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

Defining Breast Implant Illness: A Systematic Review and Meta-analysis of Patient-reported Symptoms

Background

Although no definitive scientific link has been established, public concern surrounding breast implant illness (BII) is increasing. To study this potential condition, a clear definition is necessary. This systematic review aimed to characterize BII through a meta-analysis of patient-reported symptoms.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive literature search was conducted. The relative risk (RR) of the top 10 symptoms was meta-analyzed, comparing patients with and without breast implants. Additional analyses assessed whether surgical or patient-related factors influenced symptom occurrence.

Results

A total of 36 articles were included in this study, accounting for 10,519 patients. Fatigue or malaise (RR = 3.15 [2.89-3.43]), myalgia or weakness (RR = 2.96 [2.76-3.18]), and cognitive dysfunction (RR = 2.87 [2.64-3.12]) were most strongly associated with the presence of breast implants. Implants that were ruptured (RR = 1.12 [1.04-1.21], P = 0.003) or filled with silicone (RR = 2.11 [1.49-2.99], P < 0.0001) appeared more likely to lead to BII-type symptoms. In contrast, patients who underwent explantation (RR = 0.94 [0.90-0.98], P = 0.003) or had implants for aesthetic reasons (RR = 0.91 [0.84-0.99], P = 0.02) reported fewer symptoms.

Conclusions

Given increasing awareness and concern surrounding BII, it is essential for the plastic surgery community to critically examine patient outcomes. Establishing a consistent, symptom-based definition of BII and identifying key risk factors are necessary to guide future research and improve patient care.

Safety of esthetic procedures in rheumatic patients: single-center survey of patients

The popularity of esthetic medicine is growing every year, also among patients with autoimmune inflammatory rheumatic diseases (AIRD). The objective of this study was to evaluate the safety of esthetic medicine (AM) procedures in patients with AIRD. A semi-structured, anonymous questionnaire regarding rheumatic and concomitant diseases and AM procedures was distributed among adult patients hospitalized in the rheumatology department or attending outpatient clinic in the National Institute of Geriatrics, Rheumatology, and Rehabilitation, Warsaw. The main outcome was the occurrence of an adverse event. A number of 512 patients took part in the survey and 15 were excluded (AM procedure preceded the diagnosis of AIRD). The study group consisted of 497 patients, of whom 47 had undergone AM procedures. The procedures performed included: tattooing (22 patients), piercing (16 patients), hyaluronic acid (7 patients), botulinum toxin (5 patients) injections, laser procedures (6 patients), plastic surgery (4 patients), mesotherapy (3 patients) and others. The vast majority of patients had these performed during remission or low disease activity. 70.2% of patients received treatment with disease-modifying antirheumatic drugs (DMARDs) during the AM procedure, with TNF-alfa inhibitors being the most common (63.6%). Adverse events occurred in 15% of patients. All were mild and transient site reactions. Most patients would like to repeat the AM procedure in the future. The use of esthetic medicine procedures in patients with AIRD, including those treated with biologic DMARDs, was associated with a risk of mild site reactions. Most of the patients expressed satisfaction with the results of the AM procedure.

The Incidence and Outcomes of Breast Implants Among 1696 Women over more than 50 Years

OBJECTIVE

To investigate the incidence of women with breast implants in 1964-2017 MATERIALS AND METHODS: All women with breast implants in Olmsted County, MN between January 1, 1992 and December 31, 2017 were identified, and a comprehensive review of individual medical records was performed, adding to a previously identified cohort of women with breast implants in 1964-1991. Incidence rates were calculated and were age- and sex-adjusted to the US white female 2010 population.

RESULTS

In 1992-2017, 948 women with breast implants were identified, totaling 1696 Olmsted County, MN women with breast implants in 1964-2017. Overall incidence was 63.3 (95% CI 60.2-66.4) per 100,000 women, but incidence varied significantly over time. Women in 1964-1991 were more likely to have implants for cosmetic reasons and more likely to have silicone implants compared to the 1992-2017 cohort. The overall standardized mortality ratio was 1.17 (95% CI 0.99-1.38) in 1964-1991 and 0.94 (95% CI 0.66-1.29) in 1992-2017. In 1992-2017, breast reconstruction patients had a significantly elevated risk of implant rupture and implant removal versus breast augmentation patients.

CONCLUSION

The incidence of breast implants among women in Olmsted County, MN has varied drastically over the past five decades, with significant changes in the trends for implant type and reason. The findings of this study may provide further insight regarding how risks associated with implants may vary over time.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Exploring Factors Associated with Implant Removal Satisfaction in Breast Implant Illness Patients: A PRO BREAST-Q Study

Background

Breast implant illness (BII) is a poorly understood heterogeneous disorder treated with implant removal; however, patient-reported symptoms and outcomes after treatment remain unclear.

