Clinical Management of Breast Implant Illness and Breast Implant–Associated Somatic Symptom Disorder (BIA-SSD): Case Examples of Treatment Options

Summary:

Patients presenting with systemic symptoms associated with breast implants often exhibit heightened anxiety and may meet diagnostic criteria for breast implant–associated somatic symptom disorder (BIA-SSD). BIA-SSD is characterized by persistent anxiety and preoccupation with systemic symptoms that interfere with daily functioning for 6 months or longer. Recent research has clarified diagnostic strategies and treatment approaches for somatic symptom disorders. This report presents 2 cases illustrating both nonsurgical and surgical management of patients meeting criteria for BIA-SSD. Both patients underwent comprehensive medical evaluations, including clinical examination and breast magnetic resonance imaging, which were negative for underlying medical pathology. Nonsurgical treatment, including detailed counseling by the plastic surgeon and referral for cognitive behavioral therapy with a qualified therapist, was offered to the patient who wished to retain her implants and was receptive to psychological care. For the patient who declined therapy, surgical management including explantation and simple capsulectomy was performed. Both patients experienced significant improvement in anxiety and somatic symptoms, despite pursuing different treatment pathways for BIA-SSD.

Recent investigations have identified that some patients who report systemic symptoms associated with breast implants have findings supporting the diagnosis of a breast implant–associated somatic symptom disorder (BIA-SSD).¹ This may be found in patients with severe anxiety about breast implants, somatic symptoms with a high somatic symptom burden, and excessive thoughts or worries about their health or symptoms that persist for 6 months or more.² Anxiety levels measured by psychological testing with the General Anxiety Disorder 7-item (GAD-7) scale³ shown in Table 1 and somatic symptom burden measured by the Somatic Symptom Scale-8 (SSS-8)⁴ shown in Table 2 have been useful to assess these important components of BIA-SSD. These tests have been shown to be reliable and valid measurements of anxiety and somatic symptom burden and are based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria.²

Table 1.

GAD-7 Scale

In the 2-wk Period Before This Questionnaire, How Often Were You Experiencing the Following?	Not at All	Several Days	More Than Half the Days	Almost Every Day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Scoring was calculated by totaling scores of 0, 1, 2, and 3 to the response categories, respectively, of “not at all,” “several days,” “more than half the days,” and “nearly every day.” GAD-7 total score for the 7 items ranged from 0 to 21. 0–4, minimal anxiety; 5–9, mild anxiety; 10–14, moderate anxiety; 15–21, severe anxiety.

Table 2.

SSS-8 Scale for Breast Implant Concerns

How Much Are You Bothered by the Following Problems?	Not at All	A Little Bit	Somewhat	Quite a Bit	Very Much
1. Stomach or bowel problems	______ (0)	______ (1)	_______ (2)	_______ (3)	____ (4)
2. Back pain	______ (0)	______ (1)	_______ (2)	_______ (3)	____ (4)
3. Pain in your joints, arms, or legs	______ (0)	______ (1)	_______ (2)	_______ (3)	____ (4)
4. Headaches	______ (0)	______ (1)	_______ (2)	_______ (3)	____ (4)
5. Shortness of breath or chest pain	______ (0)	______ (1)	_______ (2)	_______ (3)	____ (4)
6. Dizziness	______ (0)	______ (1)	_______ (2)	_______ (3)	____ (4)
7. Fatigue or low energy	______ (0)	______ (1)	_______ (2)	_______ (3)	____ (4)
8. Trouble sleeping	______ (0)	______ (1)	_______(2)	_______ (3)	____ (4)
SSS-8 score =	_______ +	_______ +	________ +	________ +	______

SSS-8 measures 0–32, with 0–4 showing no or minimal symptom burden, 4–7 showing low burden, 8–11 showing medium burden, 12–15 showing high burden, and 16–32 showing very high burden.

High levels of measured anxiety in patients with BII symptoms have been reported, with anxiety levels lowered by breast implant removal.^5,6 Furthermore, patients with BII symptoms have been shown to take more medications for the treatment of anxiety than patients without BII symptoms and have been shown to have a history of anxiety, which precedes breast implants in the majority of cases.⁷

Patients who present with elevated levels of anxiety related to their breast implants with persistence of systemic symptoms for at least 6 months may be treated with either nonsurgical or surgical means. Algorithms assisting with the diagnosis and treatment options for patients with BIA-SSD have been recently presented in the literature.⁸ The case reports provided here demonstrate alternative treatments with significant resolution of BII symptoms for 2 patients with findings consistent with BIA-SSD.

