Diagnosis, investigation and management of breast implant illness a narrative review

Main Article Content

Daniel WH Wong
Quoc Lam


breast implantation, connective tissue, silicones, autoimmune diseases, plastic surgery


Introduction: An increasing pool of literature proposes a link between silicone implants and autoimmune-related symptoms known colloquially as breast implant illness (BII). We describe the history of BII, reported symptoms, risk factors and previously published diagnostic criteria to aid clinicians in the diagnosis, investigations and management of patients presenting with symptoms that they attribute to their silicone breast implants.
Methods: A literature search was performed using MEDLINE®, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effect (DARE) and PubMed in September 2018. The search terms ‘autoimmune inflammatory syndrome induced by adjuvants’, ‘breast implants’ and ‘silicone’ were used alone and in combination.
Results: Thirty-four studies were reviewed including three case reports, 12 case series, 14 retrospective cohort studies, four case control studies and one prospective cohort study. Within this cohort, 18 studies were found regarding the explantation of implants relating to BII.
Conclusion: Studies have demonstrated no association between silicone breast implants and any known autoimmune diseases, but there exists a pool of literature suggestive of a relatively undefined condition colloquially known as BII. Serological testing and imaging play an important role in the assessment of patients to exclude other pathology, but these tests remain non-diagnostic for BII. Although medical treatment has shown promise, there is no established treatment for patients. The surgical explantation of implants appears to have positive outcomes for patients; however, the exact nature of the surgery required to achieve this remains unclear.


Metrics Loading ...
Abstract 437 | PDF Downloads 2 HTML Downloads 133


1. Greenland S, Finkle WD. A retrospective cohort study of implanted medical devices and selected chronic diseases in Medicare claims data. Ann Epidemiol. 2000;10(4):205–13. https://doi.org/10.1016/S1047-2797(00)00037-5
2. Derby BM, Codner MA. Textured silicone breast implant use in primary augmentation: core data uptake and review. Plast Reconstr Surg. 2015;35(1):113–24. https://doi.org/10.1097/PRS.0000000000000832 PMid:25539301
3. Goren I, Segal G, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvant (ASIA) evolution after silicone implants. Who is at risk? Clin Rheumatol. 2015;34(10):1661–666. https://doi.org/10.1007/s10067-015-2931-0 PMid:25877803
4. Alijotas-Reig J, Esteve-Valverde E, Gil-Aliberas N, Garcia-Gimenez V. Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature. Immunol Res. 2018;66(1):120–40. https://doi.org/10.1007/s12026-017-8980-5 PMid:29199390
5. Shoenfeld Y, Agmon-Levin N. ASIA: autoimmune/inflammatory syndrome induced by adjuvants. J Autoimmun. 2011;36(1):4–8. https://doi.org/10.1016/j.jaut.2010.07.003 PMid:20708902
6. Rohrich RJ, Kaplan J, Dayan E. Silicone implant illness: science versus myth. Plast Reconstr Surg. 2019;144(1):98–109. https://doi.org/10.1097/PRS.0000000000005710
7. Magnusson MR, Cooter RD, Rakhorst H, McGuire P, Adams Jr WP, Deva AK. Breast implant illness: a way forward. Plast Reconstr Surg. 2019 Suppl 3;143:74s–81s. https://doi.org/10.1097/PRS.0000000000005573 PMid:30817559
8. Soriano A, Butnaru D, Shoenfeld Y. Long-term inflammatory conditions following silicone exposure: the expanding spectrum of the autoimmune/inflammatory syndrome induced by adjuvants (ASIA). Clin Exp Rheumatol. 2014;32(2):151–54.