Methods

A retrospective review of patients undergoing bilateral breast implant removal related to BII by two surgeons at an academic medical center between 2018 and 2022 was conducted. Patients were surveyed using the BREAST-Q Reconstruction model with the American Society for Aesthetic Plastic Surgery BII survey extension. Outcomes were analyzed using multivariable logistic regression, adjusted for patient-associated factors.

Results

Forty-seven patients were surveyed with a response rate of 51% (n = 24). Of the 20 patients who completed the survey, the majority were White (85%), with 45% (n = 9) having a documented history of psychiatric illness. Six (30%) patients had capsular contracture and four (20%) had documented implant rupture. Most implant removal procedures (n = 12, 60%) were not covered by insurance. Fourteen (70%) patients reported a net improvement in their symptoms after implant removal, most commonly chest discomfort, muscle pain, fever, and headaches. Capsular contracture was predictive of reduced psychosocial, sexual, and breast satisfaction scores (P = 0.015). Self-pay was predictive of increased breast satisfaction scores (P = 0.009), but had no impact on symptomatic improvement. A reduced time to implant removal was predictive of fewer residual symptoms (P = 0.032). Psychiatric illness had no significant impact on the outcomes.

Conclusions

In the setting of suspected or diagnosed BII, a reduced time to implant removal may decrease the risk of residual symptoms and improve overall patient satisfaction. In patients with capsular contracture, preoperative counseling should emphasize that implant removal may only improve physical symptoms.

[The Emerging Interest in Breast Implant Illness and its impact on Patient Behavior]

Breast implant illness (BII) is a loosely defined term for a collection of non-specific systemic symptoms that are hypothesised to be associated with breast implants. BII symptoms include fatigue, hair loss, rashes, chronic pain, and others. However, conclusive evidence for a causal relationship between silicone implants and BII remains lacking. In the light of recent findings that textured implants can, in rare cases, lead to breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a potential link between breast implants and BII is conceivable and justifies further investigation. We observe a growing number of patients seeking consultation and treatment for systemic symptoms related to breast implants, which is reflected in increasing interest in literature and social media. The aim of this work was to investigate the growing interest in BII. We now describe the clinical features of a patient who suffers from symptoms that are consistent with BII and contextualise clinical presentation in a review of literature and google trend analysis.

Understanding Breast Implant-Associated Illness: A Delphi Survey Defining Most Frequently Associated Symptoms

BACKGROUND

Increased understanding of the constellation of symptoms referred to as breast implant illness is necessary to better address patient concerns, provide evidence-based care, and inform prospective patients about potential risks. The aim of this study was to reach consensus on the symptoms most frequently associated with breast implant illness, which will subsequently inform the development of a symptom severity scale.

METHODS

A literature search of peer-reviewed and gray literature was performed to identify a comprehensive list of symptoms associated with breast implant illness. This was followed by an online, three-round, modified Delphi survey where the list of symptoms was reviewed by an international panel to determine the top 20, 10, and five symptoms associated with breast implant illness. A virtual meeting of panelists was held to reach consensus on the symptoms to be included in a symptom severity scale.

RESULTS

A total of 44 symptoms were identified through the literature search. The modified Delphi survey panel consisted of patient research partners [n = 9 (34.6 percent)], plastic surgeons [n = 10 (38.5 percent)], researchers [n = 6 (23.1 percent)], and a member of the U.S. Food and Drug Administration [n = 1 (3.8 percent)]. The response rates of round 1, 2, and 3 were 85, 96, and 100 percent, respectively. Consensus was reached on the top 19 and top six symptoms to be included in long and short forms of a symptom severity scale.

CONCLUSIONS

There was a high level of agreement on the symptoms to be included in a symptom severity scale. The next steps include conducting in-depth qualitative interviews with women with these symptoms and breast implants to understand the experience and impact of these symptoms and develop the preliminary scale.

HISTORY OF BREAST IMPLANTS: BACK TO THE FUTURE

Modern breast implants are a staple of plastic surgery, finding uses in esthetic and reconstructive procedures. Their history began in the 1960s, with the first generation of smooth devices with thick silicone elastomer, thick silicone gel, and Dacron patches on the back. They presented hard consistency, high capsular contracture rates and the patches increased the risk of rupture. In the same decade, polyurethane coating of implants was implemented. A second generation was introduced in the 1970s with a thinner shell, less viscous gel filler and no patches, but increased silicone bleed-through and rupture rates. The third generation, in the early 1980s, featured implants with a thicker multilayered elastomer shell reinforced with silica to reduce rupture risk and prevent silicone bleed-through. A fourth generation from the late 1980s combined thick outer elastomer shells, more cohesive gel filler, and implemented for the first-time outer shell texturing. In the early 1990s, the fifth generation of devices pioneered an anatomical shape with highly cohesive form-stable gel filler and a rough outer shell surface. Surface texturing was hampered by the discovery of Breast Implant Associated-Anaplastic Large Cell Lymphoma and its link with textured devices. From the 2010s, we have the era of the sixth generation of implants, featuring innovations regarding the surface, with biomimetic surfaces, more resistant shells and variations in gel consistency. The road to innovation comprises setbacks such as the FDA moratorium in 1992, the PIP scandal, the Silimed CE mark temporary suspension and the FDA-requested voluntary recall of the Allergan BIOCELL implants.

