Unexplained neck and shoulder pain for 4 years due to a post-breast augmentation foreign body
Patient Ngân (name has been changed) presented to MD, MSc. Dr. Ho Cao Vu with breast deformity and persistent left shoulder pain lasting for several years.
According to the patient’s history, she underwent breast augmentation in 2022 via a periareolar (inferior half) incision. Over time, the right breast showed signs of implant displacement, while the left breast became firm and deformed due to Grade IV capsular contracture.
On clinical examination, MD, MSc. Dr. Ho Cao Vu diagnosed this as a case of Grade IV capsular contracture requiring implant removal, capsulectomy, and reconstruction of bilateral implant pockets in preparation for a secondary breast augmentation after 6–12 months following explantation.
Unexpected intraoperative findings
The surgical procedure was performed on the right breast implant pocket. During dissection through the superficial fascia layer, the surgeon noted that the pocket was very thin. The Motiva 255cc implant was still intact; however, there was deficiency in the superomedial quadrant and pocket descent in the inferolateral quadrant, resulting in implant malposition with downward and lateral displacement. The surgeon performed implant pocket reconstruction at the inferolateral quadrant, preparing the pocket for future implant placement with appropriate selection of implant size (diameter, projection, and brand).
In the left breast pocket, during dissection through the superficial fascia layer, markedly thickened inflammatory tissue was observed. Upon entering the implant pocket, the surgeon identified an old Motiva 255cc implant showing compromised implant integrity, with multiple surface folds and yellow discoloration of the gel.
After removal of the previous breast implant and full evaluation of the implant pocket, MD, MSc. Dr. Ho Cao Vu noted severe Grade IV capsular contracture. Notably, at the axillary region, a retained surgical gauze was found, surrounded by fibrotic encapsulation ("organized" fibrotic reaction). The implant pocket showed marked inflammatory thickening and hyperemia. This represents an extremely rare case of a retained surgical foreign body, which is difficult to dissect due to its long-standing presence in the body for 4 years, referred to as a "gossypiboma".
Gossypiboma refers to a mass formed in the body due to an unintentionally retained surgical gauze during an operation. When gauze (made of non-absorbable cotton fibers) is inadvertently left behind, the body typically responds in two main ways:
Exudative (suppurative) reaction: The body forms abscess cavities, leading to pain, swelling, and possible drainage of pus through the skin. Fibrotic reaction: The body encapsulates the retained gauze with fibrous tissue, forming a firm mass that is usually painless and may develop silently over months or years.
In this case, the patient presented with a rare clinical scenario with no significant abnormal clinical signs except for shoulder pain and left breast firmness and deformity. Even on ultrasound examination, the retained gauze was difficult to detect due to complete fibrotic encapsulation and integration with surrounding tissues in the axillary region. This explains why this case is considered extremely rare in the more than 20 years of surgical experience of MD, MSc. Dr. Ho Cao Vu.
Advantages of ultrasonic scalpel in the management of capsular contracture and foreign body complications
Faced with a fibrotically encapsulated gossypiboma and extensive adhesions with inflammatory changes, MD, MSc. Dr. Ho Cao Vu utilized an ultrasonic scalpel with cutting and hemostatic capabilities, combined with a point dissection technique, allowing safe removal of the entire gossypiboma and capsular tissue while minimizing injury to surrounding healthy tissues.
The excised gossypiboma and capsular tissue were subsequently sent for histopathological examination. Thanks to the use of the ultrasonic scalpel, hemostasis was well controlled, and minimal fluid was observed in the implant pocket; therefore, no drain was required postoperatively, helping reduce pain and shorten recovery time.
The truth behind unexplained neck and shoulder pain
A clinically significant detail in this surgical case was the complete resolution of the patient’s pain symptoms following surgery. Prior to the procedure, the patient reported frequent left shoulder pain and restricted arm movement, particularly difficulty in raising and lowering the arm. She had undergone multiple sessions of physiotherapy; however, there was no improvement.
MD, MSc. Dr. Ho Cao Vu explained that the true cause of these symptoms was a retained surgical gauze located within the implant pocket at the lateral and axillary region. This foreign body caused prolonged compression and chronic inflammation, resulting in referred pain that was initially mistaken for common musculoskeletal neck and shoulder pain.
Immediately after completion of implant removal and foreign body extraction, the patient reported complete resolution of left shoulder pain, with restoration of normal arm movement and range of motion.
The surgeon advises that patients presenting with abnormal post–breast augmentation symptoms such as breast firmness, deformity, or unexplained pain in the breast, axillary, or shoulder region—even in cases where ultrasound findings are negative—should promptly seek evaluation by specialists in breast reconstructive and plastic surgery for thorough assessment.
In some cases, fibrotic foreign bodies such as in this case may not be clearly detected on ultrasound imaging. However, clinical experience may allow the surgeon to identify subtle abnormal signs and determine appropriate timely intervention.
With extensive experience in both breast cancer surgery and aesthetic breast reconstruction, combined with the use of a next-generation ultrasonic scalpel, MD, MSc. Dr. Ho Cao Vu is able to safely dissect complex fibrotic masses while minimizing injury to surrounding healthy tissues, thereby improving treatment outcomes and postoperative recovery.