9. Narins RS, Beer K. Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006 Suppl 3;118:77s–84s. https://doi.org/10.1097/01.prs.0000234919.25096.67 PMid:16936547
10. de Boer M, Colaris M, van der Hulst RRWJ, Cohen Tervaert JW. Is explantation of silicone breast implants useful in patients with complaints? Immunol Res. 2017;65(1):25–36. https://doi.org/10.1007/s12026-016-8813-y PMid:27412295 PMCid:PMC5406477
11. Colafrancesco S, Agmon-Levin N, Perricone C, Shoenfeld Y. Unraveling the soul of autoimmune diseases: pathogenesis, diagnosis and treatment adding dowels to the puzzle. Immunol Res. 2013;56(2¬–3):200–05. https://doi.org/10.1007/s12026-013-8429-4 PMid:23733136
12. Cohen Tervaert JW, Kappel RM. Silicone implant incompatibility syndrome (SIIS): a frequent cause of ASIA (Shoenfeld’s syndrome). Immunol Res. 2013;56(2¬–3):293–98. https://doi.org/10.1007/s12026-013-8401-3 PMid:23576058
13. Rocha MC, Santos LMB, Bagatin E, Tervaert JWC, Damoiseaux JGMC, Lido AV, Longhini AL, Torello CO, Queiroz MLS. Genetic polymorphisms and surface expression of CTLA-4 and PD-1 on T cells of silica-exposed workers. Int J Hyg Environ Health. 2012;215(6):562–69. https://doi.org/10.1016/j.ijheh.2011.10.010 PMid:22153879
14. Schnur PL, Weinzweig J, Harris JB, Moyer TP, Petty PM, Nixon D, McConnell JP. Silicon analysis of breast and periprosthetic capsular tissue from patients with saline or silicone gel breast implants. Plast Reconstr Surg. 1996;98(5):798–803. https://doi.org/10.1097/00006534-199610000-00007 PMid:8823017
15. Weinzweig J, Schnur PL, McConnell JP, Harris JB, Petty PM, Moyer TP, Nixon D. Silicon analysis of breast and capsular tissue from patients with saline or silicone gel breast implants: II. Correlation with connective-tissue disease. Plast Reconstr Surg. 1998;101(7):1836–841. https://doi.org/10.1097/00006534-199806000-00009 PMid:9623824
16. Peters W, Smith D, Lugowski S, McHugh A, Keresteci A, Baines C. Analysis of silicon levels in capsules of gel and saline breast implants and of penile prostheses. Ann Plast Surg. 1995;34(6):578–84. https://doi.org/10.1097/00000637-199506000-00003 PMid:7661533
17. Institute of Medicine (US) Committee on the Safety of Silicone Breast Implants. Safety of silicone breast implants [PDF on internet]. Washington, DC: The National Academy Press, 1999. [cited 5 May 2019]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44792/pdf/Bookshelf_NBK44792.pdf
Center for Devices and Radiological Health. FDA update on the safety of silicone gel-filled breast implants. United States: Food and Drug Administration, 2011. [cited 20 September 2018 ]. Available from: http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/UCM260090.pdf
19. Cunningham B. The MENTOR study on contour profile gel silicone MemoryGel breast implants. Plast Reconstr Surg. 2007 Suppl 1;120(7):33s–39s. https://doi.org/10.1097/01.prs.0000286665.91043.bc PMid:18090812
20. Spear SL, Murphy DK, Allergan Silicone Breast Implant US Core Clinical Study Group. Natrelle round silicone breast implants: core study results at 10 years. Plast Reconstr Surg. 2014;133(6):1354–361. https://doi.org/10.1097/PRS.0000000000000021 PMid:24867717 PMCid:PMC4819531
21. Singh N, Picha GJ, Hardas B, Schumacher A, Murphy DK. Five-year safety data for more than 55,000 subjects following breast implantation: comparison of rare adverse events rates with silicone implants versus national norms and saline implant. Plast Reconstr Surg. 2017;140(4):666–79 https://doi.org/10.1097/PRS.0000000000003711 PMid:28953716
