Prevalence of silicone breast implant rupture among Danish women

Imaging of the Reconstructed Breast

The incidence of breast cancer and, therefore, the need for breast reconstruction are expected to increase. The many reconstructive options available and the changing aspects of the field make this a complex area of plastic surgery, requiring knowledge and expertise. Two major types of breast reconstruction can be distinguished: breast implants and autologous flaps. Both present advantages and disadvantages. Autologous fat grafting is also commonly used. MRI is the modality of choice for evaluating breast reconstruction. Knowledge of the type of reconstruction is preferable to provide the maximum amount of pertinent information and avoid false positives. Early complications include seroma, hematoma, and infection. Late complications depend on the type of reconstruction. Implant rupture and implant capsular contracture are frequently encountered. Depending on the implant type, specific MRI signs can be depicted. In the case of myocutaneous flap, fat necrosis, fibrosis, and vascular compromise represent the most common complications. Late cancer recurrence is much less common. Rarely reported late complications include breast-implant-associated large cell anaplastic lymphoma (BIA-ALCL) and, recently described and even rarer, breast-implant-associated squamous cell carcinoma (BIA-SCC). In this review article, the various types of breast reconstruction will be presented, with emphasis on pertinent imaging findings and complications.

Assessment of Risk Factors for Rupture in Breast Reconstruction Patients with Macrotextured Breast Implants

BACKGROUND

Breast implants (BI) are widely used in plastic surgery, though they are not lifetime devices. Average life before rupture is reported to be around 10-15 years. No consensus exists regarding which factors are involved.

OBJECTIVES

Following FDA recommendations, this study aims at identifying potential risk factors by evaluating their effect on BI rupture cases.

METHODS

In this observational study, 763 BI patients were operated between 2003 and 2019, with a mean implant indwelling of 12.2 years. Patients that returned for follow-up were administered a questionnaire regarding postoperative lifestyle and habits. Implant rupture rate was 15.1%, while BI lifespan was 10.1 years. We obtained complete data from 191 breast implant patients (288 implants). Twenty-three potential risk factors were evaluated and divided in four categories: patient-related, surgery-related, postoperative complications/symptoms, and postoperative care/lifestyle habits. Odds Ratio (OR) for each factor was calculated. Linear regression analysis was calculated for those with a significant OR.

RESULTS

We report 120 patients (195 implants) with intact and 71 (93 implants) with ruptured devices. BIs were macrotextured in 95.1% of cases (86.8% Allergan BIOCELL). OR was significant for underwire bra use (OR: 2.708), car seat belts (OR: 3.066), mammographic imaging (OR: 2.196), weightlifting (OR: 0.407) and carry-on heavy purses and backpacks (OR: 0.347).

CONCLUSION

Wearing underwire bras, seat belts and undergoing mammography increases the risk of rupture. Weightlifting and carry heavy bags do not increase that risk. Implant rupture is directly linked with time of indwelling. Postoperative recommendations in BI patients should consider findings from our study, though larger multicenter studies should be encouraged.

LEVEL OF EVIDENCE IV

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 .

Accuracy of Ultrasonography in Breast Implant Rupture Diagnosis: Systematic Review and Meta-Analysis

BACKGROUND

Breast augmentation is the most common aesthetic operation performed in the United States and worldwide; 1,862,506 breast augmentation procedures were performed in 2018, an increase of 27.6 percent compared to 2014 data.

METHODS

In the present study, the authors performed a systematic review to identify the accuracy of ultrasonography for diagnosing breast prosthesis rupture. Studies in which the ultrasound diagnostic test was compared to a surgical finding as a reference standard were reviewed.

RESULTS

As a result, 20 primary studies were included in the analyses, with a total of 1987 patients and 3297 prostheses. The use of ultrasound for diagnosis of breast prosthesis rupture presented the following results: pooled sensitivity, 73.7 percent (95 percent CI, 70.2 to 77.1 percent); pooled specificity, 87.8 percent (95 percent CI, 86.5 to 89.0); area under the receiver operating characteristic curve, 0.7762; diagnostic odds ratio, 11.04 (95 percent CI, 5.79 to 21.08).

