Risk of connective-tissue diseases and other disorders after breast implantation

Imaging spectrum of extracapsular silicone: correlation of US, MR imaging, mammographic, and histopathologic findings

The appearance of free silicone at mammography, ultrasonography (US), and magnetic resonance (MR) imaging is variable. The classic appearance is dense areas of opacity on mammograms, a highly echogenic pattern with or without hypoechoic masses on US images, and foci of low signal intensity on fat-suppressed T1-weighted MR images or high signal intensity on water-suppressed T2-weighted MR images. Mammography is a reliable, cost-effective, and readily available means of demonstrating silicone. The major disadvantage of US is that its accuracy depends on the capability of the operator to recognize the abnormality. Although MR imaging outperforms US or mammography in detection of implant rupture, it is not clear that MR imaging is superior in detection of free or residual silicone. The sequelae of noncontained silicone include granuloma formation, fibrosis, and migration. After extrusion from an implant, silicone migrates primarily to local sites, such as the ipsilateral chest wall and axillary nodes. Migration of silicone into the axilla can involve the brachial plexus, resulting in neuropathy. Silicone can also migrate into more distal regions, including the arm and subcutaneous tissues of the abdominal wall. Whatever the source, silicone in breast tissue interferes with the interpretation of mammographic findings.

Analysis of periprosthetic capsular tissue from women with silicone breast implants by magic-angle spinning NMR

The amount of silicone (polydimethylsiloxane [PDMS]) in capsular tissue surgically removed from women with breast implants was measured by using (29)Si and (1)H magic-angle spinning solid-state NMR spectroscopy. Twelve women having smooth surface silicone gel-filled implants, including a subject with "low-bleed" double-lumen implants, had detectable levels of PDMS ranging from 0. 05 to 9.8% silicon in wet tissue (w/w). No silicon-containing compounds other than PDMS were detected. No correlation was found between the amount of PDMS measured in the capsular tissue and the length of implantation time (Pearson correlation coefficient, r = 0. 22). The results showed no relationship between higher amounts of PDMS and capsular contracture (p = 0.74) or other symptoms (p = 0. 53). Magn Reson Med 42:436-441, 1999.

Sex differences in the epidemiology and outcomes of heart disease: population-based trends

We examined trends in heart disease (HD) mortality and the delivery of cardiac in Olmsted County, MN. Between 1979 and 1994, women experienced 51% of the total number of HD (ICD9 codes 390-398,402,404-429) deaths (3095). Age-adjusted HD mortality rate declined from 123 per 100,000 (95%CI 102, 144) in 1979 to 81 (67,95) in 1994. The risk ratio (RR) of HD death in 1994 compared to 1979 was 0.69 for women vs 0.53 for men (P = 0.06). This equates to a decline in HD mortality of 2.5%/y in women and 4.2%/y in men. The decline in HD mortality was less pronounced in older age groups (P < 0.001), reflecting a shift of the burden of HD towards women and the elderly. Compared to men, there was less use of stress tests among women, of cardiology visits after stress testing, and of cardiac procedures among women presenting to the emergency room with unstable angina. Further studies are needed to examine causal links between these trends.

Databases in MS research: pitfalls and promises

A database is an organized repository of data. Prospective collection of patient information in a database ('databasing') has been attempted by a few consortia of MS investigators over the past 10 years. This approach promises to facilitate epidemiologic research in MS and investigation of the natural history of the disease and how it might be altered by long-term treatments such as interferon beta. Databasing has some advantages over clinical trials in assessing new therapies, primarily because the focus is on long-term effectiveness in an entire population rather than short-term statistical significance in a highly selected population. The limitations of databasing and strategies to overcome these limitations are addressed.

Rheumatoid symptoms following breast cancer treatment: a controlled comparison

The prevalence of rheumatoid symptoms following breast cancer (BC) treatment was examined. Breast cancer patients (n = 111) who were a mean of 27.6 months postcompletion of BC treatment and 99 otherwise healthy women with benign breast problems (BBP) completed a self-report measure that assessed current joint pain, swelling, and stiffness, as well as measures of quality of life. Results supported a hypothesized link between BC and rheumatoid symptoms: (1) the BC group was more likely to report joint stiffness lasting more than 60 min following morning waking; (2) the prevalence of unilateral or bilateral joint point or swelling was greater (P < 0.10) in the BC group for four of 10 joint-symptom combinations examined, with differences between the BC and BBP groups in upper extremity joint swelling particularly pronounced; and (3) 41% of the BC group reported that current rheumatoid symptoms exceeded those experienced prior to diagnosis. Within the BC group, the data did not support postchemotherapy rheumatism as an explanation for rheumatoid symptoms. Rather, data suggested that symptoms were associated with surgical management of BC. Finally, among women in the BC group with the most severe joint pain, only a minority were receiving medication for these symptoms. Given the relationship between rheumatoid symptoms and quality of life, more systematic research examining potential contributing factors such as menopausal status, concurrent lymphedema, and weight gain is warranted.

Trends in heart disease deaths in Olmsted County, Minnesota, 1979-1994

BACKGROUND

Although age-adjusted heart disease mortality has declined since the 1960s, this decline may not have applied equally to all subgroups.

OBJECTIVE

To examine recent trends in heart disease mortality, specifically in women and in the elderly.

METHODS

Age- and sex-specific heart disease mortality (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 390-398, 402, 404-429) in Olmsted County, Minnesota, between 1979 and 1994 were studied.

RESULTS

The total number of heart disease deaths was 3095; 1578 (51%) occurred in women and 1984 (64%) in persons aged 75 years or older. Most heart disease deaths (77%) were coronary disease deaths (ICD-9-CM codes 410-414). Age-adjusted heart disease mortality rates declined from 123 per 100,000 (95% confidence interval [CI], 102-144/100,000) in 1979 to 81 per 100,000 (95% CI, 67-95/100,000) in 1994. Poisson regression analyses indicated that the trends differed according to sex and age. For women, the relative risk (RR) of heart disease death in 1994 compared with 1979 was 0.69 vs 0.53 for men (P = .06). This equates to a decline in heart disease mortality of 2.5% per year in women or 32% over the period and 4.2% per year in men or 47% over the period. The decline was less pronounced as age increased (P < .001). For 60-year-old women, the RR for 1994 compared with 1979 was 0.59, whereas for 80-year-old women, the RR for 1994 compared with 1979 was 0.76. For men, the RR for 1994 compared with 1979 was 0.60 for 80-year-old men vs 0.46 for 60-year-old men.