22. Coroneos CJ, Selber JC, Offodile AC, Butler CE and Clemens MW. US FDA breast implant postapproval studies: long-term outcomes in 99,993 patients. Ann Surg. 2019;269(1):30–36 https://doi.org/10.1097/SLA.0000000000002990 PMid:30222598
23. Watad A, Quaresma M, Bragazzi NL, Cervera R, Tervaert JWC, Amital H, Shoenfeld Y. The autoimmune/inflammatory syndrome induced by adjuvants (ASIA)/Shoenfeld’s syndrome: descriptive analysis of 300 patients from the international ASIA syndrome registry. Clin Rheumatol. 2018;37(2):483–93. https://doi.org/10.1007/s10067-017-3748-9 PMid:28741088
24. Colaris MFL, de Boer M, van der Hulst RR, Tervaert JWC. Two hundred cases of ASIA syndrome following silicone implants: a comparative study of 30 years and a review of current literature. Immunol Res. 2017;65(1):120–28. https://doi.org/10.1007/s12026-016-8821-y PMid:27406737 PMCid:PMC5406475
25. Cuellar ML, Gluck O, Molina JF, Gutierrez S, Garcia C, Espinoza R. Silicone breast implant-associated musculoskeletal manifestations. Clin Rheumatol. 1995;14(6):667–72. https://doi.org/10.1007/BF02207934 PMid:8608686
26. Vasey FB, Havice DL, Bocanegra TS, Seleznick MJ, Bridgeford PH, Martinez-Osuna P, Espinoza LR. Clinical findings in symptomatic women with silicone breast implants. Semin Arthritis Rheum. 1994 Suppl 1;24(1):22–28. https://doi.org/10.1016/0049-0172(94)90106-6
27. Freundlich B, Altman C, Snadorfi N, Greenberg M, Tomaszewski J. A profile of symptomatic patients with silicone breast implants: a Sjögren's-like syndrome. Semin Arthritis Rheum. 1994 Suppl 1;24(1):44–53. https://doi.org/10.1016/0049-0172(94)90109-0
28. Peters W, Smith D, Fornasier V, Lugowski S, Ibanez D. An outcome analysis of 100 women after explantation of silicone gel breast implants. Ann Plast Surg. 1997;39(1):9–19. https://doi.org/10.1097/00000637-199707000-00002 PMid:9229086
29. Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 2000;342(11):781–90. https://doi.org/10.1056/NEJM200003163421105 PMid:10717013
30. Perkins LL, Clark BD, Klein PJ, Cook RR. A meta-analysis of breast implants and connective tissue disease. Ann Plast Surg. 1995;35(6):561–70. https://doi.org/10.1097/00000637-199512000-00001 PMid:8748335
31. Wong O. A critical assessment of the relationship between silicone breast implants and connective tissue diseases. Regul Toxicol Pharmacol. 1996;23(1):74–85. https://doi.org/10.1006/rtph.1996.0011 PMid:8628923
32. Hochberg MC, Perlmutter DL. The association of augmentation mammoplasty with connective tissue disease, including systematic sclerosis (scleroderma): a meta-analysis. Curr Top Microbiol Immunol. 1996;210:411–17. https://doi.org/10.1007/978-3-642-85226-8_44 PMid:8565585
33. Giltay EJ, Bernelot Moens HJ, Riley AH, Tan RG. Silicone breast prostheses and rheumatic symptoms: a retrospective follow up study. Ann Rheum Dis. 1994;53(3):194–96. https://doi.org/10.1136/ard.53.3.194 PMid:8154939 PMCid:PMC1005286
34. Sánchez-Guerrero J, Colditz GA, Karlson EW, Hunter DJ, Speizer FE, Liang MH. Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med. 1995;332(25):1666–670. https://doi.org/10.1056/NEJM199506223322502 PMid:7760867
35. Wells KE, Cruse CW, Baker JL Jr, Daniels SM, Stern RA, Newman C, Seleznick MJ, Vasey FB, Brozena S, Albers SE. The health status of women following cosmetic surgery. Plast Reconstr Surg. 1994;93(5):907–12. https://doi.org/10.1097/00006534-199404001-00002 PMid:8134482
36. Hennekens CH, Lee I-M, Cook NR, Hebert PR, Karlson EW, LaMotte F, Manson JE, Buring JE. Self-reported breast implants and connective-tissue diseases in female health professionals: a retrospective cohort study. JAMA. 1996;275(8):616–21. [published correction appears in JAMA 1998;279(3):198] https://doi.org/10.1001/jama.275.8.616 PMid:8594243