CONCLUSION

This study supports that ultrasound of breast prostheses is an adequate tool in the diagnosis of rupture.

Efficacy of ultrasound, mammography and magnetic resonance imaging in detecting breast implant rupture: A retrospective study of 175 reconstructive and aesthetic sub-pectoral breast augmentation cases

To date, the effectiveness of radiological imaging in detecting silicone breast implant rupture is uncertain. The purpose of this study is to retrospectively evaluate the effectiveness of radiological imaging when diagnosing a rupture. In this study, 175 patients with 242 breast implants were included, of which 168 and 74 implants were used for breast reconstruction and aesthetic augmentation, respectively. All patients who underwent revision surgery, between January 2015 and June 2016, following breast augmentation or reconstruction were included, regardless of any pre-operative diagnosis of rupture that had been made. The diagnosis of intracapsular rupture was verified intraoperatively and compared to the pre-operative findings. With regard to pre-operative diagnostic imaging methods, we compared magnetic resonance imaging (MRI), mammography, and ultrasonography (US) findings. Among the 242 implants that were explanted, 35 clinical ruptures were confirmed and compared with the related radiological findings. We reported 22 false positives and 15 false negatives. US was the least specific and least accurate method because of its lowest positive predictive value (PPV) and negative predictive value (NPV). Mammography was the most specific and most accurate method, with the highest PPV (96%). Surprisingly, MRI was the most sensitive; however, it was neither the most specific nor the most accurate method despite having the highest NPV (98%). After comparing these three radiological techniques, we conclude that US along with MRI can be useful for young patients. Mammography, which was characterised by high specificity and accuracy, could be useful along with MRI in investigating patients over the age of 40.

Autoimmune/inflammatory syndrome induced by adjuvants (Shoenfeld’s syndrome) – An update

Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) has been widely described in many studies conducted thus far. The syndrome incorporates five immune-mediated conditions, all associated with previous exposure to various agents such as vaccines, silicone implants and several others. The emergence of ASIA syndrome is associated with individual genetic predisposition, for instance those carrying HLA-DRB1*01 or HLA-DRB4 and results from exposure to external or endogenous factors triggering autoimmunity. Such factors have been demonstrated as able to induce autoimmunity in both animal models and humans via a variety of proposed mechanisms. In recent years, physicians have become more aware of the existence of ASIA syndrome and the relationship between adjuvants exposure and autoimmunity and more cases are being reported. Accordingly, we have created a registry that includes at present more than 300 ASIA syndrome cases that have been reported by different physicians worldwide, describing various autoimmune conditions induced by diverse adjuvants.

In this review, we have summarized the updated literature on ASIA syndrome and the knowledge accumulated since 2013 in order to elucidate the association between the exposure to various adjuvant agents and its possible clinical manifestations. Furthermore, we especially referred to the relationship between ASIA syndrome and systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS).

The Pocket Protector: A New Breast Implant Device

Introduction:

Although strides have been made to improve breast augmentation surgery, they have focused on the use of single implant devices, necessitating adjustments to the type of operation performed and implants used. And although some breast types obtain excellent results, many others are less than optimal. By developing a thin synthetic expanded polytetrafluoroethylene device, the Pocket Protector, that lines the breast pocket by integrating with the body without a capsule formation, smooth-surfaced gel (or saline) implants can remain soft and provide improved augmentation mammoplasty results. Even patients with Baker class III and IV breasts refractory to all types of revisional surgery can achieve soft, natural breasts after revision with the Pocket Protector.

Materials and Methods:

Augmentation mammoplasty and revision mammoplasty, often with capsulectomy, with the Pocket Protector was performed on 38 patients with smooth gel or saline implants. Since the initial prototype in April 1995, data have been collected with each patient to evaluate the efficacy of this device.

Results:

Patients involved in the current study have yielded soft, natural-feeling breasts in the normal anatomic position. Two patients who experienced a flu syndrome in the immediate postoperative period developed refractory seromas necessitating removal of the expanded polytetrafluoroethylene. Both cases have subsequently been successfully revised with Pocket Protectors and smooth-gel implants. Three patients with very thin tissues experienced rippling in spite of using smooth-gel implants.