CONCLUSIONS

Between 1979 and 1994, in Olmsted County, the decline in heart disease mortality was of lesser magnitude in women and in the elderly, emphasizing the importance of age- and sex-specific trends to characterize time patterns in heart disease deaths to target preventive measures.

Quantitative detection of silicone in skin by means of electron spectroscopy for chemical analysis (ESCA)

BACKGROUND

Evaluation of silicone-induced morbidity in skin has been hampered by the difficulty of detecting silicone in tissue because conventional methods are nonquantitative and insensitive.

OBJECTIVE

We attempted to determine whether silicone could be identified and quantitated in skin by means of electron spectroscopy for chemical analysis (ESCA).

METHODS

Skin biopsy specimens were obtained from the nose, chin, malar region, and inner arm of a patient who had received injections of silicone gel in his nose and chin. Frozen sections were dried under vacuum and examined by means of ESCA. Contiguous sections were examined by light microscopy.

RESULTS

The surface concentrations of silicone were as follows: chin, 20.6% +/- 3.6%; nose, 19.0%; malar region, 2.6% +/- 1.6%; inner arm, 0.0% +/- 0.0%. Light microscopy revealed homogeneous "globules" consistent with silicone in the chin and nose sections only; the malar region and inner arm sections showed no evidence of silicone.

CONCLUSION

ESCA can be used to detect silicone in skin in a specific, highly sensitive, and quantitative manner. This is the first report of quantification of silicone in skin by means of ESCA.

Silicone breast implants: epidemiological evidence of sequelae

Skeptics may certainly find fault with the third study (the only one to report a significant finding) or with all or any of the statistics described. But few could argue, after examining these studies, that the relative risk for a known and well-defined connective tissue disease is likely greater than 2. Another possibility has been raised, one that calls to mind other difficult-to-study syndromes linked to exposures. In a study addressing Gulf War syndrome, signs and symptoms were often mentioned that proved difficult to describe systematically and therefore difficult to study. What if a suspected silicone exposure syndrome were so mild and transient that it did not warrant a physician visit (as in the Mayo Clinic study). receive a diagnosis (as in the Nurses' Health Study), or require admission to a hospital (as in the Danish and Swedish studies)? And if such a disorder were, in fact, mild and transient, should it merit the concern that has been shown and the compensation that has been awarded in the silicone implant litigation cases to date? We suggest that neither a well-described disorder with a relative risk of less than 2 nor a transient and mild disorder seems compatible with the number of litigants over silicone implants and the apparent seriousness of their complaints. Some 400,000 women joined in one class action suit for damages, and 170,000 joined in another. Even if there had been 2 million implants undertaken in the United States over the 3 decades in which implant surgery has been practiced (and some estimates put the number closer to 1 million), there is no conceivable way in which a relative risk of 2 or 3 (or even 4) for each of the rare syndromes reported could explain so many exposed women being affected. At most, 2200 out of 2 million unexposed women would be expected to have had any one of the listed forms of connective tissue disorders, most of which are very rare. Doubling the risk among the exposed population yields 4400, and increasing the risk 20-fold produces 44,000. At this rate, there is no way in which 400,000 litigants could all be affected. Extensions of the already-completed studies are ongoing, at least 1 of which is government funded; apparently it is thought in the United States (though not in the United Kingdom or elsewhere) that there is still room for reasonable doubt as to the supposed causal relationships. But if epidemiology is invoked in the interest of public health to prevent the many uses of silicone, the weight of the evidence abstracted here supports the inference that silicone breast implants have not been proved guilty of causing connective tissue disorders.

The immunopathology of siliconosis. History, clinical presentation, and relation to silicosis and the chemistry of silicon and silicone

Recent evidence confirms the fundamental involvement of the human immune system in the reaction to implantation of silicone-based medical devices. An as yet-to-be particularized epitope of many complex substances sharing siloxane structures is presented through the MHC-II apparatus with development and retention of T cell memory. This memory can be tested for in practical terms using one or more forms of silica, which links the immuno-histopathology and autoimmune attributes of "silicosis" with those of "siliconosis." The lesions of siliconosis are typical of those for persistent antigens and delayed, cell mediated hypersensitivity. The basic descriptive pathology of the reaction to silicone has been known since soon after introduction of silicones in medical procedures, with the exception of some details related to the more recent discoveries on the role of cytokines in the immunopathic process. The clinical consequences of siliconosis are common and can be severe in some individuals implanted with silicone devices.

Association of silicone breast implants with immunologic abnormalities: a prospective study

PURPOSE

To study the possible association of silicone-breast-implant exposure and immunologic abnormalities within the Nurses' Health Study, an ongoing prospective cohort study of women.

SUBJECTS AND METHODS

From this cohort, we randomly selected 200 women who had been exposed to silicone breast implants and who had never reported connective tissue diseases during 14 years of follow-up, and 500 age-matched, nonexposed women, including 100 with definite connective tissue diseases validated by medical record review, 100 with at least one symptom of a connective tissue disease, 100 with diabetes, and 200 healthy controls. Assays for antinuclear antibodies (ANA), including anti-dsDNA, anti-ssDNA, anti-Sm/RNP/Ro/La, and anti-Scl-70, rheumatoid factor, immunoglobulins, serum complement, and C-reactive protein level, and anticardiolipin, antithyroglobulin, antithyroid microsomal, and antisilicone antibodies were performed by standard techniques in blood samples collected in 1989 or 1990 before collection of silicone-breast-implant exposure data in 1992.