37. Englert H, Joyner E, Thompson M, Garcia H, Chambers P, Horner D, Hunt C, Makaroff J, O’Connor H, Russell N, March L. Augmentation mammoplasty and ‘silicone-osis’. Intern Med J. 2004;34(12):668–76. https://doi.org/10.1111/j.1445-5994.2004.00670.x PMid:15610211
38. Alijotas-Reig J. Human adjuvant-related syndrome or autoimmune/inflammatory syndrome induced by adjuvants. Where have we come from? Where are we going? A proposal for new diagnostic criteria. Lupus. 2015;24(10):1012–18. https://doi.org/10.1177/0961203315579092 PMid:25813870
39. Soriano A, Nesher G, Shoenfeld Y. Predicting postvaccination autoimmunity: who might be at risk? Pharmacol Res. 2015;92:18–22. https://doi.org/10.1016/j.phrs.2014.08.002 PMid:25277820
40. Versini M, Jeandel PY, Rosenthal E, Shoenfeld Y. Obesity in autoimmune diseases: not a passive bystander. Autoimmun Rev. 2014;13(9):981–1000. https://doi.org/10.1016/j.autrev.2014.07.001 PMid:25092612
41. Harel-Meir M, Sherer Y, Shoenfeld Y. Tobacco smoking and autoimmune rheumatic diseases. Nat Clin Pract Rheumatol. 2007;3(12):707–15. https://doi.org/10.1038/ncprheum0655 PMid:18037930
42. Arnson Y, Shoenfeld Y, Amital H. Effects of tobacco smoke on immunity, inflammation and autoimmunity. J Autoimmun. 2010;34(3):j258–j265. https://doi.org/10.1016/j.jaut.2009.12.003 PMid:20042314
43. Contant CM, Swaak AJ, Wiggers T, Wai RT, van Geel AN. First evaluation study of the Dutch Working Party on Silicone Breast Implants (SBI) and the silicone-related symptom complex (SRSC). Clin Rheumatol. 2000;19:458–63. https://doi.org/10.1007/s100670070006
44. Gaubitz M, Jackisch C, Domschke W, Heindel W, Pfleiderer B. Silicone breast implants: correlation between implant ruptures, magnetic resonance spectroscopically estimated silicone presence in the liver, antibody status and clinical symptoms. Rheumatol (Oxford). 2002;41(2):129–35. https://doi.org/10.1093/rheumatology/41.2.129 PMid:11886959
45. United States Department of Health and Human Services, Food and Drug Administration. Breast implants: certain labeling recommendations to improve patient communication. Draft guidance for industry and Food and Drug Administration staff. United States: Center for Devices and Radiological Health, 2020. [Draft issued 24 October 2019; cited 3 March 2020]Available from: https://www.fda.gov/media/131885/download
46. Jara LJ, García-Collinot G, Medina G, Cruz-Dominguez MDP, Vera-Lastra O, Carranza-Muleiro RA, Saavedra MA. Severe manifestations of autoimmune syndrome induced by adjuvants (Shoenfeld’s syndrome). Immunol Res. 2017;65(1):8–16. https://doi.org/10.1007/s12026-016-8811-0 PMid:27412294
47. Barker DE, Retsky MI, Schultz S. ‘Bleeding’ of silicone from bag-gel breast implants, and its clinical relation to fibrous capsule reaction. Plast Reconstr Surg. 1978;61(6):836–41. https://doi.org/10.1097/00006534-197861060-00002 PMid:351637
48. Ginsbach G, Busch LC, Kuhnel W. The nature of collagenous capsules around breast implants. Plast Reconstruc Surg. 1979;64(4):456–64. https://doi.org/10.1097/00006534-197910000-00004 PMid:482435
49. Greene WB, Raso DS, Walsh LG, Harley RA, Silver RM. Electron probe microanalysis of silicon and the role of macrophage in proximal (capsule) and distant sites in augmentation mammoplasty patients. Plast Reconstr Surg. 1995;95(3):513–19. https://doi.org/10.1097/00006534-199503000-00012 PMid:7870776
50. Colaris MJL, van der Hulst RR, Tervaert JWC. Vitamin D deficiency as a risk factor for the development of autoantibodies in patients with ASIA and silicone breast implants: a cohort study and review of the literature. Clin Rheumatol. 2017;36(5):981–93. https://doi.org/10.1007/s10067-017-3589-6 PMid:28303359 PMCid:PMC5400796