Dermal Filler Injections in Patients With Autoimmune and Inflammatory Rheumatic Diseases-The Patients' Perspective

BACKGROUND

Injecting dermal fillers in patients with autoimmune inflammatory rheumatic diseases (AIIRDs) is controversial.

OBJECTIVE

To evaluate the attitudes of patients with AIIRDs regarding the use of dermal fillers and the side effects of those who underwent them.

METHODS

Patients with AIIRDs who attended a rheumatology outpatient clinic between 2016 and 2018 filled in a questionnaire about their attitudes toward dermal filler injections. The questionnaire evaluated information received from professionals and the factors that influenced their decision of whether or not to undergo the procedures.

RESULTS

Overall, 194 patients with AIIRDs (mean age 56.5 ± 14.0, 99% women) responded. Forty-two of them had previously undergone the injections and intended to repeat them (Group A), 37 had not received filler injections but intended to do so (Group B), and 114 who had never undergone them did not intend to undergo them. The major motivation for undergoing filler injections was social. Patients treated with dermal fillers refrained from informing their rheumatologist about their injections. They were, however, highly satisfied with the procedure and reported negligible side effects.

CONCLUSION

The use of dermal fillers was apparently safe and well received by patients with AIIRDs. Physicians' recommendations to refrain from injecting them with dermal fillers should be reconsidered and evaluated in clinical studies.

A Pipeline to Understand Emerging Illness Via Social Media Data Analysis: Case Study on Breast Implant Illness

Background

A new illness can come to public attention through social media before it is medically defined, formally documented, or systematically studied. One example is a condition known as breast implant illness (BII), which has been extensively discussed on social media, although it is vaguely defined in the medical literature.

Objective

The objective of this study is to construct a data analysis pipeline to understand emerging illnesses using social media data and to apply the pipeline to understand the key attributes of BII.

Methods

We constructed a pipeline of social media data analysis using natural language processing and topic modeling. Mentions related to signs, symptoms, diseases, disorders, and medical procedures were extracted from social media data using the clinical Text Analysis and Knowledge Extraction System. We mapped the mentions to standard medical concepts and then summarized these mapped concepts as topics using latent Dirichlet allocation. Finally, we applied this pipeline to understand BII from several BII-dedicated social media sites.

Results

Our pipeline identified topics related to toxicity, cancer, and mental health issues that were highly associated with BII. Our pipeline also showed that cancers, autoimmune disorders, and mental health problems were emerging concerns associated with breast implants, based on social media discussions. Furthermore, the pipeline identified mentions such as rupture, infection, pain, and fatigue as common self-reported issues among the public, as well as concerns about toxicity from silicone implants.

Conclusions

Our study could inspire future studies on the suggested symptoms and factors of BII. Our study provides the first analysis and derived knowledge of BII from social media using natural language processing techniques and demonstrates the potential of using social media information to better understand similar emerging illnesses.

Risk of rheumatic disease in breast implant users: a qualitative systematic review

Background

Recent studies on the risk of rheumatic disease among breast implant users have reported conflicting results. The primary objective of this study was to provide a systematic and critical review of the literature on the association between breast implants and the risk of rheumatic disease.

Methods

A qualitative systematic review was conducted in PubMed, MEDLINE, EMBASE, EBM-Reviews and CINAHL Complete from database inception to June 23rd, 2021. Eligible papers were full-length articles in English or French reporting original data on the incident risk of rheumatic disease among individuals with and without breast implants. Data were extracted from published reports and appraised using the Newcastle-Ottawa scale. The main outcome was incident risk of systemic sclerosis (SSc), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), fibromyalgia and other rheumatic disorders and symptoms.

Results

Out of 3,425 identified citations, 86 met inclusion criteria. Two cohort studies suggested a two-fold increase in risk of SSc, whereas three case-control studies showed no increase in risk. Three cohort studies did not find an increased risk of incident and confirmed SS among breast implant users, however symptoms of sicca, myalgia and fatigue were reported more frequently. A meta-analysis of heterogenous studies reported a less than two-fold increase in risk of RA. Studies did not support an association with SLE. Insufficient evidence was available for autoimmune myositis and other rheumatic diseases. Implant rupture detected on imaging was not clearly associated with incident rheumatic disease, although no studies specifically examined the risk associated with acute/traumatic rupture. Little data was available on the safety of saline breast implants. Explantation often led to temporary improvement.

Conclusions

Based on a small number of high-quality and methodologically robust studies, an association between breast implants and a small increase in risk of SSc and RA could not be excluded. Symptoms of sicca, myalgia and fatigue were reported more frequently among breast implant users. Overall, there remains much uncertainty in regard to the association between breast implants and the risk of incident rheumatic diseases. Individuals considering the placement of breast implants should be informed of this uncertainty.