RESULTS

ANA was positive (> or = 1:40) in 14% of women with silicone breast implants compared with 20% of healthy women (P = 0.11). Rheumatoid factor was positive (> or = 1:40) in 5% of women with silicone breast implants and 2% of healthy women (P = 0.16). Women with silicone breast implants had a significantly higher frequency of anti-ssDNA antibodies than healthy women (41% and 29%, P = 0.012). Duration of implant was associated with a higher frequency of anti-ssDNA antibodies (P = 0.03) but not with ANA or rheumatoid factor. No other significant differences in the frequencies of autoantibodies were observed in silicone breast implant-exposed women. Antisilicone antibodies were not found in any sample.

CONCLUSION

We found no increased frequency of any immunologic abnormalities in women exposed to silicone breast implants, except for anti-ssDNA, which has unknown clinical relevance.

The socially constructed breast: breast implants and the medical construction of need

When silicone gel breast implants became the subject of a public health controversy in the early 1990s, the most pressing concern was safety. This paper looks at another, less publicized issue: the need for implants. Using a symbolic interactionist approach, the author explores the social construction of the need for implants by tracing the history of the 3 surgical procedures for which implants were used. Stakeholders in this history constructed need as legitimized individual desire, the form of which shifted with changes in the technological and social context.

Silicon and matrix macromolecules: new research opportunities for old diseases from analysis of potential mechanisms of breast implant toxicity

An understanding of the normal and essential integration of the element silicon in biosystems, as well as knowledge of its fundamental chemistry, are crucial to understanding its role in health and disease. Modern organosilicon chemistry, based in part on the artificial silicon-carbon bond, coincided with the emergence of the biomaterials and bioengineering fields fifty years ago, and was thought to be a fortunate coincidence according to conventional wisdom that high-molecular-weight polymeric siloxanes were chemically and biologically inert. These concepts have been challenged by reports of silicone migration and degradation following insertion of gel-filled breast implants, claims of a novel systemic illness appearing in many breast implant recipients, and investigations implicating varied and permeating immunotoxic mechanisms of disease causation by breast devices. The present study develops additional potential pathogenetic ideas based on alterations of cell biochemistry by silicon-containing compounds, and offers correlation of the patients' diverse clinical features with plausable disruption of basic biological processes. This in turn raises new questions concerning everyday environmental exposure, has broad implications for multiple other diseases, can provide alternative directions for future investigative research, and may contribute to the ongoing redefinition of immune dysfunction and inflammation.

The non-specific binding of immunoglobulins to silicone implant materials: the lack of a detectable silicone specific antibody

Recent studies have suggested that anti-silicone antibodies develop in patients implanted with silicone materials. The majority of these studies have utilized enzyme-linked immunosorbent assay (ELISA) methodology with a silicone material substrate as a means to detect the presence of the anti-silicone antibody. The current studies were undertaken to determine whether the binding of IgG to a silicone substrate was consistent with an antigen-specific antibody interaction or the result of non-specific hydrophobic interactions. While significant differences were detected in serum from silicone antibody "positive" and "negative" patients when the ELISA was conducted using a phosphate buffered saline (PBS)-0.05% Tween 20 (Tween) blocking system, the difference in the responses was attenuated when protein blocking systems were used or when incubation times were decreased. Furthermore, ELISA studies, using purified mouse and human IgG, demonstrated a concentration-dependent binding of IgG to silicone elastomer substrate which was also attenuated when a protein blocking system was used in lieu of Tween. In controlled animals studies in which female B6C3F1 mice were implanted with silicone gel or silicone elastomer for 180 days, no difference was observed between the implanted animals and the PBS control animals with respect to binding of IgG to the silicone substrate. Similar studies in female Fischer 344 rats implanted with silicone gel for 84 days also failed to demonstrate the presence of anti-silicone antibody. Collectively, the results suggest that the binding of IgG to silicone implant materials is non-specific in nature, consistent with the well-recognized interactions between hydrophobic molecules (IgGs) and hydrophobic surfaces (silicones) in an aqueous-based system.

Current Scientific Considerations in Regard to Defining a “Silicone Syndrome”/Disease and the Formation of Silica from Silicone

Whether the constellation of various symptoms reported in various case-study reports on some patients who have had augmentation mammoplasty with silicone implants reflects a distinct, novel “silicone syndrome”or disease is important to settingproper endpoints for the epidemiological study of this patient population. To date, epidemiology studies on breast implant patients have focused on end-points which are typical of connective tissue disease, rheumatoid disease, and/ or autoimmune disorders. The consensus at this time, as was recently stated in a paper authored by Food and Drug Administration (FDA) personnel, is that the weight of the evidence from existing epidemiology studies is that silicone breast implants do not appreciably, if at all, increase the risk of these types of diseases. Critics of the epidemiology database have countered that had the analysis of association in these studies been done for a “silicone syndrome,” as opposed to the disease types which were analyzed, an association between silicone breast implantation and increased risk of “silicone syndrome” would have been observed. In the present analysis, this question is approached from two directions: First, the available single or multi-patient case reports available in the open literature were evaluated. The objective was to define those symptoms/ complaints that were reported in all studies or in at least 50% of the patients reported and to assign frequency distributions to individual symptoms or complaints reported in breast implant patients presenting for various complaints. By definition, if a “silicone syndrome” exists, then it can only be characterized by those symptoms or complaints which appear with regular frequency in patients so afflicted. Second, the symptoms or complaints which were used as criteria in the existing epidemiology studies were correlated with their frequency of occurrence among single or multi-patient case-reported breast implant patients. The working hypothesis in this present study is that if the number of “silicone syndrome” symptoms or complaints that also are symptoms of the existing epidemiology endpoints is large, then a distinct “silicone syndrome” is not likely to exist, and it can be concluded that existing epidemiology studies have adequately addressed the relevant issues. Also, to the extent that the frequency of symptom occurrence in “silicone syndrome” is similar to the distribution seen for known connective tissue, rheumatoid, and/ or autoimmune diseases, this will then add to the weight of evidence that no distinct “silicone syndrome” needs be postulated. Conversely, if a different set of symptoms or complaints occurs in silicone breast-implanted patients than is seen in patients with connective tissue diseases, this will argue that a distinct syndrome may exist. In the present study, the more recent suggestion that silicone may be broken down to silica in the body, and evidence for and against this suggestion are also discussed. The present analysis does not support the contention that a distinct “silicone syndrome” exists, but does support the contention that the disease endpoints used in existing epidemiology studies are adequate for examining the patient population. Also, consideration of the chemistry of silicone and its potential hydrolysis or oxidative cleavage indicates that if such reactions occur in the body at any significant rate, the product will be silicic acid, a normal and necessary constituent of the body, and not silica (i.e., silicon dioxide).