Case 1

A 37-year-old woman with a history of an anxiety disorder and taking a selective serotonin reuptake inhibitor for the medical management of her anxiety presented for a breast augmentation. She indicated that her anxiety was well controlled. At surgery, highly cohesive silicone breast implants were placed in a dual-plane position with good aesthetic results. At 10 months postoperatively, the patient noted that she felt fatigued with poor memory, hair loss, worsening of her anxiety, gastrointestinal complaints, and persistent thoughts about her symptoms. She indicated the onset of symptoms within a few months of surgery. The patient reported that her anxiety became elevated when she had obtained information online about BII, including engagement with BII social media sites. She described that her symptoms had persisted and were worrisome, and that she thought about them often. Clinically, her breasts were symmetrical without evidence of capsular contracture. She voiced concerns about breast implant illness but wanted to maintain her breast implants. Her findings were consistent with BIA-SSD.

A magnetic resonance imaging scan demonstrated no evidence of implant rupture. The patient was referred to her primary care physician who performed a workup, including an evaluation of autoimmune markers and a full endocrine evaluation, all of which were negative. GAD-7 score was 19 (severe anxiety) and the SSS-8 score was 38 (very high somatic symptom burden). The patient was reassured and counseled that misinformation online can greatly escalate anxiety and produce symptoms, especially with baseline anxiety, and that working with her mental health provider might be helpful. The medical literature linking anxiety and BII symptoms were reviewed with the patient. The treatment algorithm for this patient is shown in Figure 1. We contacted the patient’s mental health provider and discussed the case, and a treatment plan was created to significantly increase the frequency of counseling. Care adjustments included psychotherapy with cognitive behavior therapy elements without an alteration in medication dosing. Within 6 months of therapy, the patient reported a significant resolution of her physical BII symptoms and her GAD-7 and SSS-8 scores had dropped to 7 and 6, demonstrating low levels of anxiety and systemic symptom burden. The patient was pleased with her outcome and decided to maintain her breast implants.

Fig. 1.

Treatment algorithm for case 1.

Case 2

A 42-year-old woman presented with 12-year-old silicone breast implants and symptoms of fatigue, joint pain, intermittent rash, “brain fog,” and anxiety, which had persisted for at least 1 year. The breasts were symmetrical without capsular contracture. Although she had been happy with her implants and had no breast pain, she was concerned that she had BII associated with her breast implants and noted that these thoughts had been interfering with her daily life activities. She reviewed that she learned about BII from social media sites and learned about “en bloc” surgery and other procedures to remove “toxins” and leaking silicone. Clinical examination demonstrated soft and symmetrical breasts with palpable breast implants. A magnetic resonance imaging scan demonstrated no evidence of implant rupture. The patient was referred for a medical workup status, which was within normal limits and included an autoimmune and endocrine evaluation. The GAD-7 score was 16 (severe) and the SSS-8 score was 20 (very high), supporting very high levels of anxiety and systemic symptom burden. The patient’s findings were consistent with BIA-SSD. See Figure 2 for a treatment algorithm for patient 2.

Fig. 2.

Treatment algorithm for case 2.

After completion of the medical workup, which was within normal limits, the patient was thoroughly counseled about her options for treatment. It was explained that a range of conditions can present with similar symptoms and that breast implant removal may or may not reduce her symptoms. A review of the medical literature and the correlation between elevated levels of anxiety with or without depression and BII symptoms were provided. After consideration, the patient chose to remove her breast implants. Explantation with capsulectomy and mastopexy was performed. At 6 months postoperatively, the patient reported significant reduction of her physical symptoms and reduction of her anxiety. The GAD-7 score was 6 (mild) and the SSS-8 score was 10 (moderate), suggesting a notable lessening of both anxiety and systemic symptom burden. The patient declined pursuing mental health evaluation and management throughout the treatment course, and was satisfied with the outcome and improvement of symptoms with surgical treatment.

DISCUSSION

The successful management of BIA-SSD requires that plastic surgeons understand the approaches to diagnose and offer treatment to patients who present with clinical findings of BIA-SSD. Typically, the plastic surgeon will collect a history, complete a breast examination, and consider imaging to verify prosthesis integrity. For patients with systemic symptoms, referral to a primary care physician or rheumatologist should be made to rule out medical conditions that may be a source for symptoms.^9,10 Should medical workup be negative, a counseling appointment should be made in which the plastic surgeon explains that the literature clearly shows a link to symptoms and anxiety, including misinformation available online and social media, conspiracy theories, and alternatives to surgical care. The plastic surgeon should review that the treatment of anxiety may in itself reduce somatic symptoms associated with breast implants. The patient can be offered a referral to a specialist skilled in anxiety or somatic symptom disorder care if the patient desires to maintain breast implants.⁸ Furthermore, the plastic surgeon can also review surgical options including simple explant, explant with capsulectomy, breast lift, and any other procedure that may be available and medically appropriate.⁶ This conversation is focused on treatment options based on evidence-based, ethical principles.

CONCLUSIONS

The cases presented demonstrate that a reduction of symptoms can be achieved in patients presenting with findings consistent with BIA-SSD with both non-surgical and surgical treatment modalities.

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.