Determining the safety of the silicone envelope: in search of a silicone antibody

Breast Implant Silicones and B Cell-Mediated Immune Responses: A Systematic Review of Literature

Introduction

Breast implants are under recent scrutiny owing to concerns about their potential for inducing immunological diseases, namely breast implant-associated anaplastic large cell lymphoma and breast implant illness. However, the impact of silicone on biologic systems remains unclear. Therefore, we performed a systematic literature review to evaluate the information available on silicone breast implants and their effect on one arm of the adaptive immune response-B lymphocytes and antibody formation.

Methods

We conducted a systematic review in EMBASE/PUBMED in accordance with the PRISMA guidelines, with search entry terms requiring discussion of silicone and immunity. The initial review returned 1079 citations. Manual screening was performed to include studies that were specific to the humoral response after exposure to silicone. Secondary full text review was performed. The extracted data included animal models and findings pertinent to B cells/antibodies in response to breast implant silicones.

Results

In total, 39 studies on B cells/antibodies and breast-implant-associated silicones were identified. Among them, 23 studies were in humans, 14 in animal models, and 2 were in vitro. Common themes included identification of antisilicone antibodies in women with breast implants, anticollagen antibodies, presence of activated B cells or immunoglobulin G in implant capsules, and sensitization of lymphocytes to silicone in vitro.

Conclusion

Despite controversial findings in the literature, there is evidence that silicone breast implants activate B cells in the breast implant capsule and may have systemic effects on the production of autoantibodies and/or sensitization of B lymphocytes to silicone. Further research is needed on how breast implants impact other arms of the immune system to understand their long-term biological impact.

Contemporary Breast Augmentation Practice in the United States

ABSTRACT

Breast augmentation is one of the most commonly performed cosmetic surgical procedures in the United States. Modern breast augmentation has evolved with the development of various implant options, as well as surgical techniques. To achieve ideal result, it is important for the surgeon to develop a systematic approach to evaluate each patient. The 5 key steps in determining the best surgical plan include: (1) assess the need for concurrent mastopexy, (2) implant selection, (3) pocket plane, (4) inframammary fold position, (5) choice of incision. The purpose of this review is to discuss the principles behind each of these key concepts and how to utilize them in achieving the optimal outcome in breast augmentation.

Possible future development of implants and breast augmentation

Since the introduction of the silicone gel prosthesis in 1962, breast augmentation has become one of the most frequently performed operations in plastic surgery. As we strive for perfect results, it is important to continue to gather and review data evaluating innovative techniques and devices. Now we even have more options available for breast augmentation, whether we use them in combination or alone. By combining all of the available options (acellular dermal matrix products, silicone implant, fat grafting), we have been able to create "bioengineered breasts" with high patient and surgeon satisfaction. As always in plastic surgery, our concern is with safety; as newer technology and products are introduced to us, patient education, consent, and follow-up remain important.

MOC-PS(SM) CME article: breast augmentation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Evaluate patients seeking breast augmentation using key variables to assist in selection from the choices for incision, implant type and size, and plane of dissection. 2. Minimize the need for revisionary surgery to factors beyond the surgeon's control.

SUMMARY

The purpose of this article is to provide guidelines for Maintenance of Certification continuing medical education using the breast augmentation module. It may be used as an aid in the extraction of data for 10 consecutive cases of breast augmentation and, in this regard, provides a template to facilitate the collection of pertinent information. Interspersed with the Maintenance of Certification-oriented format is continuing medical education information regarding the current state of practice concerning the multiple variables in the specific procedure of breast augmentation.

Bilateral areoleor depigmentation after augmentation mammoplasty: a case report and literature search

Breast augmentation is by far one of the most common aesthetic procedures performed by plastic surgeons, and silicone implants are the most common prostheses used. Complications arising from the procedure are broadly categorized as either surgery or prosthesis related. Most of the complications are well known and have been documented, but areolar depigmentation after silicone gel prosthesis has not been reported to date.

[Plastic surgical body form correction. Part II: Face-lift, periorbital surgery, and breast augmentation and reduction]

The demand for a younger appearance is increasing as the average age of the population increases. Extensive anatomic studies in recent years have improved for facial and breast reconstruction the understanding of anatomic structures and the basis of the aging process. Numerous new surgical techniques have resulted. This understanding of the anatomy of aging and the diversity of surgical methods have made the attainment of naturally young facial appearance more easily possible, in which repositioning of the tissue plays a more important role than lifting. In the past, plastic surgery of the eyelids aimed primarily at hiding the aging process, not at true anatomic restoration. Modern techniques in this field aim more toward redistribution of fatty tissues and the anatomic restoration of aging structures. In this way long-term results are stabilized and secondary stigmata can be avoided. New concepts have also been established in breast surgery that allow more natural results, particularly in augmentation. Although no single method may be designated as superior, there still exists an optimal technique suited to every patient's anatomy and personal wishes.