Silicone gel enhances the development of autoimmune disease in New Zealand black mice but fails to induce it in BALB/cAnPt mice

Anecdotal evidence links silicone gel breast implants with the development of autoimmune connective tissue disease in women. To investigate whether silicone gel is capable of directly inducing and/or enhancing the development of autoimmune disease, female BALB/cAnPt (BALB/c) and New Zealand Black (NZB) mice were injected subcutaneously with silicone gel, pristane, a nonmetabolizable substance that can cause plasmacytomas in BALB/c and NZB mice, or saline and monitored for the development of glomerulonephritis and autoantibody production. NZB, but not BALB/c, mice spontaneously develop autoantibodies and an autoimmune hemolytic anemia by 12 months of age. Over a period of 10 months, biweekly screening for proteinuria revealed increases in urinary protein in NZB mice that received multiple injections of either silicone gel or pristane. In contrast, urinary protein was unaffected in identically treated BALB/c mice. Although, silicone gel had no effect on serum titers of antierythrocyte antibodies in NZB mice, the hematocrits were significantly decreased. Moreover, silicone gel both increased the concentration of IgM anti-type I collagen antibodies and skewed the immunofluorescent staining pattern of serum autoantibodies on HEp-2 cells. In contrast, silicone gel failed to induce the production of anti-erythrocyte or antinuclear antibodies in BALB/c mice and induced only slight increases in IgG anti-type I collagen antibodies. These results suggest that silicone gel can exacerbate the development of autoimmune disease in autoimmune NZB mice, but fails to induce disease in normal BALB/c mice. This is consistent with several epidemiological studies failing to demonstrate an increase in the incidence of autoimmune disease in women with breast implants. However, because silicone gel was able to exacerbate autoimmune disease in NZB mice, it may play a similar role in the development of autoimmune disease in a small percentage of women who are genetically susceptible to such diseases.

Risk of progressive sensorineural hearing loss and Meniere's disease after breast implantation

OBJECTIVE

The association of various immunologic abnormalities with the presence of silicone breast implants in women has been described. In addition, some studies report a correlation between autoimmune disorders and silicone breast implants, whereas other studies indicate no difference in the incidence of disease between women with silicone breast implants and control groups. Until recently, no reports had attempted to identify an association between silicone breast implants and hearing impairment. A recent study suggested a possible correlation between prior silicone breast implants and the development of various forms of hearing loss. This study tried to determine whether such a correlation could be duplicated.

METHODS

To determine whether such a correlation could be established, we studied 119 female patients with either Meniere's disease or progressive sensorineural hearing loss and 100 age-matched healthy controls. Subjects completed questionnaires that provided various types of information, including the presence or absence of previous silicone breast implants. Serum from all 119 patients with Meniere's disease and progressive sensorineural hearing loss had been subjected to previous Western blot testing for reactivity to a 68 kD protein associated with certain forms of autoimmune hearing loss.

RESULTS

Results indicated no significant difference in frequency of prior silicone breast implants among the patients with Meniere's disease, patients with sensorineural hearing loss, or controls. The presence or absence of the 68 kD protein also was not significantly relevant to the frequency of silicone breast implants.

CONCLUSIONS

Our data did not show evidence of a significant relationship between the presence of silicone breast implants and later development of Meniere's disease, progressive sensorineural hearing loss, or positive 68 kD serum.

Silicon analysis of breast and capsular tissue from patients with saline or silicone gel breast implants: II. Correlation with connective-tissue disease

The silicone breast implant controversy rages on. Recent work has demonstrated that normal or baseline breast tissue silicon levels in women who had had no prior exposure to any type of breast implant may be as high as 446 microg/gm of tissue. These data ranged from 4 to 446 microg/gm of tissue, with a median of 27.0 microg/gm of tissue. In addition, numerous other epidemiologic and rheumatologic studies have demonstrated no association between silicone breast implants and any connective-tissue diseases. Despite these reports, the use of silicone implants remains restricted. The present study measured breast and capsular tissue silicon levels from 23 breasts in 14 patients with saline implants, and from 42 breasts in 29 patients with silicone implants. No patient in the saline implant group presented with signs or symptoms of connective-tissue disease. Patients with silicone implants, however, were divided into three groups based on the presence or absence of signs or symptoms of connective-tissue disease: group I, no symptoms or signs; group II, + symptoms, no signs; and group III, + symptoms, + signs. Six patients in group III were diagnosed with a specific connective-tissue disease, including systemic lupus erythematosus, rheumatoid arthritis, or scleroderma. The most common indications for implant removal or exchange were capsular contracture and implant rupture, although 41 percent of patients with silicone implants expressed media-related concern over the implant issue. The most common symptoms described by patients in groups II and III were joint pain and stiffness, arm pain and numbness, and fatigue. In all groups, capsular tissue silicon levels were significantly greater than breast tissue levels. This finding may indicate that the capsule serves as a barrier to the distribution of silicone from the implant into adjacent breast tissue. Although breast tissue silicon levels in patients with silicone implants were not significantly greater than those in patients with saline implants (p = 0.48), capsular tissue levels in patients with silicone implants were, indeed, significantly greater than those in patients with saline implants (p < 0.001). However, no statistically significant differences in tissue silicon levels were observed with relation to the presence or absence of connective-tissue disease signs or symptoms in patients with silicone implants (groups I to III). Therefore, these data strengthen the conclusion that there is no association between tissue silicon levels and connective-tissue disease.

Silicone Breast Implants and Human Rheumatic Disease is there a Connection?

