Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery

Measurement properties of the Iranian version of the breast cancer perception scale (BCPS) according to the COSMIN checklist

BACKGROUND

Breast cancer is a prevalent cancer characterized by its aggressive nature and potential to cause mortality among women. The rising mortality rates and women's inadequate perception of the disease's severity in developing countries highlight the importance of screening using conventional methods and reliable scales. Since the validity and reliability of the breast cancer perception scale (BCPS) have not been established in the Iranian context. Therefore, this study aimed to determine the measurement properties of the BCPS in women residing in Tabriz, Iran.

METHODS

The present study comprised a cross-sectional design, encompassing a sample of 372 Iranian women. The participants were selected through a multi-stage cluster random sampling technique conducted over a period spanning from November 2022 to February 2023. The measurement properties of the Iranian version of BCPS were assessed following the guidelines outlined in the COSMIN checklist. This involved conducting various steps, including the translation process, reliability testing (internal consistency, test-retest reliability, and measurement error), and methodological tests for validity (content validity, face validity, construct validity, and hypothesis testing). The study also investigated the factors of responsiveness and interpretability. The presence of floor and ceiling effects was assessed.

RESULTS

The internal consistency of the scale was assessed using Cronbach's alpha, yielding a satisfactory value of 0.68. Additionally, McDonald's omega (95% CI) was computed, resulting in a value of 0.70 (0.66 to 0.74). Furthermore, the test-retest reliability was evaluated, revealing a high intraclass correlation coefficient (ICC) of 0.97 (95% CI: 0.94 to 0.99). The CVI, CVR, and impact scores of the BCPS were determined to be 0.98, 0.95, and 3.70, respectively, indicating favorable levels of content and face validity. To assess construct validity, an examination of the Exploratory Factor Analysis (EFA) was conducted on a set of 24 items. This analysis revealed the presence of six distinct factors, which collectively accounted for 52% of the cumulative variance. The fit indices of the validity model (CFI = 0.91, NFI = 0.96, RFI = 0.94, TLI = 0.90, χ2/df = 2.03, RMSEA = 0.055 and SRMR = 0.055) were confirmed during the confirmatory factor analysis (CFA). The overall score of BCPS exhibited a ceiling effect of 0.3%. The floor effect observed in the overall score (BCPS) was found to be 0.5%. Concerning the validation of the hypothesis, Spearman's correlation coefficient of 0.55 was obtained between the BCPS and the QLICP-BR V2.0. This correlation value signifies a statistically significant association. Furthermore, it is worth noting that the minimum important change (MIC) of 3.92 exhibited a higher value compared to the smallest detectable change (SDC) of 3.70, thus suggesting a satisfactory level of response.

CONCLUSIONS

The obtained findings suggest that the Iranian version of the BCPS demonstrates satisfactory psychometric properties for assessing the perception of breast cancer among Iranian women. Furthermore, it exhibits favorable responsiveness to clinical variations. Consequently, it can serve as a screening instrument for healthcare professionals to comprehend breast cancer and as a reliable tool in research endeavors.

The effect of the use of the Gail model on breast cancer diagnosis in BIRADs 4a cases

Objective: The BI-RADS classification system and the Gail Model are the scoring systems that contribute to the diagnosis of breast cancer. The aim of the study was to determine the contribution of Gail Model to the diagnosis of breast lesions that were radiologically categorized as BI-RADS 4A.

Material and Methods: We retrospectively examined the medical records of 320 patients between January 2011 and December 2020 whose lesions had been categorized as BI-RADS 4A. Radiological parameters of breast lesions and clinical parameters according to the Gail Model were collected. The relationship between malignant BI-RADS 4A lesions and radiological and clinical parameters was evaluated. In addition, the effect of the Gail Model on diagnosis in malignant BI-RADS 4A lesions was evaluated.

Results: Among radiological features, there were significant differences between lesion size, contour, microcalcification content, echogenicity, and presence of ectasia with respect to the pathological diagnosis (p< 0.05). No significant difference was found between the lesions’ pathological diagnosis and the patients’ Gail score (p> 0.05). An analysis of the features of the Gail model revealed that there was no significant difference between the age of menarche, age at first live birth, presence of a first-degree relative with breast cancer, and a history of breast biopsy and the pathological diagnosis (p> 0.05).

Conclusion: As a conclusion Gail Model does not contribute to the diagnosis of BC, especially in patients with BI-RADS 4A lesions.

Body dysmorphic disorder and personality in breast augmentation: The big-five personality traits and BDD symptoms

BACKGROUND

Breast augmentation is one of the most performed cosmetic surgeries in the world. Personality traits predict the presence of psychological and social factors that may affect the patient satisfaction with a cosmetic surgical procedure and may be risk factors for body dysmorphic disorder. The aim of this study was to assess symptoms of body dysmorphic disorder in patients undergoing breast augmentation and identify their personality traits.

METHODS

Thirty-six women with hypoplasia of the breast (Sacchini index < 9 cm), a mean age of 28.1 years (SD = 6.2), body mass index ≤ 25 kg/m², and no history of breast surgery or breast-associated conditions were included in this prospective study.The Brazilian versions of the Structured Clinical Interview (SCID-I), Big Five Inventory (IGFP-5), and Body Dysmorphic Symptoms Scale (BDSS) were applied preoperatively and at 2 and 4 months after breast augmentation.

RESULTS

Personality traits were associated with symptoms of body dysmorphic disorder. A significant decrease (p< 0.001) in IGFP-5 scores on the Conscientiousness dimension, symptoms of body dysmorphic disorder (BDSS scores), and the number of patients with body dysmorphic disorder (SCID-I) were observed among different time points. In the study population, breast augmentation decreased the symptoms of body dysmorphic disorder, psychosocial impairment, and mean scores on Conscientiousness.

