polyurethane implants have been used for subfascial enlargement of the buttocks. In this article, the authors report a large late intracapsular bilateral seroma caused by a retrofascial polyurethane-covered implant used for buttock augmentation: 1,200 ml on one side and 300 ml on the other. This patientÕs intracapsular seroma was of sudden onset 2 years and 6 months after surgery, and apparently had no relation to any trauma, use of medication, or physical exercise. Local tissues, including the gluteal fascia, were distended such that the implant was replaced inside the muscle and there was no relapse of the seroma. Late intracapsular hematomas or seromas from implants for buttock and breast augmentation may have the same etiology, and textured implants seem to be involved. All the reports on the matter are associated with textured implants. Any late seroma or hematoma caused by a smooth implant is related to an additional factor that may be considered as the etiologic agent. Further studies aimed at a large-scale assessment of the cause and actual incidence of late seromas and hematomas from textured implants are required. Key words: Buttock augmentation—Late intracapsular seroma

Late intracapsular seroma and hematoma have been reported as a complication of breast augmentation surgery [3,4,8,9,13 16,18–21,24]. The reports relating this complication of breast augmentation are increasing, although there are few reports of late intracapsular seroma or hematoma in buttock augmentation [12,22]. The rates of this complication for either gluteal or

breast augmentation may be the same if the etiology involved is associated with the implant surface. The etiologies of a hematoma and a seroma may differ. Current theories about the intracapsular formation of those fluids with unknown etiology have not been proved to date, but several authors note that intracapsular granular tissue with neovessels is the probable cause. Such granular tissue seems to result from the microtrauma caused by the textured surface on the capsular wall. The rupture of the said neovessels would lead to hematoma formation [4,18,20]. Although seromas are considered a complication in studies involving a significant number of patients with complications after implant surgery for breast augmentation, there is no theory about their etiology or any suggestion on how to avoid them. Late seroma and hematoma without trauma have been strictly associated with textured or polyurethane implants. Clearly, the incidence of seromas increased after the introduction of textured implants. Seromas are not mentioned in older studies analyzing complications of smooth implant surgery, when textured implants were not available. All the reports on the disorder are associated with textured implants. All reported late seromas or hematomas caused by a smooth implant are associated with an additional factor that may be considered the etiologic agent [4,9,16]. There are few reports of late seroma or hematoma with gluteal implants, all them associated with rough surfaces. We present the case of a large late seroma in a patient who underwent gluteal augmentation using the subfascial technique for placement of a polyurethane implant, which was corrected changing the implant location (intramuscular).

Case Report Correspondence to R. Gonzalez, M.D., Clinica Raul Gonzalez, Amadeu Amaral, 661-Ribeirao Preto/SP, Brazil14020-050; email: [email protected]

A 47-year-old woman underwent gluteal augmentation with a silicon implant at a different institution in

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2001. Surgery was performed using the subfascial technique, and a 350-ml polyurethane De La Pen˜a (silimed, Rio de Janeiro, Brazil) implant was placed. The patient was pleased with the early aesthetic result. However, 1 year later, she noticed a palpable node on the left buttock, which an ultrasound examination showed was a small ‘‘bend’’ of the implant. At 3 years after her surgery, the patient noticed some loosening of the local tissues and a loss of the firmness earlier achieved. She reported that she could see the implant when she walked. At 3 years and 5 months after the surgery, the patient noticed that her buttocks grew bigger on both sides, followed by local discomfort, stiffness, and hardening (Fig. 1a, b, and c). The growth progressed, and 2 months later, the left buttock became evidently asymmetric. She felt some local tension followed by pain when she walked or lay on her back. An ultrasound showed a significant amount of intracapsular fluid. The patient came to our institution for an assessment. At the physical examination, we noticed that both the skin and the capsule were so distended that placement of a new implant in the same area was unlikely. Therefore, we chose to create an intramuscular implant compartment using smooth implants. During the surgical procedure, the seromas on both buttocks (1,200 ml on the left and 300 ml on the right) were aspirated (Fig. 2). The fluid in the left buttock was clear and viscous, with a urine-like color, whereas the on in the right was slightly turbid and more viscous than the former. At the microscopic examination, the fluid aspirated from the right side showed a large amount of lymphocytes and neutrophil cells, toxic granulation, and intense macrophagic activity, with a serous fibrinous precipitate and reactive mesenchymal and proliferative cells. In contrast, the fluid aspirated from the left side showed no epithelial or mesenchymal cells. No blood clots were found in either side. The implant was covered by serum fibrinous tissue, and only part of the polyurethane surface remained. The implant on the left had a skewed axis, and the larger end, which should have been on the caudal part of the buttock, was on the lateral part (Fig. 3A). We also found a large amount of loose serous fibrinous tissue in the intracapsular fluid, deposited on the bottom of the compartmentÕs caudal sac. Such tissue, formed by large grains, was abundant in fibrin and congested neovessels, and there was a very slight amount of lymphocytes, histiocytes, and neutrophil cells at the histopathologic examination. As we had expected from the physical examination, after removal of the serous fluid, the capsule was extremely large and did not provide sufficient support for an implant. Therefore, we closed the subfascial capsule, and a new intramuscular compartment was created because late hematoma relapse had been reported [20]. I myself treated a patient with a textured breast implant who had a seroma

