Breast augmentation is one of the most commonly performed operative procedures done by plastic surgeons. The American Society of Plastic Surgeons reports that in 2016 alone over 290 000 women had breast augmentation. 1 Due to their low-risk profile and well-published benefits on quality of life and body image, many millions of women currently have breast implants. 2 , 3 Surgeons who perform breast implant operations must discuss the risks and benefits of breast implants with all patients prior to the operation. The benefits of breast augmentation are generally accepted to be on quality of life, as until recently implants had never been considered life saving. Risks are always discussed with patients, and one rarer risk that is increasingly being discussed due to it being potentially fatal is the risk of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL). 4 The risk of BIA-ALCL is currently estimated to be between 1: 1000 and 1: 30 000 for patients with textured devices. 5 Gun violence is also a rare risk that women face, where according to the Centers for Disease Control in the United States, the rate of non-fatal firearm injuries was 4.94 per 100 000 women. 6 In Canada, Statistics Canada reports that there were 41 female homicides by firearm in 2015. 7 Interestingly, despite the millions of women with breast implants and the thousands of women affected by gun violence worldwide, ruptured implants after firearm injury is a rarely reported phenomenon in the literature, with only several case reports having been described previously. 8 , 9 Rosen et al were the first to show that breast implants can save a life with a case of a silicone implant stopping shotgun pellet. 10 Pannucci et al were the first to detail a report of a saline breast implant saving a patient’s life due to effects on bullet velocity. 11 Here, we report the first case in the literature of a 30-year-old female patient with silicone breast implants altering bullet trajectory and thereby saving her life. We also perform a literature review and provide treatment recommendations.

Case Presentation

A 30-year-old woman with a history of subpectoral silicone breast implants placed through a periareolar incision (450 mL smooth round) was seen by the trauma service for evaluation of penetrating chest trauma due to gunshot wound. The events of the evening are the subject of investigation. The patient reported walking down street and feeling heat and pain in her left chest, looking down and seeing blood, and taking herself into the local emergency department. The firearm was never recovered, and the shooter remains unknown. The patient was transferred to our trauma center in stable condition with no additional injuries. Clinical examination revealed a comfortable patient in no distress with a single entry wound in the superior pole of the left breast (Figure 1). The entry wound demonstrated thermal injury surrounding the bullet hole indicating a close proximity to the discharging firearm. A hard, subcutaneous, bullet-like mass was also palpable in the right lower anterior thoracic wall inferior to the right breast. Trauma radiographs (Figures 2 and 3) demonstrate the radio-opaque bullet in the right lateral thoracic wall, a fractured rib and gas in the left breast. These 3 pieces of evidence give clues to the bullets trajectory from left breast entrance to right thoracic wall resting place. A computed tomography (CT) scan was obtained which revealed areas of pulmonary contusion but no intrathoracic injury. In the left-sided breast implant, there were debris and air. There was also some air noted in the right breast implant. The patient was evaluated and cleared by our trauma service.

The surgical plan was to remove the implants via bilateral 5-cm incisions in the inframammary folds. This approach would provide maximal exposure of the implants, pockets, and any areas of injury. On the right side after dissecting through skin, we came upon a subcutaneous hematoma continuous with the breast capsule and tracking subcutaneously and inferolaterally toward the bullet. We used blunt dissection to follow the hematoma along this tunnel and retrieve the bullet which was handed off to police services and sent for forensics. The bullet was determined to be copper jacketed 0.40 caliber by the police services. Next, we performed bilateral capsulotomies that revealed hematoma surrounding both breast implants. The left implant was removed first. Upon examination of this implant, a bullet tract was found beginning directly underlying the entry wound in the right breast (Figure 4). This bullet tract tracked through the implant exiting from the medial aspect of it (Figure 5) and at this point penetrated the capsule and went through the parasternal tissues and presternal tissues, entering the right breast implant pocket. At this point, we removed the right breast implant, which was found to be in a completely flipped position, with the posterior aspect of the implant riding superficially. The area of damage on the right breast implant (Figure 6) was at the dome of the implant. The right breast capsule had a medial rent within the capsule, and there was tracking of the bullet tract along the chest wall tissues in the region of the intercostal muscles tracking posterior to the posterior capsule, and then exiting out in the inferolateral subcutaneous and breast tissue and then traversing to the right lateral chest wall region where we had previously located the bullet. We irrigated both pockets copiously with normal saline and betadine. We then closed the capsule and areas of damage in layers over drains. The entry wound was debrided conservatively and treated with daily wound care.

Postoperatively, ballistics analysis was performed using helically acquired 0.625-mm axial CT (Figures 7 –9) images with multiplanar and 3D reformats (Figures 10 and 11) in conjunction with clinical assessment of the surface wounds. Reconstructed maximal intensity projections images demonstrate the bullet exit from the left implant to the posterior aspect of the right implant. Also revealed is the bullet in the right thoracic wall. Based on trajectory of bullet entry clinically and evaluation radiologically, the only source of bullet deflection of the bullet is the left breast implant. This implant overlies the heart and intrathoracic cavity and therefore likely saved the women’s life. There is a contact wound to thoracic wall based on cavitation of soft tissues and charring of skin at the entry wound. Clinically, the tract was palpable and headed straight from anterior to posterior through the chest wall; however, on radiograph the bullet was not where expected. It had been deflected and was resting in the right anterior chest subcutaneously. The CT scan views show the bullet tract that correlates clinically with the level of breast implant. Examination of the axial CT shows the transverse tract that can clearly be seen crossing the midline. Consequently, a deflection must have occurred. The only source of deflection is the patient’s silicone implant. On clinical examination of the removed implant (Figure 5), an oblique tract through the implant lines up with both tracts across the chest wall. This indicates that deflection occurred within the implant likely at the point of the bullet pressing in on and rupturing the implant membrane. Both clinical and radiologic evidence support this theory of bullet deflection.