51. Maijers MC, de Blok CJ, Niessen FB, van der Veldt AA, Ritt MJ, Winters HA, Kramer MH, Nanayakkara PW. Women with silicone breast implants and unexplained systemic symptoms: a descriptive cohort study. Neth J Med. 2013;71(10):534–40. PMid: 24394743
52. Beekman WH, Feitz R, van Diest PJ, Hage JJ. Migration of silicone through the fibrous capsules of mammary prostheses. Ann Plast Surg. 1997;38(5):441–45. https://doi.org/10.1097/00000637-199705000-00001 PMid:9160123
53. Walden KJ, Thompson JK, Wells KE. Body image and psychological sequelae of silicone breast explantation: preliminary findings. Plast Reconstr Surg.1997;100(5):1299–306. https://doi.org/10.1097/00006534-199710000-00036 PMid:9326796
54. Endo LP, Edwards NL, Longley S, Corman LC, Panush RS. Silicone and rheumatic diseases. Semin Arthritis Rheum. 1987;17(2):112–18. https://doi.org/10.1016/0049-0172(87)90033-3
55. Bridges AJ, Conley C, Wang G, Burns DE, Vasey FB. A clinical and immunologic evaluation of women with silicone breast implants and symptoms of rheumatic disease. Ann Intern Med. 1993;118(12):929-36. https://doi.org/10.7326/0003-4819-118-12-199306150-00003 PMid:8489106
56. Shoaib BO, Pattern BM, Calkjins DS. Adjuvant breast disease: an evaluation of 100 symptomatic women with breast implants or silicone fluid injections. Keio Med J. 1994;43(2):79–87. https://doi.org/10.2302/kjm.43.79 PMid:8089958
57. Solomon G. A clinical and laboratory profile of symptomatic women with silicone breast implants. Semin Arthritis Rheum. 1994 Suppl 1;24(1):29–37. https://doi.org/10.1016/0049-0172(94)90107-4
58. Wells KE, Roberts C, Daniels SM, Kearney RE, Cox CE. Psychological and rheumatic symptoms of women requesting silicone breast implants removal. Ann Plast Surg. 1995;34(6):572–77. https://doi.org/10.1097/00000637-199506000-00002 PMid:7661532
59. Shoaib BO, Patten BM. Human adjuvant disease: presentation as a multiple sclerosis-like syndrome. South Med J. 1996;89(2):179–88. https://doi.org/10.1097/00007611-199602000-00005 PMid:8578347
60. Kao CC, Rand RP, Holt CA, Pierce RH, Timmons JH, Wood DE. Internal mammary silicone lymphadenopathy mimicking recurrent breast cancer. Plast Reconstr Surg. 1997;99(1):225–29. https://doi.org/10.1097/00006534-199701000-00034 PMid:8982209
61. Thomas WO 3rd, Harper LL, Wong SW Michalski JP, Harris CN, Moore JT, Rodning CB. Explantation of silicone breast implants. Am Surg. 1997;63(5):421–29. PMid: 9128231
62. Meier LG, Barthel HR, Seidl C. Development of polyarthritis after insertion of silicone breast implants followed by remission after implant removal in 2 HLA-identical sisters bearing rheumatoid arthritis susceptibility genes. J Rheumatol. 1997;24(9):1838–841. PMid: 9292814
63. Melmed EP. A review of explantation in 240 symptomatic women: a description of explantation and capsulectomy with reconstruction using a periareolar technique. Plast Reconstr Surg. 1998;101(5):1364–373. https://doi.org/10.1097/00006534-199804010-00036 PMid:9529228
64. Contant CME, Swaak AJG, Obdeijn AIM, van der Holt B, Tjong Joe Wai R, van Geel AN, Eggermont AM. A prospective study on silicone breast implants and the silicone-related symptom complex. Clin Rheumatol. 2002;21(3):215–219. https://doi.org/10.1007/PL00011221 PMid:12111627
65. De Jong WH, Goldhoorn CA, Kallewaard M Re G, van Loveren H, Bijlsma JWJ, Schouten JSAG. Study to determine the presence of antipolymer antibodies in a group of Dutch women with a silicone breast implant. Clin Exp Rheumatol. 2002;20(2):151–60.