Trial Registration

This study was registered in the PROSPERO database (#CRD42019133616).

Outcomes of Implant Removal and Capsulectomy for Breast Implant Illness in 248 Patients

BACKGROUND

Breast implant illness (BII) is a term popularized by social media to describe systemic symptoms that patients ascribe to their breast implants. Though the concept of implants as an underlying cause for a systemic illness remains controversial, few studies have delineated the implant characteristics, capsular histology, and outcomes of patients who undergo explantation for BII.

METHODS

We retrospectively reviewed the demographics, presenting symptoms, outcomes, capsular histology, and culture results of all women who presented to the senior author with symptoms attributed to BII and underwent breast implant removal with capsulectomy from August 2016 to February 2020. Chi-square and logistic regression analyses were performed to evaluate association between implant type, composition, and findings of inflammation on capsule pathology.

RESULTS

Among 248 patients, 111 (23%) capsules demonstrated inflammatory changes on permanent pathology. Capsular inflammation was independently associated with silicone versus saline (right odds ratio [OR] = 2.18 [1.16-4.11], P = 0.016, left OR = 2.35 [1.08-5.12], P = 0.03) and textured versus smooth implants (right OR = 2.18 [1.16-4.11], P = 0.016, left OR = 2.25 [1.17-4.31], P = 0.01). Silicone material was present in the capsules of 12 patients (4.8%). Fourteen patients had positive cultures. There was one pneumothorax (0.4%), three hematomas requiring evacuation (1%), and two DVTs (0.8%). Of 228 patients, 206 (90.4%) reported high satisfaction with the outcome of the procedure.

CONCLUSIONS

In a large cohort of BII patients, we found that capsular inflammation is significantly associated with silicone and textured implants. Implant removal with capsulectomy can be safely performed in patients with BII with a low complication rate and high patient satisfaction.

A Case of Silicone and Sarcoid Granulomas in a Patient with "Highly Cohesive" Silicone Breast Implants: A Histopathologic and Laser Raman Microprobe Analysis

Foreign body giant cell (FBGC) reaction to silicone material in the lymph nodes of patients with silicone breast implants has been documented in the literature, with a number of case reports dating back to 1978. Many of these case reports describe histologic features of silicone lymphadenopathy in regional lymph nodes from patients with multiple sets of different types of implants, including single lumen smooth surface gel, single lumen textured surface gel, single lumen with polyethylene terephthalate patch, single lumen with polyurethane coating, and double lumen smooth surface. Only one other case report described a patient with highly-cohesive breast implants and silicone granulomas of the skin. In this article, we describe a patient with a clinical presentation of systemic sarcoidosis following highly cohesive breast implant placement. Histopathologic analysis and Confocal Laser Raman Microprobe (CLRM) examination were used to confirm the presence of silicone in the axillary lymph node and capsular tissues. This is the first report where chemical spectroscopic mapping has been used to establish and identify the coexistence of Schaumann bodies, consisting of calcium oxalate and calcium phosphate minerals, together with silicone implant material.

En Bloc Capsulectomy for Breast Implant Illness: A Social Media Phenomenon?

BACKGROUND

En bloc capsulectomy has recently increased in prominence as a potential surgical therapy for patients with breast implant illness (BII). However, this procedure has chiefly been recommended for treating breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

OBJECTIVES

This study aimed to review the current literature and evaluate the public understanding of treatment options for BII via social media to characterize any potential communication disconnect between clinicians and patients.

METHODS

An electronic literature review was performed to identify all available publications mentioning evidence-based support for en bloc capsulectomy as treatment for BII and BIA-ALCL. Twitter social media posts referencing BII or BIA-ALCL were analyzed from 2010 to 2019. Author identity and any mention of surgical treatment were assessed.

RESULTS

A total of 115 publications on the subject of BII and 315 articles on BIA-ALCL were identified. En bloc resection was recommended only for patients with a diagnosis of BIA-ALCL. A total of 6419 tweets referencing BII and 6431 tweets referencing BIA-ALCL were identified. Tweets referencing BIA-ALCL were significantly more likely to be authored by physicians (25.9% vs 5.3%, P < 0.001), and tweets referencing BII were significantly more likely to mention any surgical treatment (7.8% vs 1.9%, P < 0.001) and en bloc capsulectomy (1.4% vs 0.3%, P < 0.001).

CONCLUSIONS

This study demonstrates that a communication disconnect exists between the scientific literature and social media regarding treatment options for BII and BIA-ALCL. Physicians should be aware of these potential misconceptions to empathetically address patient concerns in a patient-centered manner.

