Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of systemic symptoms attributed to breast implants. Symptoms include [fatigue, brain fog, arthralgia, myalgia, hair loss, rashes, dry eyes]. Patient reports onset [timeframe] following [primary/revision] augmentation. Denies history of autoimmune disease prior to implantation. Patient expresses significant concern regarding implant-associated symptoms and desires discussion of en-bloc capsulectomy.
Clinical Examination Findings
Breast exam: Implants are [soft/firm/contracted]. No palpable masses, lymphadenopathy, or skin changes suggestive of BIA-ALCL. Surgical scars are well-healed. Systemic review: No objective signs of acute inflammation or systemic toxicity. Neurological and musculoskeletal exams are non-focal.
Treatment Protocol
Discussed the clinical entity of BII, noting the lack of standardized diagnostic criteria. Options include: 1. Observation, 2. Implant exchange, 3. Total capsulectomy and explantation. Risks of surgery, including anesthesia, bleeding, infection, and potential for incomplete symptom resolution, were reviewed in detail. Patient elects to proceed with [procedure].