Silicone has been used with apparent safety in implanted medical devices since 1952. Despite the long history of clinical use of this material, concern has been expressed in some quarters about systemic disease etiologically related to silicone implantation. The first report concerning this phenomenon was in 1964 when Miyoshi et al. published 2 cases in the Japanese literature of patients with vague clinical syndromes occurring after the injection of probably adulterated silicone material into breasts for purposes of augmentation. Since that time there have been numerous case reports and series (<400 patients) reporting a variety of rheumatic diseases occurring after the implantation of silicone gel prosthesis. Approximately 20 epidemiological studies have been published investigating the possible relationship between silicone breast implants and rheumatic disease. Several studies have found very weak, but statistically significant, effects showing either a negative or positive association with connective disease syndrome. However, in the aggregate the existing epidemiology strongly supports the lack of association between the presence of silicone gel breast implants and any detectable risk of or protection from systemic disease. This presentation will review the existing clinical and epidemiologic data relating to the use of silicone breast implants.

The exploitation of autoimmune disease: breast implant litigation and its dire implications for women's health

Men, women, and children are subject to a number of disease conditions that have been documented over many centuries. Among the most recently described and the least understood of these conditions are autoimmune diseases. As we unfortunately have seen in recent years, the obscure nature of autoimmune disorders has allowed scientific distortion by individuals who stand to profit by claiming a cause-and-effect relationship among some types of autoimmune conditions and a number of medical products, resulting in a rapidly expanding use of "junk science" in our courtrooms. Attempts have been made recently to implicate a number of environmental factors in the development of autoimmune disorders, most notably silicone gel-filled breast implants. The controversies surrounding these alleged relationships have proved to be among the most contentious, costly, and dangerous events ever to occur in women's health care.

Accuracy of self-report of breast implants

The accuracy of self-report of breast implants was analyzed using a random sample of 130 of 850 available records from a retrospective cohort study of women who underwent cosmetic surgical procedures from 1963 to 1985. Women with breast implants correctly reported having the surgery 89.3 percent of the time, whereas women having other cosmetic surgical procedures correctly reported having the index surgery 92.7 percent of the time. Younger age at surgery, younger age at survey response, and higher level of education were significantly associated with higher sensitivity of self-report. Despite high validity of reporting of surgery, accuracy of self-report of time of surgery was low, with only 9 percent of women who reported their breast implant surgery providing the correct month and year of surgery. These results are in contrast with a previous validity study.

Aesthetic management of the breast following explantation: evaluation and mastopexy options

This retrospective study reviews 720 patients referred for evaluation of their silicone gel-filled breast implants from December of 1992 to January of 1996. Of the 720 patients evaluated, 282 (39.2 percent) subsequently underwent explantation, and 59 of these patients (20.9 percent) had a breast contouring procedure performed at the time of explantation. Our definition of explantation is the operative removal of the implant as well as the implant capsule. The overall complication rate for explantation was 5 out of 282 patients (1.8 percent), whereas the rate of complication among the patients who underwent simultaneous breast contouring was 2 out of 59 patients (3.4 percent). This article presents the management of the breast following explantation, implant removal, and capsulectomy. We review both the preoperative assessment of patients seeking explantation and our technique of explantation. Additionally, we address the importance of preoperative breast ptosis in technique selection and have developed a practical clinical algorithm for guiding simultaneous explantation and breast contouring. We also identify those patients who should undergo delayed breast contouring due to associated risk factors (smoking, need for > 4 cm of nipple movement, and paucity of breast parenchyma).

Silicone breast implants and systemic rheumatic disease. Some smoke but little fire to date

For over 20 years silicone breast implants have been used for cosmetic and breast reconstruction purposes. They have been recently banned by the American Food and Drug Administration other than for reconstruction or in the setting of a study. Complications of rupture, leaking, bleeding, capsular thickening and contracture are acknowledged but the potential of silicone implants in causing classic rheumatic diseases or a new syndrome has caused much controversy; there are millions of dollars at stake in legal suits. The biological plausibility of silicone breast implants causing disease is not without merit. The epidemiological evidence linking the two are reviewed. There is considerable concern as to whether there will ever be a definitive study of the question.

Adjuvancy effect of different types of silicone gel

Women with silicone gel-filled breast implants (SBIs) are likely to be at a slightly higher risk of developing an autoimmune-like syndrome. This risk, although small, may be associated with the immunological adjuvancy property of the silicone gel. However, not all silicone gels are chemically formulated exactly the same and their adjuvancy behavior may vary. This study compared, in rats, the adjuvant effect of three different lots of silicone gel using ovalbumin (OVA) as the test antigen. Test bleeds were taken at 21, 48, 62, and 84 days post immunization and the rat sera were analyzed for anti-OVA antibodies by enzyme linked immunosorbent assay (ELISA). A delayed type hypersensitivity (DTH) test was performed on all the treated rats beginning at 14 post-immunization days. The results showed that silicone gel #3 (McGhan lot #S0400488) produced the highest mean anti-OVA antibody titer followed by silicone gel #1 (DC lot #HH019581) and silicone gel #2 (McGhan lot #DP9339). The DTH results showed that rats treated with silicone gel #1 and #3 had a clear positive response, whereas silicone gel #2 caused only a minimal response. These results demonstrate the immunological adjuvancy difference among three types of silicone gel. The chemical composition of each of these silicone gels, that would help explain these results, is yet to be determined.

Life span of silicone gel-filled mammary prostheses

The discussion on possible side effects of implanted silicone has resulted in a growing number of patients inquiring whether or not their mammary prostheses are intact and when failure of the prostheses is to be expected. Between November 1988 and May 1995, 182 patients had their silicone mammary prostheses replaced, repositioned, or removed one to three times. Capsular contraction, dislocation, pain paresthesia, and/or suspected rupture were common indications for surgery. To try and be able to provide an indication as to the correlation of implant age and integrity, we recorded the status of all 426 prostheses observed during secondary surgery. In this selected group of patients, approximately 50 percent of the mammary prostheses with an implant age of 7 to 10 years showed gel bleed or rupture. Applying the survival Kaplan-Meier curve, 50 percent of implants may be expected to bleed or be ruptured at the age of 15 years. Rupture was observed more frequently than gel bleed. It seems that there is no chronologic relation between gel bleed and rupture.