Breast implant illness: a topic in review

Recently, the term breast implant illness has become popularized in social media to describe a constellation of symptoms which have been attributed to a patient's breast implants. These symptoms include fatigue, chest pain, hair loss, headaches, chills, photosensitivity, rash, and chronic pain amongst others. While physicians aim to treat these physical symptoms, currently the evidence supports the safety of silicone breast implants. This article entitled "Breast implant illness: a topic in review" presents an up-to-date review focusing on the safety of silicone breast implants. Patients retain the right to decide to keep or remove their breast implants and for those who choose to pursue explantation, they should be advised to seek the care of a board-certified plastic surgeon. As a scientific community is our duty to continue to conduct well-designed scientific studies to gain more insight into the safety of breast implants as it related to cancer detection, autoimmune disease, and other health concerns to improve patient safety, awareness, and education. This review article aims to delineate both the content and timing of all research and evidence as it pertains to the newly coined phrase "breast implant illness". The authors of this study support that currently there have not been any concrete or evidence-based studies which support the formation of a new syndrome "silicone implant illness".

Research trends and performances of breast reconstruction: a bibliometric analysis

BACKGROUND

The need for postmastectomy breast reconstruction surgery has increased dramatically, and significant progress has been made both in implant and autologous based breast reconstruction in recent decades. In this paper, we performed a bibliometric analysis with the aim of providing an overview of the developments in breast reconstruction research and insight into the research trends.

METHODS

We searched the Science Citation Index Expanded database and the Web of Science Core Collection for articles published between 1991 to 2018 in the topic domain, using title, abstract, author keywords, and KeyWords Plus. Four citation indicators TCyear, Cyear, C0 and CPPyear were employed to help analyse the identified articles.

RESULTS

The number of scientific articles in breast reconstruction in this period steadily increased. It took most articles nearly a decade to hit a plateau in terms of citation counts. Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and Journal of Plastic Reconstructive and Aesthetic Surgery published the largest number of articles on breast reconstruction. Nine of the top ten most prolific publications were based in the USA. The research highlights related to breast reconstruction were implant-based breast reconstruction, deep inferior epigastric perforator (DIEP) flap breast reconstruction, and superficial inferior epigastric artery (SIEA) flap breast reconstruction.

CONCLUSIONS

This bibliometric analysis yielded data on citation number, publication outputs, categories, journals, institutions, countries, research highlights and tendencies. It helps to picture the panorama of breast reconstruction research, and guide the future research work.

Perception of Implants among Breast Reconstruction Patients in Montreal

Supplemental Digital Content is available in the text.

Background:

In light of the recent surge of media coverage and social media influence regarding breast implants, it is essential to understand patients’ concerns and misconceptions so that we can better serve them.

Methods:

The authors designed a survey study for assessing the awareness and perception of patients toward breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII). In total, 130 patients presenting to the senior author’s breast reconstruction clinic completed the survey. The survey assessed patients’ knowledge on and their perception of BIA-ALCL and BII.

Results:

“News article” and “Television” were most often selected as sources of information for BIA-ALCL (21% and 20%, respectively) and BII (20% and 25%, respectively). A total of 100 patients (77%) had previous knowledge of BIA-ALCL. Forty-seven percent (n = 47/100) responded that they were unsure of the fate of a person diagnosed with BIA-ALCL, and 25% (n = 25/100) were unaware of the association between BIA-ALCL and specific implant type. Patients who were unaware of BIA-ALCL prognosis reported being less likely to receive breast implants in the future (P = 0.012, χ² = 19.48). Eighty-nine patients (68%) had previous knowledge of BII. A total of 60 symptoms were mentioned by patients, with “Fatigue” (12%, n = 26) being cited the most often.

Conclusions:

The present survey highlights the importance for plastic surgeons to frequently discuss these entities with their patients. This should be done despite the obscurity of BII, in an effort to offer the best available evidence to our patients.

The Evolution of Breast Implants

Breast augmentation remains one of the most commonly performed aesthetic procedures in the United States and worldwide. Throughout the last few decades, the implants used for this procedure have undergone significant advancements, which has allowed surgeons to provide safer and more aesthetically pleasing outcomes. This article discusses the history of breast implants since their invention in 1962. Particular emphasis is given to the evolution of silicone implants with its many challenges, which has resulted in the development of the currently used fourth- and fifth-generation devices. Knowledge of these advances will allow physicians to more critically evaluate their results, and also will encourage them to provide more up-to-date scientific data on these devices to further improve the clinical outcomes of their patients.

Silicone Implant Illness: Science versus Myth?

The purpose of this Special Topic article is to present the current state of scientific evidence related to the safety of silicone breast implants. There is presently overwhelming evidence to support the safety of silicone breast implants. Ultimately, the decision to obtain, keep, or remove breast implants is the choice of the patient. If a patient chooses to have her breast implants removed, it is important to find a board-certified plastic surgeon with expertise in breast surgery. Ongoing studies are strongly encouraged in all areas, from cancer detection to autoimmune disease, as we strive for improved patient safety, patient awareness, and patient education. To the best of our body of scientific knowledge to date, there have not been any concrete or evidence-based studies or peer-reviewed data concerning the formation of a new syndrome: "silicone implant illness." Silicone breast implants are used in nearly 300,000 breast augmentation and 100,000 breast reconstruction operations annually in the United States. Silicone gel-filled implants were first approved by the U.S. Food and Drug Administration in 1962. Since that time, few medical devices have been studied as closely for their safety and associated adverse outcomes. Despite multiple generations of implant shells and gel fillers, the basic components remain as originally designed.