CONCLUSION

Personality traits varied in intensity and overlapped over time, and were associated with core symptoms of body dysmorphic disorder and the onset of body dissatisfaction.

Association of Breast Implants with Nonspecific Symptoms, Connective Tissue Diseases, and Allergic Reactions: A Retrospective Cohort Analysis

BACKGROUND

Given the rising media attention regarding various adverse conditions attributed to breast implants, the authors examined the association between breast implantation and the risk of being diagnosed with connective tissue diseases, allergic reactions, and nonspecific constitutional complaints in a cohort study with longitudinal follow-up.

METHODS

Women enrolled in a regional military health care system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match women who underwent breast implantation with women who did not undergo breast implantation. The propensity score included age, social history, health care use, comorbidities, and medication use. Outcomes assessed included International Classification of Diseases, Ninth Revision, diagnoses codes for (1) nonspecific constitutional symptoms, (2) nonspecific cardiac conditions, (3) rheumatoid arthritis and systemic lupus erythematosus, (4) other connective tissue diseases, and (5) allergic reactions.

RESULTS

Of 22,063 women included in the study (513 breast implants and 21,550 controls), we propensity score-matched 452 breast implant recipients with 452 nonrecipients. Odds ratios and 95 percent confidence intervals in breast implant recipients compared to nonrecipients were similar, including nonspecific constitutional symptoms (OR, 0.77; 95 percent CI, 0.53 to 1.13), nonspecific cardiac conditions (OR, 0.97; 95 percent CI, 0.69 to 1.37), rheumatoid arthritis and systemic lupus erythematosus (OR, 0.66; 95 percent CI, 0.33 to 1.31), other connective tissue diseases (OR, 1.02; 95 percent CI, 0.78 to 1.32), and allergic reactions (OR, 1.18; 95 percent CI, 0.84 to 1.66).

CONCLUSIONS

Women with breast implants did not have an increased likelihood of being diagnosed with nonspecific constitutional symptoms, connective tissue disorders, and/or allergic reaction conditions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Accuracy of self-perceived risk perception of breast cancer development in Iranian women

BACKGROUND

The accuracy of subjective risk perception is a matter of concern in breast cancer development. The objective of this study was to evaluate the accuracy of self-perceived risk assessment of breast cancer development and compared to actual risk in Iranian women.

METHODS

The demographic, clinical, and reproductive characteristics of 800 women aged 35-85 years were collected with an in-person interview. The self-perceived risk and the actual risk were assessed using the visual analog scale (VAS) and he Gail model respectively. Gail's cutoff of 1.66% risk was used to categorize the estimated 5-year actual risk as low/average risk (< 1.66%) and high risk (≥ 1.66). In low/average risk, if the self-perceived risk > actual risk, then individuals were considered as overestimating. Similarly, in high-risk women, if the perceived risk < actual risk, then, the subjects were labeled as under-estimate; otherwise, it was labeled as accurate. The Kappa statistics were used to determine the agreement between self-perceived risk and actual risk. ROC analysis was applied to determine the accuracy of self-perceived risk in the prediction of actual risk.

RESULTS

The perceived risk was significantly higher than actual risk (p = 0.001, 0.01 for 5-year and lifetime risk respectively). Both in low and high-risk groups about half of the women over-estimate and underestimate the risk by subjective risk perception. For a 5-year risk assessment, there was no agreement between perceived risk and actual risk (Kappa = 0.00, p = 0.98) but a very low agreement between them in lifetime risk assessment (Kappa = 0.09, p = 0.005). The performance of accuracy of risk perception versus actual risk was very low (AUC = 0.53, 95% CI 0.44-0.61 and AUC = 0.58, 95% CI 0.54-0.62 for the 5-year risk and lifetime risk respectively).

CONCLUSION

The clinical performance of risk perception based on VAS is very poor. Thus, the efforts of the public health education program should focus on the correct perception of breast cancer risk among Iranian women.

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".

Body image, cosmetic surgery, and minimally invasive treatments

Over the past 60 years, a growing body of research has investigated the psychological aspects of cosmetic surgery and related minimally-invasive treatments. While the earliest studies were influenced by psychoanalytic thinking, much of the work over the past several decades has been influenced by Thomas Cash's cognitive-behavioral theory of body image and has focused on the appearance concerns of patients who seek these procedures. The majority of individuals interested in the procedures report heightened dissatisfaction typically focused on the feature being considered for treatment. Studies from around the world also have suggested that between 5-15% of patients who present for cosmetic procedures meet diagnostic criteria for body dysmorphic disorder (BDD). While individuals with BDD typically do not report a reduction in their BDD symptoms following a cosmetic procedure, the great majority of patients without the disorder do report improvement in body image. The paper reviews this literature and also discusses the role of body image in three newer areas of plastic surgery-body contouring after massive weight loss, genital procedures (either for cosmetic purposes or as part of gender reassignment), and vascularized composite allotransplantation, including face and hand transplantation.

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.

US FDA Breast Implant Postapproval Studies: Long-term Outcomes in 99,993 Patients

OBJECTIVE

To analyze the long-term safety and efficacy outcomes of patients with breast implants.

SUMMARY BACKGROUND DATA

Research is ongoing regarding the safety of silicone breast implants. Despite the number of patients with breast implants followed by United States Food and Drug Administration large postapproval studies (LPAS), this database has not been thoroughly analyzed or reported.

METHODS

This is a multicentered, cohort study. LPAS prospectively monitor long-term implant-related outcomes and systemic harms for silicone/saline implants from 2 manufacturers (Allergan and Mentor) placed for primary/revision augmentation/reconstruction. Systemic harms, self-harm, and reproductive outcomes are compared with normative data. Implant-related complications are analyzed by implant composition and operative indication in the short and long terms.