Rupture of silicone-gel breast implants: causes, sequelae, and diagnosis

Silicone-gel-filled breast implants have been widely used for breast augmentation and reconstruction after mastectomy. The rate of implant rupture and its sequelae are not known. We review the frequency, causes, sequelae, and detection of implant rupture. Materials testing of removed implants provides evidence that as implants age in vivo, they weaken and may rupture. Sequelae of rupture include migration of gel accompanied by inflammation and silicone granuloma formation. The role of free silicone gel in relation to idiopathic or atypical connective tissue disease is not clear. Magnetic resonance imaging is substantially more sensitive in the detection of rupture than is mammography or ultrasonography.

From cadavers to implants: silicon tissue assays of medical devices

A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels in patients with saline implants or tissue expanders. We have compared these levels with tissue samples from a variety of patients with and without medicinal silicone devices from both the northeast and southwest United States over a 4-year period. All specimens were harvested by a "no touch" technique, non-formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was used to obtain the tissue silicon measurements. Silicon tissue values in cadaveric tissue (n = 20 cadavers; n = 120 specimens) averaged 2.2 mcg/gm of tissue with undetectable silicon levels in over 50 percent of the specimens (range 0 to 45 mcg/gm; median = 0). Silicon levels surrounding port-a-catheter devices (n = 15 patients; n = 15 specimens) averaged 8.04 mcg/gm of tissue (range 0 to 41 mcg/gm; median = 0). Tissue levels in the capsules surrounding saline (n = 10 patients; n = 22 specimens) and silicone implants (n = 31 patients; n = 58 specimens) averaged 292 mcg/gm (range 0 to 1380 mcg/gm; median = 110) and 1439 mcg/gm (range 0 to 9800 mcg/gm, median = 490), respectively. Tissue levels, however, from distant sites (n = 22 specimens) in these same patients were equivalent to the cadaveric nonaugmented values (average = 3.2 mcg/gm; range 0 to 5.8 mcg/gm; median = 2.7). The results imply that there is a continuum of exposure to silicone medical devices based on the mechanical properties of silicone. The data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicone exposure a person has over his or her lifetime. It is our hope that these levels will serve as a baseline for our continuing knowledge of implantable medical devices.

Body image and psychological sequelae of silicone breast explantation: preliminary findings

Twenty-two breast explantation (implant removal) and 20 cholecystectomy patients were assessed preoperatively and postoperatively and compared with 20 nonsurgical control subjects on several body-image measures, depression, self-esteem, and self-reported health status. Explantation patients had higher breast anxiety and upper torso dissatisfaction than either control group and levels were unaffected by implant removal. The discrepancy between self-rated ideal and current breast size increased substantially after implant removal for the explantation group, but did not change for controls. Overall appearance satisfaction level and positive appearance-related cognitions decreased as a function of surgery for explantation patients, but remained unchanged in cholecystectomy and nonsurgical controls. Depression levels were elevated in explantation patients and did not change as a function of surgery; self-reported health status level improved for the explantation group, but levels still remained below those of both control groups after explantation. Therapeutic indications for the elevated depression levels and unique body-image issues that patients undergoing explantation experience are discussed.

Breast implants and cancer

BACKGROUND

Although silicone breast implants have been linked to various short-term complications, less is known about their long-range effects. Most attention has focused on connective tissue disorders, but the range of immunologic disturbances observed in women with implants suggests that consideration also be given to other chronic diseases, including cancer. The greatest attention has focused on breast cancer, given clinical reports suggesting an association and observations that mammographic visualization is deterred by implants. Findings from epidemiologic studies, however, actually suggest that breast cancer risk might be reduced among women with implants, although the biologic mechanism remains undefined. In addition, most studies do not suggest that women with breast implants have more advanced breast cancer at diagnosis or a worse prognosis than those without implants. The majority of studies have focused on women who received implants for cosmetic reasons, with little previous investigation of women who received implants for breast reconstruction following cancer surgery. In terms of other cancers, animal as well as clinical data suggest potential risks of sarcomas and hematologic cancers, including multiple myeloma. The risk of these cancers has not yet been adequately addressed by epidemiologic studies, although several ongoing studies should provide insights. It will be important for studies to consider effects of other lifestyle factors as well as to analyze relationships according to duration of implantation, a demonstrated determinant of implant deterioration. In addition, consideration should be given to type of implant, including implants with polyurethane foam covers, which can leak toluene diamine, a demonstrated carcinogen in animals.

Carcinogenic potential of silicone breast implants: a Connecticut statewide study

To clarify the carcinogenic potential of silicone breast implants, 680 implant procedures performed on women in Connecticut with no prior history of cancer were correlated with the subsequent development of primary breast and nonbreast cancers. Neoplastic events after the placement of silicone breast implants during the 13-year interval from October 1, 1980, through September 30, 1993, were quantified using a retrospective, linked-registry method. ICD-9-CM discharge codes contained in the Uni formed Hospital Discharge Data Sets (UHDDS) from 34 hospitals across Connecticut were linked to procedure codes for unilateral and bilateral implants, and to medical histories for new malignancies after the implant procedures. Data were cross-linked to the Connecticut Tumor Registry to confirm the clinical history of each cancer. The rates of breast and nonbreast cancers in patients with silicone breast implants were compared with those of a control population drawn from the UHDDS of 1022 women undergoing sterilization by tubal ligation between 1981 to 1985. Ages (mean +/- SD) were similar in the implant group (34 +/- 10 years) and in the sterilization group (32 +/- 6 years). The mean follow-up in the implant group (4.6 years) was also similar to that of the control group (5.4 years). Compared with the control group, the implant group demonstrated lower rates of breast cancer (0.59 versus 0.88 percent, p = 0.35) and nonbreast cancer (0.59 versus 2.7 percent, p = 0.001). Correspondingly, the implant group had a lower relative risk of breast cancer (relative risk = 0.67, 95 percent, confidence interval = 0.20 to 2.17) and nonbreast cancer (relative risk = 0.21, 95 percent, confidence interval = 0.07 to 0.60). Based on these data, it was concluded that silicone breast implants are not carcinogenic, because they are not associated with increased rates of either breast or nonbreast cancers. The validity and threats to the conclusions are discussed, and the results are placed into context with similar findings from other studies.