A Review of the Literature on the Management of Silicone Implant Incompatibility Syndrome

BACKGROUND

Silicone implant breast augmentation has been routinely performed since the 1960s. Emerging literature suggests the existence of a clinical syndrome, silicone implant incompatibility syndrome (SIIS) resulting from silicone implants. Autoimmune reactivity develops, with subsequent symptoms including myalgias, arthralgias, chronic fatigue, sleep disturbance and cognitive impairment. While the existence of a clinical entity is currently being established in the literature, there are currently no guidelines on management.

METHOD

Literature review was conducted using Medline and PubMed databases with key terms searched for, prior to hand-searching and bibliographical review until February 2019. The relevant literature was reviewed to determine whether consensus exists on the most appropriate management strategy.

RESULTS

Forty-nine articles relevant to SIIS were identified with twenty-one of these specifically outlining treatment. Of these, only five provided data on larger cohorts, three provided conclusions from literature reviews, and the remainder were small case series or isolated case reports. Improvement in symptoms was obtained by medical management of their immune response, by explantation and by simply counselling on the condition itself.

CONCLUSIONS

A new clinical condition is being described that appears to suggest a link between silicone implant use and various symptoms in a cohort of patients. The subsequent treatment of SIIS is yet to be agreed upon. Further research is required to establish guidelines for diagnosis and ensure evidence-based treatment, and that patients and clinicians have a more refined understanding of the potential risks of silicone breast implant use.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Does Long-Term Exposure to Gel-Filled Silicone Implants Increase the Risk of Relapse after Breast Cancer?

Background

An increased risk of cancer and autoimmune diseases associated with gel-filled silicone implants, debated by FDA experts since 1991, has given rise to a profusion of literature on the subject. However, such effects have not been adequately investigated in patients with breast cancer. In a previous report we compared 146 breast cancer patients with gel-filled silicone implants for breast reconstruction to 146 control patients in whom no reconstruction had been performed. The observed results were reassuring, as the evolution of the disease after 10 years was better in the reconstruction group than in the control group. We now report the end results of this study with a median follow-up of 13 years after the breast reconstruction (range, 10-20 years).

Method

The relative risks of detrimental events were estimated with Cox's Proportional Hazards Model, with stratification according to age at diagnosis.

Results

The risks of locoregional recurrences and distant metastasis were significantly lower in the BR group than in the control group. The risks of death, of a second breast cancer and of a second primary cancer at a site other than the breast were not significantly different between the two groups of patients.

Conclusion

Long-term follow-up of patients exposed to gel-filled silicone implants confirms the absence of detrimental effects after breast cancer. The power of our study is, however, below that required to detect a very slight increase in the risks studied.

ASIA syndrome, calcinosis cutis and chronic kidney disease following silicone injections. A case-based review

An immunologic adjuvant is a substance that enhances the antigen-specific immune response preferably without triggering one on its own. Silicone, a synthetic polymer used for reconstructive and cosmetic purposes, can cause, once injected, local and/or systemic reactions and trigger manifestations of autoimmunity, occasionally leading to an overt autoimmune disease. Siliconosis, calcinosis cutis with hypercalcemia and chronic kidney disease have all been reported in association with silicone injection. Here, we describe a case of autoimmune/auto-inflammatory syndrome induced by adjuvants, calcinosis cutis and chronic kidney disease after liquid silicone multiple injections in a young man who underwent a sex reassignment surgery, followed by a review of the literature. To our knowledge, this is the first report describing the concomitance of the three clinical conditions in the same patients. The link between silicone and the immune system is not completely understood yet and requires further reports and investigations with long-term data, in order to identify the main individual and genetical risk factors predisposing to the wide spectrum of the adjuvant-induced responses.

Silicone breast implant rupture: a review

Silicone breast implants have been in use for nearly 6 decades. In this time they have undergone significant changes in design and use. They have been subject to intense scrutiny with regard to safety and efficacy, including an almost 10 years moratorium on their use. The current generations of implants have been followed via the manufacturer's Core studies in order to obtain long term data regarding safety and complications. The results of the more recent studies are compiled in this review. Rupture rates are initially very low and begin to increase after 6-8 years of implantation. Implant rupture may be detected by physical exam, ultrasound or magnetic resonance imaging (MRI). The majority of silicone implant ruptures are clinically undetectable. Symptomatic patients may present with capsular contracture, breast lumps or changes in breast shape. The most common cause of implant rupture is instrument damage during placement. Implant rupture may be confined to the peri-prosthetic capsule or may extravasate into the breast tissue. Patients with ruptured implants have been studied closely and the consensus of the literature states there are no health risks associated with implant rupture. Symptomatic patients with ruptured implants should be offered the choice of observation, or explantation and capsulectomy with or without replacement.