Discussion:

The net result yields a soft, ripple-free (or near ripple-free) breast. Additionally, gel implants inside the Pocket Protector are potentially shielded from the body, should the implants rupture. Implants are easily exchangeable if necessary without need for capsulectomy or capsulotomy. The Pocket Protector may also represent an implant device appropriate to treat breasts refractory to traditionally attempted augmentations, such as subcutaneous mastectomy. Although the first case performed in April 1995 has remained successful, most of the experience has been gathered over the past year. This preliminary paper presents the experience with the past 38 cases.

Comparison of the Explantation Rate of Poly Implant Prothèse, Allergan, and Pérouse Silicone Breast Implants within the First Four Years after Reconstructive Surgery before the Poly Implant Prothèse Alert by the French Regulatory Authority

Background. In March 2010, ANSM (Agence Nationale de Sécurité du Medicament), the French Medical Regulatory Authority, withdrew Poly Implant Prothèse (PIP) breast implants from the market due to the use of non-medical-grade silicone gel. The aim of this study was to compare the removal rate (and reasons thereof) of breast implants produced by different manufacturers before the ANSM alert. Materials and Methods. From October 2006 to January 2010, 652 women received 944 implants after breast cancer surgery at the Gustave Roussy Comprehensive Cancer Center, Paris (France). The complications and removal rates of the different implant brands used (PIP, Allergan, and Pérouse) were evaluated and compared. Results. PIP implants represented 50.6% of the used implants, Allergan 33.4%, and Pérouse 16%. The main reasons for implant removal were patient dissatisfaction due to aesthetic problems (43.2%), infection (22.2%), and capsular contracture (13.6%). Two years after implantation, 82% of Pérouse implants, 79% of PIP, and 79% of Allergan were still in situ. There was no difference in removal rate among implant brands. Conclusion. Before the ANSM alert concerning the higher rupture rate of PIP breast implants, our implant removal rate did not predict PIP implant failure related to the use of nonapproved silicone gel.

Allergan’s silicone gel breast implants

In the USA, women seeking breast implants for augmentation, revision or reconstruction can choose between saline-filled devices and round, silicone gel-filled devices. Form-stable, highly cohesive silicone gel-filled breast implants are marketed in other countries and are currently under review by the US FDA. Allergan has conducted clinical studies to investigate the safety and effectiveness of its round and anatomical (Style 410) devices for US marketing approval. The most frequently reported complications were reoperation, implant removal with replacement, implant malposition and capsular contracture. The FDA approved the round devices in 2006. The weight of the scientific literature suggests that silicone gel-filled breast implants do not increase a patient's risk of cancer, autoimmune disease, reproductive effects or suicide. As differently shaped, cohesive breast implants continue to be introduced, breast implant surgery will become more customized to the patient's biological conditions and desires.

Image quality and diagnostic performance of silicone-specific breast MRI

PURPOSE

To compare the image quality of three techniques and diagnostic performance in detecting implant rupture.

MATERIALS AND METHODS

The study included 161 implants for the evaluation of image quality, composed of water-saturated short TI inversion recovery (herein called "water-sat STIR"), three-point Dixon techniques (herein called "Dixon"), and short TI inversion recovery fast spin-echo with iterative decomposition of silicone and water using least-squares approximation (herein called "STIR IDEAL") and included 41 implants for the evaluation of diagnostic performance in detecting rupture, composed of water-sat STIR and STIR IDEAL. Six image quality categories were evaluated and three classifications were used: normal implant, possible rupture, and definite rupture.

RESULTS

Statistically significant differences were noted for the image quality categories (p<0.001). STIR IDEAL was superior or equal to water-sat STIR in all image quality categories except artifact effects and superior to Dixon in all categories. Water-sat STIR performed the poorest for water suppression uniformity. The sensitivity and specificity in detecting implant rupture of STIR-IDEAL were 81.8 % and 77.8 % and the difference between two techniques was not statistically significant.