RESULTS

LPAS data includes 99,993 patients, 56% of implants were silicone for primary augmentation. Long-term magnetic resonance imaging surveillance is under 5%. Compared with normative data, silicone implants are associated with higher rates of Sjogren syndrome (Standardized incidence ratio [SIR]8.14), scleroderma (SIR 7.00), rheumatoid arthritis (SIR5.96), stillbirth (SIR4.50), and melanoma (SIR3.71). One case of BI-ALCL is reported. There is no association with suicide. In the short term, rupture is higher for saline (2.5% vs. 0.5%, P < 0.001), and capsular contracture higher for silicone (5.0% vs. 2.8%, P < 0.001). At 7 years, reoperation rate is 11.7% for primary augmentation, and 25% for primary/revision reconstruction. Capsular contracture (III/IV) occurs in 7.2% of primary augmentations, 12.7% primary reconstructions, and is the most common reason for reoperation among augmentations.

CONCLUSIONS

This is the largest study of breast implant outcomes. Silicone implants are associated with an increased risk of certain rare harms; associations need to be further analyzed with patient-level data to provide conclusive evidence. Long-term safety and implant-related outcomes should inform patient and surgeon decision-making when selecting implants.

Quality of Life After Breast Enlargement With Implants Versus Augmentation Mastopexy: A Comparative Study

BACKGROUND

Research regarding quality of life (QoL) among women who have undergone breast aesthetic surgery is expanding. A comparative, anonymous study between the two main breast aesthetic procedures is needed.

OBJECTIVES

The authors compared patient characteristics and aspects of QoL among women who underwent breast enlargement with implants (BI group) and those who underwent augmentation mastopexy (AM group).

METHODS

Patients at the Oslo Plastic Surgery Clinic were given a 47-question survey to measure QoL. The survey was anonymous; 61 patients who received breast implants and 37 patients who underwent augmentation mastopexy between 2005 and 2009 responded. Answers were processed by a QuestBack return mail system and sent to the authors. Statistical analyses were performed to evaluate significance between the groups.

RESULTS

The response rate was 67% in the BI group and 88% in the AM group. Mean follow-up time was 2.8 years in both groups. Motivation for surgery was primarily cosmetic (65%) and emotional (48%) in the BI group as well as cosmetic (78%) and physical (31%) in the AM group. The effects on psychosocial aspects were significant in the BI group regarding life changes and feeling like a "whole" person (68.9% vs 40.5% and 73.8% vs 40%). BI group also had a significantly higher satisfaction with overall cosmetic result, enlargement, and breast volume (93.4 %, 90.2%, 80% vs 69.4%, 70.2% vs 67% in AM group). Additionally, the BI group was more satisfied with shape, scar, and symmetry (90.1% vs 63.9%, 70.6% vs 40.5%, and 83.6% vs 54.0%, respectively).

CONCLUSIONS

None of our patient groups were stereotypical and motivation for surgery was primarily cosmetic in both groups. BI patients were significantly more satisfied with the aesthetic outcome and the QoL of many psychosocial aspects. AM patients may have had different expectations than BI patients and a significant dissatisfaction was reported in shape, scarring, symmetry, and the nipple-areola complex.

LEVEL OF EVIDENCE 3

Predictors of satisfaction in patient with silicone breast implants and its association with drug intake habits

BACKGROUND

Satisfaction is an important outcome variable in surgical success. The purpose of this study is to evaluate predictors of satisfaction in women submitted to silicone textured breast implant surgery.

METHODS

A retrospective evaluation of women receiving textured silicone breast implants was performed. Patients were divided in four groups: cosmetic cohort (n = 104), reconstructive cohort (n = 120), general population control cohort (n = 120) and aesthetic control cohort (n = 54). Data were collected based on information retrieved from patient records, a planned consultation and a self-administered structured questionnaire.

RESULTS

Patient satisfaction was influenced by preoperative information (p = .007), cohort (p < .001), and occurrence of postoperative complications (p < .001). The degree of satisfaction was also related with drug intake habits: women using psychotropic drugs were 3-fold more likely to report poor satisfaction than those that never used these drugs (p < .001).

CONCLUSION

The purpose of the surgery, preoperative information and the occurrence of postoperative complications have an impact on the degree of satisfaction of women submitted to silicone breast implant surgery. Women using psychotropic drugs are more likely to report poor satisfaction.

Self-reported psychological development in cosmetic breast surgery patients

Cosmetic breast surgery is the only therapeutic alternative for psychological and physical complications associated with micromasty, breast ptosis, and macromasty. We analyzed the effects of 2 variables, time, and type of cosmetic breast surgery, on anxiety symptomatology and quality of life.Following a mixed 3 × 4 design, 3 groups of women with breast augmentation (n = 63), mastopexy (n = 42), and breast reduction (n = 30) were selected and evaluated using the State-Trait Anxiety Inventory and the 12-Item Short-Form Health Survey at 4 different times, the preoperative stage, and at 1, 6, and 12 months postoperative. Pearson's chi square, Welch's U, Games-Howell tests, mixed analysis of variance, and Cohen's d and w for effect size were calculated.Results relating to anxiety (state and trait) showed that the time factor was significant (P < 0.001) with differences between the preoperative stage (higher anxiety levels) and the 3 postoperative stages: at 1 month (P < 0.001), 6 months (P < 0.001), and 12 months (P < 0.001). In quality of life, type of surgery and time factors were found to have interactive effects on vitality (P = 0.044) and role-emotional (P = 0.023) dimensions. Compared to the other 2 groups, women who had undergone mastopexy felt worse (vitality) at 1 month since surgery than in the other stages, and better at 6 months since surgery (role-emotional). In the rest of the dimensions, and focusing on the most relevant effect sizes, the type of surgery made a difference in the physical functioning (P = 0.005) and role-physical (P = 0.020) dimensions, where women who had had breast reduction felt worse than those who had had augmentation. Time also resulted in differences in the physical functioning (P < 0.001), role-physical (P < 0.001), and bodily pain (P < 0.001) dimensions, where women felt worse at 1 month since surgery than during the rest of the stages, as well as in the social functioning dimension (P < 0.001) at 1 month, compared to 6 months postoperative.We conclude that in the long term, women who have cosmetic breast surgery recover their physical and psychological well-being.