Cellular immune reactivities in women with silicone breast implants: a preliminary investigation

BACKGROUND

Surgical implantation of silicone breast prostheses has been conducted and considered safe for over 30 years. Some implant recipients, however, complain of a group of symptoms similar to those observed in connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, or polymyositis. To date, immunologic sequelae have not been confirmed and remain controversial.

OBJECTIVE

To examine an autoimmune-like basis for the "silicone associated disease" reported by some women with silicone breast prostheses.

METHODS

Proliferative responses of peripheral blood mononuclear cells against a panel of control and connective tissue proteins and to compounds common to silicone prostheses were measured in 26 women who received silicone breast implants (with implants in place an average of 166.4 [standard deviation (SD) 58.3] months), and 23 age-matched and sex-matched healthy controls.

RESULTS

The frequency and intensity of cellular immune responses against collagen I, collagen III, fibrinogen, and fibronectin were significantly increased in silicone breast implant recipients versus controls. In implant subjects, the highest frequency of immune reactivity was directed against collagen I (11/26, 42%) with collagen III being the most immunostimulatory self-antigen with a mean stimulation index (SI) of 8.2 [95% confidence interval (95% CI) 3.2]. In addition, 10/26 (39%) of the implant recipients responded to more than one of the connective tissue antigens versus 0/23 (0%, P = .0007) healthy controls. Immunologic reactivities to other antigens, including silicone-based compounds, were remarkably similar.

CONCLUSIONS

The identification of self-reactivity towards these connective tissue antigens may provide important information for attempts at associating silicone breast implants with disease.

Lessons from litigation over silicone breast implants: a call for activism by scientists

In ongoing litigation to determine whether silicone breast implants cause autoimmune disease, the question of what constitutes good science is being addressed by courts, and the answer has implications for approximately $50 billion in settlements. A federal court recently used neutral scientific advisers in excluding the admissibility of the “expert” opinion that implants cause systemic disease. The lesson from this litigation paradigm is that scientists should actively ensure that neutral, reliable scientific expertise is available to the court.

The influence of silicone implantation on type II collagen-induced arthritis in mice

OBJECTIVE

To determine whether silicone implantation exacerbates autoimmune disease in a murine experimental model of arthritis.

METHODS

DBA/1 mice were implanted with silicone in the form of an elastomer, gel, or oil, and immunized with type II collagen. The influence of silicone implantation on collagen-induced arthritis and the immune response to type II collagen were determined by comparison against control mice receiving sham implantation. Adjuvant effects of silicone implantation were examined by measuring cytokine levels in implanted animals and assessing autoantibodies against proteins extracted from recovered silicone implants.

RESULTS

No adverse influence of silicone implantation on the clinical aspects of collagen-induced arthritis was observed. Further, polydimethylsiloxane silicone oil failed to serve as an adjuvant in the immune or arthritogenic response to type II collagen in mice. Cytokine analysis indicated that tumor necrosis factor alpha levels were lower and interleukin-2 levels were higher in silicone-implanted mice. The development of arthritis increased protein binding to implanted elastomers and gel, and autoantibodies against silicone-bound proteins were present in sera from arthritic mice and absent in sera from nonarthritic mice.

CONCLUSION

The data suggest that silicone implantation may result in autoantibodies against silicone-bound proteins, and the presence of arthritis may either provoke or increase the level of such autoantibodies. However, silicone implantation did not increase the incidence or severity of disease compared with sham-operated controls. Thus, it appears that autoantibodies against silicone-bound proteins may not have pathologic significance in this experimental model of arthritis.

Silicone breast implants: pathology

Questions as to the bioreactivity of silicone breast implants (SBIs) have recently been intensely scrutinized, most notably by the media and legal system. Pathologists must be aware of the controversy and treat each SBI and associated tissue as a potential lawsuit. Grossly, silicone is a clear, viscous substance that may be observed either within or extruding from a silastic bag. By light microscopy, silicone is a nonstainable, nonpolarizable, refractile substance. Thicker sections, especially when viewed by non-Köhler illumination, phase-contrast, and darkfield microscopy will enhance visualization. Ultrastructurally, silicone is an electron-dense, amorphous substance often located within phagocytic vacuoles or extracellularly within the stroma. Correlating electron probe microanalysis allows for reliable identification. In most cases, a fibrous capsule surrounds the SBI, with the interface lining varying from a virtually acellular to a synovial-like lining composed of phagocytic and secretory cells. Silicone can often be identified within the fibrous capsule and also in distant tissues biopsied for suspected autoimmune disorders, such as synovium, skin, and lymph nodes, often without ultrastructural evidence of cytologic effects. This study has demonstrated that silicone accumulates at distant tissue sites due to preexisting inflammation acting as a stimulus. Thus, silicone is not a primary inducer of inflammatory disease processes. These findings are supported by various large epidemiologic studies.

Local Management of Primary Breast Cancer

BACKGROUND: Various options are available for the local control of cancer in the breast -- mastectomy, conservation therapy, and mastectomy with reconstruction. METHODS: To evaluate the benefits and drawbacks of the available management options, the authors combine their extensive experience with a review of the literature on outcomes from these approaches. RESULTS: Conservation therapy provides survival outcomes similar to those from mastectomy. Differences in local recurrence rates can be minimized by close adherence to guidelines for patient selection, operative approach, and radiation technique. CONCLUSIONS: The role of the physician in selecting a local therapy for breast cancer has changed from one of informing the patient of the treatment to assessing the presence of medical contraindications to any of the treatments, educating the patients on each treatment approach, providing access to multidisciplinary consultation, and allowing the patient to choose an appropriate treatment approach.