Breast Augmentation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the different variables that are inherent to breast augmentation. 2. Identify certain breast shape characteristics that make one approach more advantageous than others. 3. Take into account certain patient characteristics to develop a logical surgical plan for breast augmentation.

SUMMARY

The optimal technique for breast augmentation has always been debated, and numerous variables fit the needs of the variously shaped patients in our population. The purpose of this article is to present the advantages and disadvantages of the various techniques available in breast augmentation so that, in conjunction with the patient's physical examination, a sound surgical plan can be developed for aesthetic augmentation of the breast.

Anthropometric measurements of the endoscopic eyebrow lift in the treatment of facial paralysis

Endoscopic eyebrow lift was performed on 51 patients presenting with eyebrow ptosis due to facial paralysis. The resulting anthropometric measurements of eyebrow position were analyzed statistically to evaluate the effectiveness of this method. When preoperative eyebrow differences between the paralyzed and nonparalyzed sides were measured, the average difference at midpoint was 4.4 mm, and at the highest point, 4.6 mm. When the same points were measured postoperatively, the average difference at midpoint was 2.4 mm, and at the highest point, 2.3 mm. The difference in eyebrow height between the paralyzed and nonparalyzed sides correlated positively with age, both preoperatively and postoperatively. However, differences between preoperative and postoperative eyebrow height (which reflects the effectiveness of endoscopic eyebrow lift) at the highest point did not correlate with age and at the midpoint displayed a slightly negative correlation with age. These results suggest that endoscopic eyebrow lift is effective among young patients whose eyebrow ptosis is minor and is relatively ineffective among elderly patients whose eyebrow ptosis is severe. The conventional method of juxta-brow excision is indicated for elderly patients, for whom the operative scar is almost inconspicuous.

Anti-silicone antibodies and silicone containing breast implants

The detection of anti-silicone antibodies in patients with silicone breast implants (SBI) has been undertaken principally in the USA. We undertook a study of 20 women with SBI from different manufacturers from 6 weeks to 20 years after surgery, including those with ruptured implants. They were compared with three control groups: 20 women without implants, 20 women with auto-immune disease and 20 anonymous blood donors. Potential anti-silicone antibodies (IgG) were tested against a variety of silicone polymer antigens using an enzyme linked immunosorbent assay (ELISA) technique which had previously detected positive results in an uncontrolled series. Silicone-free collecting tubes were used. No differences were found between the patients with SBI and controls. However, samples that had been stored for the longest time, or frozen and thawed several times, had the highest levels. These false positives appear to be due to an unknown but human specific IgG binding phenomenon. We conclude that there is no demonstrable anti-silicone antibody formation in these patients with SBI and we would caution that the effect of storage may have been an important factor in previously published assay methods. This study supports the safety of silicone containing breast implants.

Lipid infiltration as a possible biologic cause of silicone gel breast implant aging

The cause of silicone gel implant aging and rupture is not known. Recent reports indicate the failure rate is higher than previously published, and implant aging and rupture may be due to progressive mechanical deterioration of the outer vulcanized silicone shell. It is known that lipids are absorbed by the hydrophobic silicone elastomer, and lipid infiltration causes mechanical attenuation and possible failure of the elastomer. The purposes of this article are to analyze the silicone envelope/gel of explanted prostheses and the silicone elastomer of other medical grade silicone devices for lipid content and to suggest its possible role in implant aging and rupture. We assayed 33 ruptured silicone breast implant shells (mean age 13.1 years; range 8 to 26 years) and 8 medical grade silicone elastomer devices (mean age 3.7 years; range 3 months to 12 years) for evidence of lipid infiltration using thin layer chromatography. These were compared with control group assays from two nonimplanted silicone gel implants and one unused Silastic catheter. Ninety-eight percent of implants and other previously implanted silicone devices were found to have evidence of lipid infiltration compared with none in nonimplanted controls (p < 0.005). We conclude that lipids infiltrate the outer silicone shell and may be a factor related to breast implant aging and rupture due to progressive mechanical weakening of the outer silicone shell.

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.

Development of alternative breast implant filler material: criteria and horizons

The introduction of the silicone gel-filled breast implant more than 30 years ago changed the nature of alloplastic breast augmentation and reconstruction. Over the last three decades, it is estimated that one million American women have undergone implantation with some variation of these devices. Recent medical, legal, and regulatory developments have forced a moratorium on the unrestricted uses of the silicone gel-filled implants, and it appears unlikely that its general use will return. However, there is a continued need for some type of breast implant in both aesthetic and reconstructive surgery. The Food and Drug Administration has proposed testing guidelines for the development of any new breast implant before unrestricted clinical use. These guidelines will direct the creation of new filler materials from their earliest stages, through long-term postimplantation follow-up studies. This article succinctly examines the central issues in the breast implant controversy in relation to the FDA's recommendations for the development of new implants, discusses breast implant filler materials currently under development, and offers guidelines fro the development of breast implant fillers that are safe and effective.