Reflections on the ethics of biomaterials science

The subject of biomaterials science concerns artificial materials used in medical devices to repair or reconstruct natural human tissue damaged by disease or trauma. It embraces the emerging field of tissue engineering, where artificial materials are used as scaffolds to provide the architecture for replacement organs. As such, the field raises numerous ethical issues, which are reviewed in this paper. These include the use of animal models, the testing materials and devices in patients, and what may be viewed as potential abuses, where augmentation and repair are carried out for cosmetic as opposed to clinical reasons. The paper gives detailed consideration of the recent problems of metal-on-metal hip replacements as an exemplar of some of the key ethical issues that arise in this field.

Canadian breast implant cohort: extended follow-up of cancer incidence

Cosmetic breast implants are not associated with increased breast cancer incidence, but variations of risk according to implant characteristics are still poorly understood. As well, the assessment of cancer risk for sites other than breast needs to be clarified. The purpose of this study was to fill these research gaps. This study presents an extended analysis of 10 more years of follow-up of a large Canadian cohort of women who received either cosmetic breast implants (n = 24,558) or other cosmetic surgery (15,893). Over 70% of the implant cohort was followed for over 20 years. Cancer incidence among implant women was compared to those of controls using multivariate Poisson models and the general female population using the standardized incidence ratios (SIRs). Women with breast implants had reduced rates of breast and endometrial cancers compared to other surgery women. Subglandular implants were associated to a reduced rate of breast cancer compared to submuscular implants [incidence rate ratio (IRR) = 0.78, 95% confidence interval (CI) = 0.63-0.96] and this reduction persisted over time. We observed a sevenfold increased rate (IRR = 7.36, 95% CI = 1.86-29.12) of breast cancer in the first 5 years after the date of surgery for polyurethane-coated subglandular implant women but this IRR decreased progressively over time (p value for trend = 0.02). We also observed no increased risk of rarer forms of cancer among augmented women. A reduction in breast cancer incidence was observed for women with subglandular implants relative to women with submuscular implants. Possible increase of breast cancer incidence shortly after breast augmentation with polyurethane implants needs to be verified.

[Special considerations in breast cancer treatment of an augmented breast]

Breast augmentation surgery involving the use of implants has been one of the most popular plastic surgical procedures for decades. As the multi-million female population who received breast implants ages, the risk of cancer is increasing rapidly, therefore the incidence of malignant disease in association with breast implants will increase as well. Although there is no relationship between tumor development and implants, these cases require special considerations in diagnostics, therapy and follow-up methods. Appropriate multidisciplinary treatment of tumors in augmented breasts corresponding with modern oncoplastic principles can only be accomplished based on adequate oncological, breast and plastic surgical knowledge. Supposing a possible increase of this condition in Hungary, too, authors provide a wide review of the literature on the special oncological and esthetic considerations, for the first time in Hungarian language.

Breastfeeding after augmentation mammaplasty with saline implants

It has been reported that breastfeeding problems occur in women who have breast implants. The breastfeeding success of women who had augmentation with saline implants and subsequently had a live birth (n = 107) was compared with that of women of similar age who had hypoplastic breasts and had children before their consultation (n = 105). A self-administered 11-item questionnaire was used to collect data on demographics and breastfeeding success. The information requested included age, weight, height, whether breastfeeding was attempted, if it was successful, and the need to supplement. Additional information requested from the study group included position of breast scar, implant volume, and whether loss of nipple sensation had occurred after the surgery (as judged by the patient). The groups were not significantly different in age (22 +/- 7 vs. 23 +/- 5). There was, however, a significant difference (P < 0.05) in the breastfeeding success and need to supplement feedings. Successful breastfeeding occurred in 88% of the control and 63% of the study group. A need to supplement breastfeeding occurred in 27% of the control group but increased to 46% in the study group. No significant difference (P > 0.05) was found in the breastfeeding experience between periareolar and inframammary approaches. Loss of nipple sensation after augmentation mammaplasty was reported by 2% of both the periareolar and inframammary subgroups. The success rate of breastfeeding decreases approximately 25% and the need to supplement breastfeeding increases 19% in young women with hypoplastic breasts after augmentation mammaplasty, irrespective of whether a periareolar or inframammary approach is used.

Excess suicide risk and other external causes of death among women with cosmetic breast implants: a neglected research priority

Five large epidemiologic mortality studies of women with cosmetic breast implants have consistently reported a two- to threefold higher rate of suicide compared with the general female population. Overall, 135 suicides have been observed, compared with 66.9 expected, yielding a significantly elevated standardized mortality ratio of 2.0 (95% CI, 1.5-2.6). In addition to suicides, excesses from other external causes of death related to drug and alcohol abuse/dependence, atypical motor vehicle accidents, and other self-harm causes have been consistently reported. These observations, together with limited but direct epidemiologic evidence of preimplant psychiatric hospitalization, as well as self-reports of preimplant psychiatric disorders, including depression, eating disorders, and body image dissatisfaction, among implant women raise the possibility of significant underlying psychiatric morbidity for a subgroup of implant patients. Research into the psychiatric profiles and history of the women who have committed suicide in the investigated cohorts appears warranted.