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relapse. Although there are no reports in literature, this complication may be more frequent than expected (Fig. 3B). We brought the anterior and posterior aspects of the subfascial compartment together using several Vicryl 000 sutures to improve bonding and to achieve the correct closure of the pocket (Fig. 4). The capsuleÕs anterior leaflet was moved aside using the XYZ intramuscular technique to provide access to the major gluteal muscle. The technique, which I described in 2004, allows the surgeon to direct the intramuscular undermining through three known points: X, Y, and Z. These are palpable points at the bone pelvis. It ensures a good intramuscular undermining by creating a pocket within the gluteus major muscle mass [12]. A smooth oval-shaped, 300-ml implant was placed by the described technique. The muscle compartment was carefully sutured, as well as the subfascial compartment. On both compartments, we put a catheter for aspiration, and great effort was made to avoid communication between the two compartments. The blood, originating from the intramuscular compartment, could enter the subfascial compartment, preventing the anterior and posterior aspects of the compartment from bonding well. A strong compression dressing was applied, and an elastic band (gynecomasty type) served as a restriction and compression ‘‘girdle’’ to help the subfascial compartment closure. The draining catheter in the intramuscular compartment was removed after 48 h. However, the catheter in the left subfascial pocket was kept until postoperative day 6 because during the first 72 h, a clear serous fluid similar to the that found at surgery drained through it when the catheter was removed: 50 ml on day 1, 30 ml on day 2, 20 ml on day 3, and 5 ml on day 6. Rest was recommended to the patient, and she was instructed to avoid flexing the chest over the thighs at an angle exceeding 90° for 30 days. The restriction adhesive dressings were removed after 21 days. At 8 months, there was no change in the postoperative result, and the patient was completely pleased with the aesthetic effect achieved (Fig. 1d, e, f). Because we have not had a single seroma in the 746 cases of smooth intramuscular gluteal implant reported in our description of the XYZ technique [12], the reported patientÕs long-term evolution should be favorable, with no seroma recurrence in the new intramuscular compartment. Discussion Textured-surface and polyurethane implants have been used because they show lower rates of capsular contraction, as compared with smooth surface implants, in the subglandular compartment in breast augmentation surgery. Although capsular contracture rates have decreased with this type of implant, a

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Fig. 1. (a,b,c) Preoperative view of a patient with an intracapsular seroma and gluteal augmentation with a subfascial polyurethane implant (350 ml). (d,e,f) Postoperative view 4 months after treatment of the seroma and placement of a 300-ml smooth intramuscular implant.

complication arose that still requires further studies and whose incidence rates are yet unknown: late hematoma and seroma. There are no reports of late hematomas or seromas with smooth implants, except those associated with other factors. Georgiade et al. [9] reported a late hematoma after a smooth implant in which the patient also took 40 mg of prednisolone. Marques et al. [16] also reported late hematomas in cases of failing implants and implants that had microfractures, and in cases of breast reconstruction preceded by the use of expanding devices [4]. However, unbroken textured or polyurethane implants associated with no other factor are known to present late seroma and hematoma [3,4,8,13 15,18,20,21,23].