CONCLUSION

STIR-IDEAL is a useful silicone-specific imaging technique demonstrating more robust water suppression and equivalent diagnostic accuracy for detecting implant rupture, than water-sat STIR, at the cost of longer scan time and an increase in minor motion artifacts.

High-resolution ultrasound in the detection of silicone gel breast implant shell failure: background, in vitro studies, and early clinical results

BACKGROUND

Magnetic resonance imaging (MRI) has historically been considered the "gold standard" for imaging silicone gel breast implants and is currently recommended by the US Food and Drug Administration for device surveillance. Recent studies, however, have questioned its accuracy as the best screening test for implant failure. In addition, the high cost of MRI is a significant deterrent to follow-up, especially among asymptomatic patients. Recent advancements in ultrasound technology have led to the development of high-resolution devices with the potential to accurately image breast implants and breast tissues.

OBJECTIVES

The authors evaluate the feasibility of portable, high-resolution ultrasound (HRUS) for imaging of silicone gel breast implants and perform preliminary comparisons of HRUS to MRI in the assessment of both intact and failed implants in a clinical setting by both radiologists and plastic surgeons.

METHODS

Phase 1 was composed of in vitro and ex vivo scanning model assessments in a variety of implant models utilizing multiple HRUS hardware platforms (GE LOGIQ-9, LOGIQ-e, LOGIQ-i, and Venue-40 devices) and transducer heads (range, 8-16 MHz, mainly GE12ML transducer). In Phase 2, these technologies were applied clinically to provide imaging experience in three patients previously diagnosed with unilateral implant failure. Phase 3 was a preliminary prospective evaluation of HRUS of 29 implants in 15 consecutive patients for whom MRI and independent surgeon-performed and radiologist-performed HRUS scans were compared to subsequent surgical findings.

RESULTS

In Phase 1, all hardware models easily detected both intact and intentionally damaged shells in currently marketed fourth-generation responsive gel implants and in investigational, fifth-generation highly-cohesive gel devices. Although multiple transducers were able to detect shell failure, the 12-MHz head produced the best images at the normal clinical depth range. In Phase 2, confirmatory HRUS scans correctly identified the side of rupture and were consistent with MRI and surgical findings in all patients. In Phase 3, MRI, surgeon-performed HRUS, and radiologist-performed HRUS scans were all accurate in predicting implant shell integrity in 29 of 29 imaged breasts (100%) as confirmed at the time of surgery in both symptomatic and asymptomatic patients.

CONCLUSIONS

Preliminary results with a variety of base and transducer systems demonstrated that HRUS provides excellent visualization of current fourth- and fifth-generation silicone gel implants both in the in vitro and ex vivo scanning models. In vivo surgeon-performed HRUS accurately identified implant status and correlated with radiologist-performed HRUS, MRI, and surgical findings. An ongoing Phase 4 prospective study is under way to help define the sensitivity and specificity of HRUS technologies in the evaluation of current implant designs. However, the relative affordability, accessibility, availability, and dynamic real-time visualization provided by HRUS represent significant potential advantages of HRUS over MRI in both the screening and future diagnosis of breast implant shell failure.

Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.

Removal of Silicone Breast Implants and Review of Literature

Silicone breast implants have a finite life span and may need changing over the lifetime of the patient. The experience with removing first- and second-generation implants is frustrating, because thick capsules often form, in association with rupture and spread of the silicone gel into the surrounding tissue. Different techniques have been employed to try and avoid an unnecessarily large incision, yet still control the dissection so that entire capsule and contained silicone can be removed en bloc. The authors describe a technique that facilitates atraumatic removal using an effective and time-saving vacuum principle.

The Mentor Study on Contour Profile Gel Silicone MemoryGel Breast Implants

BACKGROUND

Two-year safety and efficacy data were presented to the Canadian Therapeutic Products Directorate Scientific Advisory Panel, in Ottawa, Ontario, Canada.

METHODS

The 955 women enrolled in the 10-year, multicenter, Mentor MemoryGel study were distributed into four cohorts: 572 augmentation patients, 123 revision-augmentation patients, 191 reconstruction patients, and 69 revision-reconstruction patients. The surgeons in the study received an intensive clinical educational program in addition to the protocol.