The influence of cosmetic breast augmentation on the stage distribution and prognosis of women subsequently diagnosed with breast cancer

This study aimed to determine whether cosmetic breast implants impair the early detection of breast cancer, and adversely influence survival. This analysis derives from a cohort of 24,558 women who received bilateral cosmetic breast implants, and 15,893 women who underwent other plastic surgery procedures at the same practices in Ontario and Quebec, Canada, between 1974 and 1989. Incident cancers and vital status through 1997 were determined by record linkage to the Canadian Cancer Registry and Canadian Mortality Database. Analyses are based on a total of 182 and 202 incident cases of breast cancer identified among the implant and control groups, respectively. Contingency table analyses were performed to test for differences in the stage distribution of breast cancers between the 2 groups. Potential differences in survival were evaluated using the Kaplan-Meier estimates and Cox proportional hazards models. Women who received breast implants were more likely to have advanced stage breast carcinoma relative to the other plastic surgery patients (crude and adjusted ps </= 0.01). No statistically significant differences in distributions between the implant and control patients were found for age at diagnosis, tumor size, histological type, period of diagnosis or length of follow-up. The delayed diagnosis in augmented women did not appear to influence the overall prognosis. Breast cancer-specific survival was similar in both groups (hazard ratio = 1.06; 95% confidence interval = 0.65-1.74). In conclusion, this study suggests that breast implants delay the detection of breast cancer, but there was no statistically significant difference in survival between the breast implant and other plastic surgery groups.

Psychological considerations in cosmetic breast augmentation

Within the past decade, the popularity of cosmetic breast augmentation has surged and, with it, the interest in the psychological aspects of the procedure. Investigations of women who seek cosmetic breast augmentation have examined both their psychosocial characteristics and their motivations for surgery. Dissatisfaction both with body image and with breast size and/or shape are thought to be primary motivators for surgery. It is common for women seeking cosmetic breast augmentation to have some body image dissatisfaction. However, a considerable minority may suffer from excessive dissatisfaction consistent with the psychiatric diagnosis of body dysmorphic disorder, which is believed to contraindicate cosmetic surgery. Following breast augmentation, most women report satisfaction with the aesthetic result and improvements in body image. The impact of the procedure on other areas of functioning, such as self-esteem and quality of life, is less clear. These positive outcomes have been tempered by recent epidemiological studies that have identified a relationship between cosmetic breast implants and suicide. This article reviews this literature and provides recommendations to plastic surgical nurses regarding the psychological assessment and management of patients seeking breast augmentation.

Cancer among Scandinavian women with cosmetic breast implants: a pooled long-term follow-up study

No increased risks of specific types of cancer following breast implantation have been consistently reported, but data on risk beyond 15 years are limited. We have pooled the results of 2 nationwide cohort studies of 3,486 Swedish and 2,736 Danish women who underwent cosmetic breast implantation between 1965 and 1993. Cancer incidence through 2002 was ascertained through nationwide cancer registries. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated to compare cancer incidence among women with implants with women in the general population. Mean duration of follow up was 16.6 years (range 0.1-37.8 years). Over 50% of women were followed for 15 years or more after breast implantation and 13.3% for at least 25 years. There was a reduced incidence of breast cancer (SIR=0.73; 95% CI 0.58-0.90), whereas lung cancer was above expectation (SIR=1.64; 95% CI 1.10-2.36). The increased risk of lung cancer is expected due to the high prevalence of smoking among the women with implants in our study. With respect to other site-specific cancers, no significantly increased or decreased SIR was observed. This study, which includes women followed for almost 4 decades, represents the longest follow up of women with cosmetic breast implants to date. The results provide no evidence of an association between breast implants and any type of cancer.

The relationship of silicone breast implants and cancer at other sites

BACKGROUND

Although most attention regarding the effects of silicone breast implants on cancer risk has focused on breast cancer, there have also been concerns regarding effects on other cancers. This includes malignancies that could occur as a result of foreign-body carcinogenesis (sarcomas) or immune alterations (hematopoietic malignancies), or cancers suggested as possibly elevated on the basis of previous epidemiologic studies (cancers of the cervix, vulva, lung, and brain).

METHODS

Searches of the English language literature on the topic of silicone breast implants and cancer risk were conducted and reviewed to determine relationships that might have etiologic relevance.

RESULTS

Epidemiologic studies provide no support for an increased risk of either sarcoma or multiple myeloma among breast implant recipients, disputing clinical and laboratory findings suggesting such a link. Although a number of epidemiologic studies have demonstrated elevated risks of cervical, vulvar, and lung cancers among breast implant patients, it is likely that these excesses relate more to lifestyle characteristics (e.g., cigarette smoking, sexual behavior) than to the effects of the implants. Brain cancer excesses, suggested in one study, have not been confirmed in either an update of the mortality experience in this study or on the basis of other investigations.

CONCLUSIONS

At present, there is no convincing evidence that breast implants alter the risk of nonbreast malignancies. Breast implant patients should continue to be monitored for longer term risks and to assess whether cancer risk is influenced by various patient and implant characteristics.

The psychological aspects of cosmetic breast augmentation

BACKGROUND

The psychological aspects of cosmetic breast augmentation have been the focus of a great deal of empiric study over the past 40 years.

METHODS

Studies investigating the preoperative characteristics and psychosocial status of women interested in breast augmentation are reviewed. Investigations of postoperative satisfaction and psychosocial changes are discussed. The results of the seven epidemiologic studies that have identified a relationship between cosmetic breast augmentation and suicide are detailed.

RESULTS

Methodologic limitations of the studies investigating the preoperative psychosocial status of breast augmentation candidates make it difficult to draw firm conclusions about the potential psychological differences between these women and those not interested in breast augmentation. Postoperative satisfaction rates are high, and several studies suggest that patients experience improvements in body image following surgery. The effects of breast augmentation on other areas of psychological functioning are less clear. Based on the seven epidemiologic studies published to date, the suicide rate among women with cosmetic breast implants is two to three times the expected rate.