Breast implant design

Breast Augmentation remains as one of the most common procedures performed in the United States. This article explores the evolution of breast implants with special emphasis on the advancement of the silicone implants.

Destiny rides again: the reappearance of silicone gel-filled breast implant toxicity

Background Twenty-five years ago attorneys representing ailing women in class action litigation against silicone breast implant manufacturers made the procedural error of defining silicone-induced toxicity in the courtroom before it was properly studied in the exam room. This aberrant methodology perverted the proper research process, rendered verification of any real disease elusive, and cemented the groundwork for a repeat public health crisis potentially affecting two million women in the USA who possess new silicone gel devices inserted over the past 10 years. Patients and methods Six women, previously well, aged 27 to 53 (mean 42), were recipients of the new generations of cohesive silicone gel-filled breast implants approved for general use by the Food and Drug Administration (FDA) since December of 2006. They averaged seven years of total implantation time, and none experienced implant rupture. Results All six became ill on average 3.5 years from the time of implantation. By seven years the women manifested multiple types of skin rashes, polyarthritis, fatigue, protracted AM stiffness, myalgias, headaches, photosensitivity, hair loss, paresthesias, tinnitus, lymphadenopathy, chest pain, cognitive dysfunction, dry eyes, skin pigment changes, itching, muscle twitching, dizziness, nausea, easy bruising, and odor and smell sensitivity. Three of the four who were explanted noted improvement and/or resolution of at least 50% of their total disease manifestations. Conclusions These six women are representative of over 70,000 other breast implant recipients who, over the past three years, have had their new silicone devices permanently removed because of alleged gel-induced toxicity. The recurrence of this public health crisis has been fueled by manufacturers' research fraud, FDA ineptness, faulty informed consent, patient abandonment, proprietary manufacturing secrecy, misleading advertising, physician indifference, aberrant research methodology, and lax Congressional oversight.

A case series and a review of the literature on foreign modelling agent reaction: an emerging problem

Foreign modelling agent reactions (FMAR) are the result of the injection of unapproved high-viscosity fluids with the purpose of cosmetic body modelling. Its consequences lead to ulceration, disfigurement and even death, and it has reached epidemic proportions in several regions of the world. We describe a series of patients treated for FMARs in a specialised wound care centre and a thorough review of the literature. A retrospective chart review was performed from January 1999 to September 2015 of patients who had been injected with non-medical foreign agents and who developed cutaneous ulceration needing treatment at the dermatology wound care centre. This study involved 23 patients whose ages ranged from 22 to 67 years with higher proportion of women and homosexual men. The most commonly injected sites were the buttocks (38·5%), legs (18%), thighs (15·4%) and breasts (11·8%). Mineral oil (39%) and other unknown substances (30·4%) were the most commonly injected. The latency period ranged from 1 week to 17 years. Complications included several skin changes such as sclerosis and ulceration as well as systemic complications. FMAR is a severe syndrome that may lead to deadly complications, and is still very common in Latin America.

Silicone Breast Implants, Breast Cancer and Specific Connective Tissue Diseases: A Systematic Review of the Data in the Epidemiological Literature

Unanswered concerns about the systemic safety of silicone breast implants (BI) underlay the Food and Drug Administration's moratorium pronouncement in 1992. Since then, many epidemiological studies have been reported that examined either the association between BI and cancer, particularly breast cancer, or the association between BI and connective tissue diseases (CTD), particularly scleroderma. These studies are reviewed, and their data are synthesized. Three breast cancer easel control studies that examine BI as a risk factor show no association between BI and breast cancer. Nor do four BI cohort studies. The data appear to show a reduced risk. No association has been seen between Bl and either breast sarcomas or total cancers. Case-control studies do not show an association between BI and scleroderma (four studies), rheumatoid arthritis (three studies), systemic lupus erythematosus (two studies), or other connective tissue diseases. Eight cohort studies of women with breast implants sought an association between BI and CTD. Seven had negative results. One found a statistically significant risk of self-reported CTD of 1.24 (upper confidence limit = 1.41), but medical record review for diagnostic confirmation has not yet been performed. In toto, the epidemiological studies do not indicate an association between breast implants and breast cancer, though they suggest possibly a negative association. In toto, the epidemiological studies do not indicate an association between breast implants and specific connective tissue diseases, though one study's current results present a small statistically significant association with self-reported CTD.

The Evolution of Breast Implants

Breast augmentation remains one of the most common procedures performed in the United States. However, shape, feel, safety, and longevity of the implants remain important areas of research. The data provided by manufacturers show the safety and efficacy of these medical devices. Clinicians should strive to provide ongoing data and sound science to continue to improve clinical outcomes in the future. This article explores the evolution of breast implants with special emphasis on the advancement of silicone implants.

Levels of Evidence in the Plastic Surgery Literature: A Citation Analysis of the Top 50 'Classic' Papers

Background

The plastic surgery literature is vast, consisting of a plethora of diverse articles written by a myriad of illustrious authors. Despite this considerable archive of published material, it remains nebulous as to which precise papers have had the greatest impact on our specialty. The aim of this study was to identify the most cited papers in the plastic surgery literature and perform a citation analysis paying particular attention to the evidence levels of the clinical studies.