A review of the possible health implications of silicone breast implants

BACKGROUND

The silicone gel breast implant has long been an important method of reconstruction for the mastectomy patient. Because of concerns about possible health implications of the implant, the Food and Drug Administration banned its use for augmentation mammaplasty and limited its use in the mastectomy patient to a research protocol study. This article reviews the recent literature about the possible health hazards of the silicone implant.

METHODS

In this review of the literature, specific attention was directed toward structural failure of the device as well as the diagnosis of rupture, tissue response to silicone, systemic immunologic response to silicone, the relationship of silicone to connective tissue diseases, and the association of the silicone implant with breast carcinoma in both the augmentation mammaplasty patient and the patient undergoing postmastectomy reconstruction. A total of 88 works were reviewed.

RESULTS

The literature fails to support an association between silicone gel breast implants and systemic diseases. Although implants may cause local symptoms, rupture over time, or be associated with an immunologic reaction, comprehensive epidemiologic studies have concluded that there is no connection between breast implants and the known connective tissue diseases or between the implants and breast carcinoma. There is no increase in the risk of recurrence in mastectomy patients reconstructed with implants and no delay in the detection of recurrences. Recent laboratory studies in animals suggest that silicone may have anticarcinogenic effects.

CONCLUSIONS

Silicone gel breast implants may rupture and cause local symptoms, but they have not been demonstrated to be a systemic health hazard for patients who have undergone augmentation mammaplasty or postmastectomy reconstruction.

Complications leading to surgery after breast implantation

BACKGROUND

Local complications that require additional surgical procedures are an important problem for women with breast implants.

METHODS

We studied 749 women who lived in Olmsted County, Minnesota, and received a first breast implant at the Mayo Clinic between 1964 and 1991. We identified complications that occurred after the initial procedure and after any subsequent implantation. A complication was defined as a surgical procedure performed for any of the following reasons: capsular contracture; rupture of the implant; hematoma or bleeding; infection or seroma of the wound; chronic pain; extrusion, leakage, or sweating of the implant; necrosis of the nipple, areola, or flap; malfunction of the filler port of a tissue expander; and wound dehiscence.

RESULTS

During follow-up (mean, 7.8 years; range, 0 to 25.8), 208 (27.8 percent) of the women underwent 450 additional implant-related surgical procedures. Ninety-one (20.2 percent) were anticipated, staged procedures or were done because the patient requested a size change or aesthetic improvement, and 359 procedures (79.8 percent) had at least one clinical indication (thus constituting a complication). Complications occurred in 178 (23.8 percent) of the 749 women and involved 274 (18.8 percent) of the 1454 breasts with implants and 321 (18.8 percent) of the 1703 implants. The most frequent problem was capsular contraction (272 cases), followed by rupture of the implant (60), hematoma (55), and wound infection (23). The rate of complications was significantly lower (P<0.001) among women with cosmetic implants (6.5 percent at one year, 12 percent at five years) than among women who underwent implantation after mastectomy for breast cancer (21.8 percent at one year, 34 percent at five years) or prophylactic mastectomy (17.3 percent at one year, 30.4 percent at five years).

CONCLUSIONS

Women who have had breast implantation frequently experience local complications during the subsequent five years. Complications were significantly less frequent among patients who received implants for cosmetic reasons than among those who received implants after mastectomy for cancer or for cancer prophylaxis.

Breast implants in patients with differentiated and undifferentiated connective tissue disease

OBJECTIVE

To assess the frequency of breast implantation and the relationship of the implants to the onset of symptoms in patients with differentiated and undifferentiated connective tissue disease (CTD).

METHODS

We evaluated an inception cohort of patients with differentiated and undifferentiated CTD and symptoms of < 12 months duration when enrolled in 1983-1987. The risk of having breast implants in those patients with early symptoms of CTD was determined in comparison with that in a non-concurrent control group.

RESULTS

Only 3 of 323 women in the cohort had historical, physical, or chest radiographic evidence of breast implantation. In 1 of the 3 patients, the symptoms of CTD began before the breast implantation. The odds ratio was calculated at 1.15, with a 95% confidence interval ranging from 0.23 to 3.41.

CONCLUSION

This study showed an absence of significant risk for prior breast implantation surgery in patients with well-defined or undifferentiated CTD.

Use of antipolymer antibody assay in recipients of silicone breast implants

BACKGROUND

Local complications (encapsulation, rashes, rupture, and leakage) can occur after placement of silicone gel-containing breast implants (SBI). Whether SBI exposure results in systemic manifestations in some recipients is controversial. We have carried out a blinded study to assess whether there is any difference between SBI recipients and non-exposed controls in the proportions positive for serum antibodies directed against polymeric substances.

METHODS

We recruited female SBI recipients (including those without symptoms) who presented to a single rheumatology clinic. A physician global assessment was used to classify SBI recipients who did not meet criteria for specific autoimmune diseases according to the severity of local and systemic signs and symptoms. Controls were recruited from among clinic staff and their acquaintances. Results of the antipolymer antibody (APA) assay were compared with those of an assay for antinuclear antibodies (ANA) and with the severity of the signs and symptoms.

FINDINGS

Positive APA results were found in one (3%) of 34 SBI recipients with limited symptoms, two (8%) of 26 with mild symptoms, seven (44%) of 16 with moderate symptoms, and 13 (68%) of 19 with advanced symptoms. Four (17%) of 23 healthy non-SBI-exposed controls and two (10%) of 20 non-exposed women with classic autoimmune diseases were positive for APA. Thus, women with moderate or advanced symptoms were significantly more likely than those with limited or mild symptoms, or non-exposed controls to have APA (p < 0.001). The proportion with positive ANA results was higher for women with classic autoimmune diseases 14 (70%) of 20 than for any SBI-exposed subgroup (0-33%).

INTERPRETATION

The APA assay can objectively contribute to distinguishing between SBI recipients with limited or mild signs and symptoms. SBI recipients with more severe manifestations, and patients with specific autoimmune diseases. Further studies will be needed to define the signs and symptoms associated with exposure to SBI.