CONCLUSIONS

The literature in this area should be used to guide the psychosocial assessment and management of cosmetic breast augmentation patients. There currently is little evidence to support a recommendation that all women who present for cosmetic breast augmentation be required to undergo a psychiatric evaluation before surgery. Given the relationship between breast implants and suicide, however, it is recommended that women with a history of psychopathology who present for breast augmentation, or those who are suspected by the plastic surgeon of having some form of psychopathologic abnormality, should undergo a mental health consultation before surgery.

Psychological considerations in cosmetic breast augmentation

Within the past decade, the popularity of cosmetic breast augmentation has surged and, with it, the interest in the psychological aspects of the procedure. Investigations of women who seek cosmetic breast augmentation have examined both their psychosocial characteristics and their motivations for surgery. Dissatisfaction both with body image and with breast size and/or shape are thought to be primary motivators for surgery. It is common for women seeking cosmetic breast augmentation to have some body image dissatisfaction. However, a considerable minority may suffer from excessive dissatisfaction consistent with the psychiatric diagnosis of body dysmorphic disorder, which is believed to contraindicate cosmetic surgery. Following breast augmentation, most women report satisfaction with the aesthetic result and improvements in body image. The impact of the procedure on other areas of functioning, such as self-esteem and quality of life, is less clear. These positive outcomes have been tempered by recent epidemiological studies that have identified a relationship between cosmetic breast implants and suicide. This article reviews this literature and provides recommendations to plastic surgical nurses regarding the psychological assessment and management of patients seeking breast augmentation.

Cancer risk among Los Angeles women with cosmetic breast implants

BACKGROUND

As the first generation of women who received cosmetic breast implants ages, questions remain about cancer risk. This study is an update of the Los Angeles Augmentation Mammaplasty Study and examines cancer risk among women with long-term exposure to breast implants.

METHODS

The authors conducted a record linkage cohort study of patients with cosmetic breast implants by abstracting from records of the private practices of 35 board-certified plastic surgeons in Los Angeles County, California. They included 3139 Caucasian women who received cosmetic breast implants between 1953 and 1980. Spanish-surnamed women, nonresidents of Los Angeles County, and patients with prior subcutaneous mastectomy or breast cancer were excluded. Cancer outcomes through 1994 were ascertained through record linkage with the Los Angeles County Cancer Surveillance Program.

RESULTS

With a mean follow-up period of 15.5 years, 43 cases of breast cancer were observed, compared with 62.6 expected, based on Los Angeles County population-based incidence rates (standardized incidence ratio, 0.69; 95% CI, 0.50 to 0.93). Significant increases were observed for cancer of the lung and bronchus (standardized incidence ratio, 2.14; 95% CI, 1.42 to 3.09) and vulvar cancer (standardized incidence ratio, 3.47; 95% CI, 1.39 to 7.16).

CONCLUSIONS

The breast cancer results of this study are consistent with the previous reports of the Los Angeles study as well as with several other long-term cohort studies. Lung cancer has previously been found to be increased in this cohort and also in some, but not most, other studies. The increased risk of vulva cancer has previously been observed in this cohort and just one other.

Mortality among Canadian women with cosmetic breast implants

There is widespread concern about possible long-term health effects among women who have received breast implants for cosmetic purposes; few studies have reported on the mortality patterns of such women. The authors examined cause-specific mortality in a cohort of 24,558 women with breast implants and 15,893 women who underwent other plastic surgery procedures in Ontario and Quebec, Canada, between 1974 and 1989. Deaths through 1997 were identified through linkage to the national mortality database. The authors compared the mortality of women who received implants with that of the general population by using standardized mortality ratios; Poisson regression was used to perform internal cohort comparisons. Overall mortality was lower among women who received breast implants relative to the general population (standardized mortality ratio = 0.74, 95% confidence interval: 0.68, 0.81). In contrast, higher suicide rates were observed in both the implant (standardized mortality ratio = 1.73, 95% confidence interval: 1.31, 2.24) and other plastic surgery (standardized mortality ratio = 1.55, 95% confidence interval: 1.07, 2.18) patients. No differences in mortality were found between the implant and other surgeries group for any of the 20 causes of death examined. Findings suggest that breast implants do not directly increase mortality in women. Further work is needed to evaluate risk factors for suicide among women who undergo elective cosmetic surgery.

Cancer incidence in a cohort of Ontario and Quebec women having bilateral breast augmentation

The possibility that women, who receive breast implants for cosmetic purposes, have increased long-term risks of developing cancer continues to be debated. The objective of our study was to prospectively examine cancer incidence among women who received breast implants. A cohort was assembled of 24,558 women, 18 years of age and older, who underwent bilateral cosmetic breast augmentation, and 15,893 women who underwent other cosmetic procedures in Ontario or Quebec between 1974 and 1989. These plastic surgery patients were selected from the same clinics as the implant population. Incident cancers were identified by linking to Canadian registry data up to December 31, 1997. In total, 676 cancers were identified among women who received breast implants compared to 899 expected based on general population rates (standardized incidence ratio (SIR) = 0.75; 95% confidence interval (CI) = 0.70-0.81). Overall cancer incidence rates among women who received breast implants were similar to that of the other plastic surgery patients (relative risk (RR) = 0.91, 95% CI = 0.81-1.02). However, women who received breast implants had lower breast cancer rates than the plastic surgery patients (RR = 0.64, 95% CI = 0.53-0.79). No increased risks were observed among the implant population for any of the other cancer sites examined. Comparisons involving only women who received breast implants found no association between long-term breast cancer incidence and implant site (submuscular vs. subglandular), fill (saline vs. silicone) or envelope (polyurethane-coated or not). In conclusion, women undergoing cosmetic breast augmentation do not appear to be at an increased long-term risk of developing cancer.