66. Vermeulen RC, Scholte HR. Rupture of silicone gel breast implants and symptoms of pain and fatigue. J Rheumatol. 2003;30(10):2263-267. PMid: 14528527
67. Kulmala I, McLaughlin JK, Pakkenen M, Lassila K, Hölmich LR, Lipworth L, Boice JD Jr, Raitanen J, Luoto R. Local complications after cosmetic breast implant surgery in Finland. Ann Plast Surg. 2004;53(5):413–19. https://doi.org/10.1097/01.sap.0000131275.62449.c8 PMid:15502454
68. Siggelkow W, Klosterhalfen B, Klinge U, Rath W, Faridi A. Analysis of local complications following explantation of silicone breast implants. Breast 2004;13(2):122–28. https://doi.org/10.1016/j.breast.2003.08.003 PMid:15019692
69. Spear S, Murphy DK, Slicton A, Walker PS, Inamed Silicone Breast Implant US Study Group. Inamed silicone breast implant core study results at 6 years. Plast Reconstr Surg. 2007 Suppl 1;120(7):8s–16s;discussion 17s–18s. https://doi.org/10.1097/01.prs.0000286580.93214.df PMid:18090808
70. Wolfram D, Oberreiter B, Mayerl C, Soelder E, Ulmer H, Piza-Katzer H, Wick G, Backovic A. Altered systemic serologic parameters in patients with silicone mammary implants. Immunol Lett. 2008;118(1):96–100. https://doi.org/10.1016/j.imlet.2008.03.007 PMid:18462807
71. Kappel RM, Prujin GJM. The monoblock hydrogel breast implant, experiences and ideas. Eur J Plast Surg. 2012;35(3):229–33. https://doi.org/10.1007/s00238-011-0591-0 PMid:22389555 PMCid:PMC3276769
72. Zambacos GJ, Molnar C, Mandrekas AD. Silicone lymphadenopathy after breast augmentation: case reports, review of the literature, and current thoughts. Aesthet Plast Surg. 2013;37(2):278–89. https://doi.org/10.1007/s00266-012-0025-9 PMid:23354761
73. Kappel RM, Cohen Tervaert JW, Pruijn GJM. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) due to silicone implant incompatibility syndrome in three sisters. Clin Exp Rheumatol. 2014;32(2):256–58. PMid: 24739521
74. Pavlov-Dolijanovic S, Vujasinovic Stupari N. Women with silicone breast implants and autoimmune inflammatory syndrome induced by adjuvants: description of three patients and a critical review of the literature. Rheumatol Int. 2017;37(8):1405–411. https://doi.org/10.1007/s00296-017-3731-4 PMid:28466365
75. Nunes E, Silva D, Grundler C, Spengler MGMT, Horimoto AMC, Machado MA, Frazão IC, Takita LC. Autoimmune syndrome induced by adjuvants (ASIA) after silicone breast augmentation surgery. Plast Reconstr Surg Glob Open. 2017;5(9):e1487. https://doi.org/10.1097/GOX.0000000000001487 PMid:29062654 PMCid:PMC5640359
76. Kaiser W, Biesenbach G, Stuby U, Grafinger P, Zazgornik J. Human adjuvant disease: remission of silicone induced autoimmune disease after explanation of breast augmentation. Ann Rheum Dis. 1990;49(11):937–38. https://doi.org/10.1136/ard.49.11.937 PMid:2256743 PMCid:PMC1004268
77. Wallace DJ, Basbug E, Schwartz E, Clements P, Metzger AL, Furst DE, Klinenberg JR. A comparison of systemic lupus erythematosus and scleroderma patients with and without silicone breast implants. J Clin Rheumatol. 1996;2(5):257–61. https://doi.org/10.1097/00124743-199610000-00005 PMid:19078080
78. Jara LJ, Medina G, Gomez-Banuelos E, Saavedra MA, Vera-Lastra O. Still’s disease, lupus-like syndrome, and silicone breast implants. A case of ASIA (Shoenfeld’s syndrome). Lupus. 2012;21(2):140–45. https://doi.org/10.1177/0961203311430970 PMid:22235044
79. Young VL, Nemecek JR, Schwartz BD, Phelan DL, Schorr MW. HLA typing in women with breast implants. Plast Reconstr Surg. 1995;96(7):1497–519. https://doi.org/10.1097/00006534-199512000-00001
80. O’Hanlon T, Koneru B, Bayat E, Love L, Targoff I, Malley J, Malley K, Miller F. Environmental Myositis Study Group. Immunogenetic differences between Caucasian women with and those without silicone implants in whom myositis develops. Arthritis Rheum. 2004;50(11):3646–650. https://doi.org/10.1002/art.20587 PMid:15529361
81. Smigoc Schweiger D, Mendez A, Kunilo Jamnik S, Bratanic N, Bratina N, Battelino T, Brecelj J, Vidan-Jeras B. Genetic risk for co-occurrence of type 1 diabetes and celiac disease is modified by HLA-C and killer immunoglobulin-like receptors. Tissue Antigens 2014;84(5):471–78. https://doi.org/10.1111/tan.12450 PMid:25329633