Gluteal implants for buttock augmentation have been used since 1979 for both aesthetic and reconstruction purposes [1,2,6,7,10 12,17,23). Subcutaneous implants were used for some time, then discontinued due to the high rate of complications [3 5]. In 1984, Robles [17] described a technique by which the implant is placed between the major and medium gluteal muscles in the subgluteal space. There are no reports of capsular contracture or seroma with smooth implants placed by this technique. In 1996, Vergara and Marcos [23] suggested placing the intramuscular textured implants in the major gluteal muscle. In 2004, I demonstrated a technique for intramuscular placement of smooth implant following

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Fig. 2. Fluid collection aspirated from the right (1,200 ml) and left (300 ml) capsules. From each side, 150 ml of fluid was sent to the lab for histopathologic analysis.

Fig. 3. (A) Patient in the operating room immediately before surgery. Significant asymmetry can be observed. (B) Patient immediately after the seroma was aspirated and a 300-ml smooth implant was placed in the muscle.

Fig. 4. Detail of the subfascial area closure with Vicryl 3.0 absorbable suture.

reference points on the pelvis to guide its correct positioning in a safe and reproducible manner [12]. The option for smooth implants existed because there

was no capsular contracture in any of the cases, indicating that textured implants were not necessary to avoid such a problem. Another advantage of textured-surface implants is that they adhere to the area and may avoid slippage. However, if the intramuscular gluteal compartment is the same size as the implant and not larger, as we recommend, it easily avoids slippage. In 2004, De la Pen˜a [5] described a technique for placement of gluteal implants in a detached area before the gluteal fascia using textured or polyurethane implants. To achieve the correct shape and to avoid double buttocks filling almost the whole area from the lower crease to the upper third of the buttocks, he recommended that the detachment should go down to the lower gluteal crease or close to it. He developed special implants for that purpose, almond-shaped and with a longer axis than the oval implants used inside the muscle. The purpose for using textured polyurethane implants is to avoid capsular contraction and to ensure good bonding to the area, thus preventing any slippage.

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The assumption that textured implants for gluteal augmentation may cause late seroma or hematoma, as with breast implants, seems to be correct. Textured implants used in intramuscular gluteal augmentation may cause late seroma. In 2004, we reported that in four textured implant placement cases using the XYZ technique, there was one unilateral 500-ml seroma 18 months after surgery [12]. The high rate (25%) of this complication in our hands induced us to discontinue using this type of implant. Vergara and Amezcua [22] reported using a draining catheter in the gluteal intramuscular compartment for 1 week to avoid seroma formation, showing their concern about having an intracapsular seroma. They reported a 4% rate for seroma in their series. Late intracapsular seroma and hematoma rates for both buttocks and breast augmentation may be higher than expected because most reports are presented as case reports and not as part of a wider, long-term study or an investigation involving significant number of patients and surgeons. Implants from different manufacturers have different textured surfaces, and this may have an impact on the etiology of seroma formation. New studies assessing the different textures more or less likely to cause trauma may disclose more thoroughly how to avoid the problem. Something to be considered with regard to the polyurethane implant is the role played by the polyurethane surface degradation. Reports have shown that the time at which it occurs somehow coincides with late hematoma [24], in which the polyurethane surface was already degraded, exactly as happened in the reported case (Fig. 5). Because the rate for late seroma and hematoma with textured implants, both in gluteal and breast augmentation, may be higher than currently expected, it should be included in the informed consent form to be signed by the patient. New encompassing long-term studies analyzing the possible etiologic factors may be useful for avoiding the problem in the future. Currently, when the technique and type of implant are chosen, the problem must be considered. Conclusion Textured and polyurethane implants are subject to late seroma and hematoma. Few large studies have assessed the actual rate of seroma caused by textured or polyurethane implants in breast or gluteal surgery. On the other hand, smooth implants seem to be a rare cause of late seroma and hematoma. There are no reports of such problems with implants for either intramuscular or submuscular gluteal augmentation when smooth implants alone are used, but there have been reports of late seroma with textured implants using intramuscular methods. This is the first report of a non smooth implant causing such problems

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Fig. 5. Detail of the polyurethane implant used on the left buttock, showing the degradation of the polyurethane cover.

