The Breast Choice: Improving clinical care for women with suspected silicone breast implant-associated symptoms

This thesis aims to improve the clinical care of women presenting with suspected breast implant illness (BII), a complex and heterogeneous condition characterized by a wide range of local and systemic symptoms presenting in women with silicone breast implants. These symptoms commonly include systemic manifestations such as fatigue, myalgia, arthralgia, cognitive impairment, and neurological symptoms, as well as breast-related complaints such as pain or axillary lymphadenopathy. As the systemic complaints are often non-specific and overlap with symptoms seen in the general population, diagnosing BII remains challenging. The research presented in this thesis is largely based on a cohort of more than 2,000 women evaluated at a specialized silicone outpatient clinic. This unique clinical setting allowed for detailed characterization of symptom patterns, evaluation of diagnostic strategies, and assessment of clinical outcomes following implant removal. One of the key findings is that the combination of local breast symptoms and multiple systemic complaints, in the absence of an alternative explanation, may help to identify patients with a higher likelihood of BII. Importantly, the majority of these women experienced improvement of both local and systemic symptoms after explantation. This improvement was more pronounced in women with a higher clinical suspicion of BII and in those who underwent implant removal within ten years after implantation. These findings suggest that early recognition of symptom patterns may be clinically relevant. Despite these observations, the etiology and pathophysiology of BII remain unclear. Several potential mechanisms are discussed, including immune-mediated responses to silicone, chronic inflammation due to silicone leakage or “gel bleed,” and, in some cases, psychosomatic factors. The thesis also presents a rare case of silicone-associated scleroderma-like disease, in which silicone particles were histologically identified in distant tissues, supporting the hypothesis that silicone migration may induce inflammatory responses in susceptible individuals. However, such findings are not universal, indicating that individual susceptibility likely plays an important role. A major challenge highlighted in this thesis is the lack of reliable biomarkers for BII. Extensive investigations into immunological markers and other potential diagnostic tools, such as platinum levels in hair, did not yield clinically useful results. As a consequence, the diagnosis of BII currently remains one of exclusion, relying on clinical assessment, recognition of symptom patterns, and the exclusion of other medical conditions. Imaging modalities such as ultrasound and MRI can support the evaluation of implant integrity and detection of complications such as rupture or silicone leakage. In addition to biomedical factors, psychological aspects are also considered. A substantial proportion of women in the studied cohorts reported symptoms of depression, anxiety, or burnout, which may interact with physical symptoms and influence illness perception. The interplay between psychological and somatic factors further complicates both diagnosis and management. Based on these findings, this thesis proposes a more structured and patient-centered clinical approach, emphasizing careful history taking, recognition of characteristic symptom patterns, appropriate use of imaging, and shared decision-making regarding explantation. Importantly, transparent communication about uncertainties, expectations, and potential outcomes is essential in guiding patients. Finally, this work highlights the broader societal impact of BII, including its effect on quality of life, work participation, and healthcare utilization. It underscores the need for improved information provision, standardized care pathways, and large-scale longitudinal research to further elucidate the mechanisms underlying BII and to optimize diagnostic and therapeutic strategies. In conclusion, while breast implant illness remains an ill-defined and multifactorial condition, this thesis contributes to a better understanding of its clinical presentation and management, and provides a foundation for improving care for affected women.