Methods

We identified the 50 most cited papers published in the 20 highest impact plastic surgery journals through the Web of Science. The articles were ranked in order of number of citations acquired and level of evidence assessed.

Results

The top 50 cited papers were published in six different journals between the years 1957 and 2007. Forty-two of the papers in the top 50 were considered as level IV or V evidence. No level I or II evidence was present in the top 50 list. The average level of evidence of the top 50 papers was 4.28.

Conclusions

In the plastic surgery literature, no positive correlation exists between a high number of citations and a high level of evidence. Anatomical reconstructive challenges tend to be the main focus of plastic surgery rather than pathologic diseases and consequently, papers with lower levels of evidence are relatively more valuable in plastic surgery than many other specialties.

An Analysis of the "Classic" Papers in Aesthetic Surgery

INTRODUCTION

Over the past 50 years, there has been a significant increase in published articles in the medical literature. The aesthetic surgery literature is vast, consisting of a plethora of diverse articles written by a myriad of illustrious authors. Despite this considerable archive of published material, it remains nebulous as to which precise papers have had the greatest impact on our specialty. The aim of our study was to identify and analyse the characteristics of the top 50 papers in the field of aesthetic surgery in the published literature.

METHODS

The 50 most cited papers were identified in several surgical journals through the Web of Science. The articles were ranked in order of the number of citations received. These classic 50 papers were analysed for article type, their journal distribution, level of evidence as well as geographic and institutional origin.

RESULTS

Six journals contributed to the top 50 papers in aesthetic surgery with Plastic and Reconstructive Surgery contributing the most with 31 papers.

Breast implants and the risk of breast cancer: a meta-analysis of cohort studies

BACKGROUND

The popularity of cosmetic breast augmentation and the incidence of breast cancer have been increasing worldwide. It has been hypothesized that the risk of breast cancer may be greater among patients who have undergone cosmetic breast implantation.

OBJECTIVES

The authors performed a meta-analysis of the available literature on the risk of breast cancer among women with cosmetic breast implants.

METHODS

The study was designed as a meta-analysis of observational studies. A systematic search of the English literature (published by August 28, 2013) was conducted in PubMed and EMBASE. Eligible reports were those that included relative risk (RR; the increased or decreased risk of breast cancer associated with breast implants) or the standardized incidence ratio (SIR) of the observed number of cases of breast cancer to the expected number of cases among patients that previously underwent cosmetic breast augmentation.

RESULTS

Seventeen studies representing 7 cohorts were selected. Some of these were follow-up reports of previously published studies; in such cases, only the most recent reports were included in the meta-analysis. Summary SIR and RR rates and the corresponding 95% confidence intervals (CIs) were calculated with a random-effects (SIR) or fixed-effects (RR) model. The overall SIR estimate was 0.69 (95% CI, 0.56-0.85), and the overall RR, based on 4 studies, was 0.63 (95% CI, 0.56-0.71).

CONCLUSIONS

Finding of this meta-analysis suggest that women who have undergone cosmetic breast implantation do not have an increased risk of breast cancer.

Plastic surgery and the breast: a citation analysis of the literature

Background:

A large proportion of the plastic surgery literature is dedicated to the breast. It is one of the most common topics in our specialty, yet it is unclear which articles have been the most influential. The purpose of this study was to identify the top 100 most-cited articles on breast in the plastic surgery literature and examine the characteristics of each individual article.

Methods:

Using an electronic database through the Web of Science, we were able to determine the 6 journals that contributed to the 100 most-cited articles on breast in the plastic surgery literature.

Results:

Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. Plastic and Reconstructive Surgery contributed the most articles to the top 100 with 81 articles including the most-cited article which has been referenced 673 times to date. The United States produced 73% of the top 100 articles, and the most prolific institution was the University of Texas M. D. Anderson Cancer Center with 15 articles.

Conclusions:

This study has identified the most influential articles on breast in the plastic surgery literature over the past 68 years and highlighted many important scientific breakthroughs and landmarks that have occurred during this time.

Silicone lymphadenopathy: presentation of a further case containing asteroid bodies on fine-needle cytology sample

Silicone lymphadenopathy is a recognized complication of breast augmentation. It is thought to occur when silicone droplets migrate from breast implants to lymph nodes. We report the cytologic findings in axillary and inguinal lymph node aspirate smears from a 35-year-old Italian woman, who came to our observation 10 years after bilateral cosmetic breast augmentation. A fine-needle cytology of the axillary lymph node showed extensive granulomatous inflammation, numerous histiocytes, and multinucleated giant cells containing star-shaped structures known as "asteroid bodies." The inguinal lymph node aspirate simply showed an aspecific reactive hyperplasia. No evidence of malignancy was present in any of the smears as well as in the excised axillary lymph node.