Long-Term Cancer Risk Among Swedish Women With Cosmetic Breast Implants: An Update of a Nationwide Study

Epidemiologic evidence does not support a consistently increased cancer risk among women with cosmetic breast implants, but few studies have assessed risk beyond 15 years. Swedish women who underwent cosmetic breast implantation for the first time between January 1, 1965, and December 31, 1993 (N = 3486), were followed through December 31, 2002. Cancer incidence was ascertained through the nationwide Swedish Cancer Registry. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated to compare cancer incidence of women with implants with women in the general population. Mean follow-up among women with breast implants was 18.4 years (range = 0.1-37.8 years). The incidence of breast cancer was below expectation (SIR = 0.7, 95% CI = 0.6 to 1.0), whereas lung cancer was above expectation (SIR = 2.2, 95% CI = 1.3 to 3.4). With respect to cancer overall and all other specific cancer sites, including brain cancer and sarcoma, non-Hodgkin lymphoma, and multiple myeloma, no statistically significantly increased or decreased SIRs were observed. Stratification by duration of follow-up revealed no statistically significantly increased or decreased SIR, with the exception of a two- to threefold excess of lung cancer among women followed for more than 15 years, which would be expected due to the high prevalence of smoking among the Swedish women with implants in our study.

Mortality Rates Among Augmentation Mammoplasty Patients

BACKGROUND

A large follow-up study of cosmetic breast implant patients previously suggested an overall decrease in mortality but increased risks of brain and respiratory cancers and of suicides.

METHODS

This cohort of 12,144 implant patients and 3614 patients with other types of plastic surgeries was followed for 5 additional years, enabling derivations of standardized mortality ratios (SMRs) based on population rates and relative risks (RRs) based on comparisons with the other patients.

RESULTS

A total of 443 implant and 221 other plastic surgery patients were identified as deceased (SMR = 0.65 [95% confidence interval (CI) = 0.6-0.7] and 0.56 [0.5-0.6], respectively). Despite evidence that implants can interfere with mammographic visualization, there was no evidence that implant patients had a higher risk of death from breast cancer as compared with either the general population or other plastic surgery patients. The previous excess risk of brain cancer deaths among implant patients was attenuated by follow-up (as the result of no additional deaths; SMR = 1.43, 0.8-2.5; RR = 2.07, 0.5-8.9). A previously observed excess risk of respiratory cancer deaths persisted in comparisons with other plastic surgery patients (RR = 1.63; 1.0-2.7), but there was no evidence of a trend of risk with follow-up time. Implant patients also showed an elevated risk of suicide (SMR = 1.63, 1.1-2.3; RR = 2.58, 0.9-7.8) and of deaths caused by motor vehicle accidents (RR = 1.73; 0.6-5.4).

CONCLUSIONS

Although several elevations in cause-specific mortality were attenuated by additional follow-up, the excess risk of suicide among the implant patients remains of concern.

Do breast implants after a mastectomy affect subsequent prognosis and survival?

In a large study, published in this issue of Breast Cancer Research, Le and colleagues report that women receiving implants after mastectomies for early-stage breast cancer experience lower breast cancer mortality than women not receiving implants. Assessment of survival patterns among women receiving reconstructive implants is complex given unique patient characteristics, disease attributes, and treatment patterns. The interpretation of reduced mortality from breast cancer must be assessed in light of significantly reduced risks of death from most other causes. In contrast, patients receiving post-mastectomy implants had elevated rates of suicide, consistent with findings among women with cosmetic implants. Additional well-designed investigations are needed to clarify survival patterns among women receiving reconstructive implants.

Increased Risk of Suicide Among Patients With Breast Implants: Do the Epidemiologic Data Support Psychiatric Consultation?

Four epidemiologic studies have examined mortality among women with cosmetic silicone gel-filled breast implants and have found that risk of death from suicide is two- to threefold higher in this group than among women of comparable age in the general population. The authors review the literature on the psychological and psychiatric hypotheses concerning women undergoing plastic surgery, although these hypotheses do not specifically address the association with suicide. Epidemiologic research is urgently needed to evaluate whether this association is an artifact of a higher prevalence of underlying and unreported psychopathology and other risk factors for suicide among women receiving breast implants or whether implants have an actual causal role in the risk of suicide. Until such studies are completed, psychiatric consultation should be considered before breast augmentation, especially for patients perceived to be at high risk by the plastic surgeon.

Causes of Death Among Finnish Women with Cosmetic Breast Implants, 1971–2001

Mortality patterns among women with cosmetic breast implants have not been well characterized. We examined cause-specific mortality among women who underwent cosmetic breast implantation at major public hospitals and private clinics in Finland from 1970 through 2000. Causes of death through 2001 were identified through the national mortality register. Expected numbers of deaths were calculated on the basis of mortality rates in the general female population, and standardized mortality ratios (SMR), i.e. ratios of observed to expected deaths, and 95% confidence intervals (CI) were calculated. Among the 2166 women with cosmetic breast implants, we observed 31 deaths versus 32.1 expected. Overall disease mortality was below expectation, mainly due to low mortality from diseases of the circulatory system (SMR, 0.28; 95% CI, 0.03-1.02). Mortality from cancer was close to expectation. There was a statistically significant excess of suicide, based on 10 deaths, which was most pronounced during the first 5 years of follow-up (SMR, 4.26; 95% CI, 1.56-9.26). In conclusion, although based on small numbers, women with cosmetic breast implants did not experience higher mortality overall than women in the general population. The high suicide risk supports other studies and warrants further detailed investigation.

Attitudes of adolescents about cosmetic surgery

Although the number of teenagers choosing to have cosmetic procedures is increasing at a rapid rate, few studies have been published describing their attitudes about aesthetic surgery. To understand better their beliefs about cosmetic surgery, voluntary, confidential surveys were sent to the entire junior class of a suburban high school. Although two thirds of the respondents knew someone who had undergone cosmetic surgery, only one third would choose it for themselves. Those who desired aesthetic surgery described people who have cosmetic procedures as "motivated," whereas those who would not choose this option believed individuals who do so are "vain." The most desired procedures were liposuction, rhinoplasty, and breast augmentation. The main reasons for not proceeding were health risks, cost, and fear of a bad result. The most common source of information about plastic surgery among the students was teen magazines and television.

