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Surgical Pathology Criteria

Breast Implants


  • Foreign substances employed for breast augmentation; they may produce pathologic lesions

Diagnostic Criteria

  • Silicone bag containing saline, silicone gel or silicone liquid
    • Fibrous capsule may form around the bag
      • Dense fibrosis with chronic inflammation
      • May exhibit so called synovial metaplasia at interface with bag
      • Does not require leakage of bag contents for formation
      • Silicone as described below may shed from the bag surface and be found in the capsule
    • If leakage or rupture occurs, silicone, if present,elicits a histiocytic response
      • Silicone in tissue forms oval refractile globules
        • It is not birefringent
      • If bag contains saline, rupture produces no tissue response
  • Polyurethane bag containing any of above fillings
    • Same potential reactions as above
    • Polyurethane in tissue forms refractile triangular bodies
      • It is not birefringent
  • Direct injection of various substances, including paraffin wax
    • Typically forms lipid granulomas
  • Talc has been associated with capsular contracture
    • Talc is birefrengent with a maltese-cross pattern
    • Talc was banned on surgical gloves in 1991 in the USA
  • Polarization may reveal rare birefringent needle-like crystals consistent with silica
    • Laser Raman spectroscopy has failed to identify this material as silica
  • All foreign substances in the breast may migrate to local and occasionally distant draining nodes

Richard L Kempson MD
Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting:: May 27, 2006

Supplemental studies


  • The cells associated with pseudo-synovial metaplasia of the implant capsule are CD68 positive
  • No specific synovial markers are available for testing


Substance Birefringence
Silicone No
Polyurethane No
Talc Yes, maltese-cross
Silica Yes, needle-like crystals


Differential Diagnosis

Identification of various substances associated with breast implants
Foreign Substance Tissue Pattern Birefringence
Silicone Globules, refractile No
Polyurethane Triangular, refractile No
Talc Inconspicuous Yes (maltese cross)
Silica (questionable occurence) Needle shaped crystals Yes


  • The question of an association between implants and various disorders including autoimmune disorders has been hotly debated in both scientific and legal settings
    • Because of the potential for legal action, the gross specimen should be carefully described
      • Any identifying characters or numbers should be recorded
      • The specimen should be photographed
      • We retain the gross specmens indefinitely



  • The implant should be photographed
  • Any identifying marks, characters or numbers should be recorded
  • Because of the potential for legal action, we retain the gross specimens indefinitely


Potentially Granulomatous Breast Lesions


  • Rosen PP, Oberman HA. Tumors of the Mammary Gland, Atlas of Tumor Pathology, AFIP Third Series, Fascicle 7, 1993
  • Chandler PJ Jr. Talc and capsular contracture. Ann Plast Surg. 2004 Mar;52(3):288-92.
  • Pasteris JD, Wopenka B, Freeman JJ, Young VL, Brandon HJ. Analysis of breast implant capsular tissue for crystalline silica and other refractile phases. Plast Reconstr Surg. 1999 Apr;103(4):1273-6.
  • Abbondanzo SL, Young VL, Wei MQ, Miller FW. Silicone gel-filled breast and testicular implant capsules: a histologic and immunophenotypic study. Mod Pathol. 1999 Jul;12(7):706-13.
  • Emery JA, Spanier SS, Kasnic G Jr, Hardt NS. The synovial structure of breast-implant-associated bursae. Mod Pathol. 1994 Sep;7(7):728-33.
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