with a subfascial buttocks augmentation. Because the seroma seems to be caused by the rough surface of the implant, the rate for late seromas in gluteal augmentation can be the same as that for breast implants. However, more studies encompassing a larger number of cases are needed to verify this. The intramuscular technique has proved to be a good option for replacement of the implant in cases of late seroma after subfascial procedures and when the fascia no longer provides good support for the implant because of tissue distension. In addition, it helps to avoid relapses. References 1. Avelar J: Reconstruc¸a˜o de na´degas. J Brazil Med 32:43, 1997 2. Bartels RJ, OÕMalley JE, Douglas WM, Wilson RG: Unusual use of the Cronin breast prosthesis. Plast Reconstr Surg 44:500, 1969 3. Brickman M, Parsa NN, Don Parsa F: Late hematoma after breast implantation. Aesth Plast Surg 28:80 82, 2004 4. Daw JL, Lewis VL, Smith JW: Chronic expanding haematoma within a periprosthetic breast capsule. Plast Reconstr Surg 97:1469 1472, 1996 5. De la Pen˜a JA: Subfascial technique for gluteal augmentation. Aesth Surg J 24:265 273, 2004 6. Douglas WM, Bartels RJ: Experience buttocks augmentation. Clin Plast Surg 2:471, 1975 7. Ford RD, Simpson WD: Massive extravasation of traumatically ruptured buttock silicone prosthesis. Ann Plast Surg 29:86 88, 1992 8. Gatti JE: PolandÕs deformity reconstructions with a customized, extrasoft silicone prosthesis. Ann Plast Surg 39:122 130, 1997 9. Georgiade NG, Serafin D, Barwik W: Late development of hematoma around a breast implant, necessitating removal. Plast Reconst Surg 64:708 710, 1979 10. Gonzalez R: Gluteoplasty: Personal modifications of the Robles technique. In: Raps 90. Sa˜o Paulo, Grafica do Estada˜o: Sa˜o Paulo, pp 166 171, 1992

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11. Gonzalez R: Pro´tese para a Regia˜o Glu´tea In: Tournieux A (ed) Atualizac¸a˜o em cirurgia pla`stica cap. 59 Robe Editorial, Sa˜o Paulo, pp 555 570, 1994 12. Gonzalez R: Augmentation gluteoplasty: ‘‘The XYZ method’’. Aesth Plast Surg 28:417 425, 2004 13. Gorgu M, Aslan G, Tunncel A, Erdogon B: Late and long-standing capsular hematoma after aesthetic breast augmentation: A case report. Aesth Plast Surg 23:443 444, 1999 14. Goyal A, Mansel RE: Hematoma as a late complication after breast reconstruction with implant. Br J Plast Surg 56:189 191, 2003 15. Hester TR, Cukic J: Use of stacked polyurethanecovered mammary implants in aesthetic and reconstructive breast surgery. Plast Reconstr Surg 88:503 509, 1991 16. Marques AF, Brenda E, Salvido PH: Capsular hematoma as late complication in breast reconstruction. Plast Reconstr Surg 89:543 545, 1992 17. Robles JM, Tagliapietra JC, Grandi M: Gluteoplastia de aumento: Implante submuscular. Cir Plast Iberolat 10:4, 1984

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18. Schiavon M, Fraccalanza E, Baraziol R: Late current capsular hematoma after augmentation mammaplasty. Aesth Plast Surg 29:10 12, 2005 19. Siao HT, Tung KY, Ling ES: Late hematoma after aesthetic breast augmentation. Aesth Plast Surg 26:368 371, 2002 20. Siggelkow W, Klosterhalfen B, Klinge U, Rath W, Faridi A: Analysis of local complications following explantation of silicone breast implants. Breast 13:122 128, 2004 21. Svahn JK, Vastine VL, Landon BN, Dobke MK: Outcome of mammary prostheses explantation: A patient perspective. Ann Plast Surg 36:594 600, 1996 22. Vergara R, Amezcua H: Intramuscular gluteal implants. Aesth Surg J 23:86 91, 2003 23. Vergara R, Marcos M: Intramuscular gluteal implants. Aesth Plast Surg 20:259 262, 1996 24. Wang BH, Chang BW, Sargeant R: Late capsular hematoma after reconstruction with polyurethane covered implant. Plast Reconstr Surg 102:450 452, 1998