Stage of breast cancer at diagnosis among women with cosmetic breast implants

Concern has been raised about the potential delay in breast cancer diagnosis in the augmented breast. We linked a cohort of 2955 women, who received cosmetic breast implants in Denmark during the period 1973-1997 with the Danish Cancer Registry and the Danish Breast Cancer Cooperative Group register. We identified 23 incident cases of invasive breast cancer diagnosed subsequent to breast implantation. We randomly selected 11 controls for each case from the Danish Breast Cancer Cooperative Group's register, and obtained detailed information on all study subjects about surgery, histopathology and stage of breast cancer at diagnosis, intended adjuvant treatment according to trial protocols and overall survival. We found that women with breast implants on average were diagnosed with breast cancer at the same stage as controls. Significantly more women with breast implants had tumour cells in the surgical margins according to the Danish Breast Cancer Cooperative Group's data. There was no significant difference in overall survival between the two groups after an average of 6.4 years of follow-up. Based on this limited number of women with breast cancer subsequent to breast augmentation, breast implants do not appear to delay the diagnosis of breast cancer, and no evidence of impaired survival after breast cancer diagnosis in augmented women was found.

Characteristics of women with cosmetic breast implants compared with women with other types of cosmetic surgery and population-based controls in Denmark

Herein the authors describe characteristics of women with breast implants compared with women with other types of cosmetic surgery as well as population controls. All women who acquired breast implants from 1977 to 1997 were identified from the files of two private plastic surgery clinics in Denmark. Patient characteristics were obtained through a self-administered questionnaire. The magnitude of differences between patient and control groups was estimated using odds ratios and 95% confidence intervals. Women with breast implants had a significantly lower body mass index and reported a two-fold greater incidence of current smoking compared with women from the general population and compared with women with other cosmetic surgery. Women with implants reported a greater number of full-term pregnancies and were less likely than controls to have had their first birth at age 30 years or older. Women with implants were not more likely than women in either control group to report a history of diseases, including connective tissue diseases, cancer, or depression before their implant surgery. Women with cosmetic breast implants differ from women with other forms of cosmetic surgery and from general population controls with respect to characteristics that may importantly influence health outcomes and that need to be addressed in future breast implant studies.

Mortality among augmentation mammoplasty patients

Much attention has focused on disease risks among women receiving silicone breast implants, but there has been little evaluation of their mortality experience. We undertook a retrospective cohort study of 13,488 women receiving cosmetic implants and 3,936 patients with other types of plastic surgery at 18 plastic surgery practices. After an average of 13 years of follow-up, deficits in overall mortality were found as compared with the general population (U.S. rates) for both implant [255 deaths; standardized mortality ratio (SMR) = 0.69, 95% confidence interval (CI) = 0.6-0.8] and comparison subjects (125 deaths; SMR = 0.58, 95% CI = 0.5-0.7). These findings indicate that patients seeking plastic surgery are in general healthier than their peers. Implant patients, however, experienced excess risks of death compared with the general population for brain cancer (SMR = 2.45) and suicide (SMR = 1.54). Internal analyses showed a higher overall mortality among the implant than among the comparison patients (relative risk = 1.27, 95% CI = 1.0-1.6). This overall excess reflected increases for respiratory tract (SMR = 3.03) and brain (SMR = 2.25) cancers and for suicide (SMR = 4.24).

Cancer risk at sites other than the breast following augmentation mammoplasty

PURPOSE

There has been limited investigation of cancer risk other than breast cancer among patients with breast implants, despite some clinical and laboratory evidence suggesting links with certain cancer sites, including hematopoietic and connective tissue malignancies.

METHODS

A retrospective cohort study of 13,488 patients who received cosmetic breast implants at 18 plastic surgery practices in six geographic areas was conducted to assess long-term health effects. After an average of 12 years of follow-up, questionnaires were administered to subjects located and alive (78% of eligible population). Attempts were made to obtain death certificates for deceased subjects and medical verification for all reported cancers. Expected numbers of cancers were derived using general population cancer incidence rates and an internal comparison series of 3936 patients who received other types of plastic surgery at the same practices as the implant patients.

RESULTS

A total of 359 malignancies was observed versus 295.95 expected based on general population rates, resulting in a standardized incidence ratio (SIR) of 1.21 [95% confidence interval (CI) 1.1-1.4]. Individual malignancies for which incidence was significantly elevated included cancers of the stomach (SIR = 2.65), cervix (SIR = 3.18), vulva (SIR = 2.51), brain (SIR = 2.16), and leukemia (SIR = 2.19). No excess risks were observed for other hematopoietic malignancies, including multiple myeloma. The internal analyses, however, based on cancer rates derived among the comparison patients, showed no increased cancer risk among the implant patients [relative risk (RR) = 1.00, 95% CI 0.8-1.2], as well as no statistically significant elevations for most individual sites. Cervical cancer continued to be elevated (RR = 1.78), although to a lesser extent than in the external analyses, while the risk for respiratory cancers was higher (RR = 2.40). Non-significant elevations in risk persisted in this analysis for liver cancer (RR = 2.65), brain cancer (RR = 2.83), and leukemia (RR = 1.83). Many of the cancers showing excesses were defined on the basis of death certificates, requiring caution in interpretation. The histologies of the leukemias were quite varied, which makes a biologic relationship appear unlikely. However, respiratory cancers showed some evidence of increasing risk with follow-up time and both respiratory and brain cancers were elevated in the mortality analyses.

CONCLUSIONS

Although excesses of cervical and vulvar cancer among implant patients might be attributable to lifestyle factors, reasons for excesses of respiratory and brain cancers were less apparent.