RESULTS

Mentor's 2-year study results indicate that the risk of any complication or reoperation at some point through 2 years after implant surgery is 24.5 percent for primary augmentation patients, 30.2 percent for revision-augmentation patients, 42.9 percent for primary reconstruction patients, and 41.8 percent for revision-reconstruction patients. The rupture rates reported from the magnetic resonance imaging cohort were 0 percent for all groups. Patients reoperated on at least one time were as follows: 9.4 percent for primary augmentation, 12.8 percent for revision-augmentation, 27.3 percent for primary reconstruction, and 19.4 percent for revision-reconstruction. Also, 2.4 percent of primary augmentation patients, 7.3 percent of revision-augmentation patients, 8.9 percent of primary, and 11.6 percent of reconstruction patients had their implants removed, with patient choice and capsular contracture being the most common reasons.

CONCLUSIONS

The data from the Mentor CPG Gel Study resulted in approval of these implants for general use on October 20, 2006. The educational program resulted in improved clinical outcomes and probably should be required for all surgeons using the devices.

Breast implant rupture and connective tissue disease: a review of the literature

BACKGROUND

Large-scale epidemiologic studies to date have not found any credible association between silicone breast implants and either well-defined connective tissue diseases or undefined or atypical connective tissue diseases. It has been hypothesized that implant rupture could prompt an immunologic reaction giving rise to autoimmune or related diseases. In this article, the authors review the available literature on implant ruptures and connective tissue disease.

METHODS

Articles were identified from PubMed and by cross-checking reference lists of retrieved articles.

RESULTS

Five publications were identified. In none of the studies were diseases or symptoms related to well-defined or ill-defined connective tissue diseases associated with rupture status.

CONCLUSIONS

There appears to be little scientific basis for any association between implant rupture and well-defined connective tissue disease or undefined or atypical connective tissue diseases. The concept of silicone-related disease was developed by rheumatologists based on highly selected groups of symptomatic breast implant patients seen in their practices. It is likely that nonspecific complications or symptoms related perhaps to capsular contracture or implant rupture may be misinterpreted as representing a systemic disease.

The Mentor Core Study on Silicone MemoryGel Breast Implants

BACKGROUND

In 2005, convincing safety and efficacy data were presented, resulting in the approval of Mentor MemoryGel Implants, with conditions.

METHODS

The 1007 women enrolled in the 10-year, multicenter, Mentor Core MemoryGel Study were distributed into four cohorts: 551 primary augmentation patients, 146 revision-augmentation patients, 251 primary reconstruction patients, and 59 revision-reconstruction patients. Preoperatively and postoperatively, study instruments and physical examinations were administered to assess medical history, patient satisfaction, quality of life and body image, connective tissue disease diagnosis, rheumatology symptoms, and chest size change to determine the efficacy of surgery.

RESULTS

Safety assessments included complication rates and rates of reoperation. Results at 3 years were reported at the U.S. Food and Drug Administration panel. Results indicate that the risk of any complication (including reoperation) at some point through 3 years after implant surgery is 36.6 percent for primary patients, 50.1 percent for revision-augmentation patients, 49.4 percent for primary reconstruction patients, and 47.5 percent for revision-reconstruction patients. Suspected rupture rates reported from the magnetic resonance imaging cohort were 0.5 percent for primary augmentation, 7.7 percent for revision-augmentation, 0.9 percent for primary reconstruction, and 0 percent for revision-reconstruction. Only two implants, in a single patient, were found surgically to be ruptured. There were 4.7 percent primary and 12.3 percent revision-augmentation patients who had their implants removed, with patient choice and severe capsular contracture being the most common reasons.

CONCLUSION

The data demonstrated safety and efficacy of the devices, but also indicate that a focus must be placed on better education and technique to improve clinical outcomes in the future.

Style 410 Cohesive Silicone Breast Implants: Safety and Effectiveness at 5 to 9 Years after Implantation

BACKGROUND

Inamed introduced a fourth-generation implant, the Style 410 cohesive silicone breast implant, in 1993. To date, little has been published on this implant despite its widespread use in Europe, and no data are available on its long-term rupture rate.

METHODS

Women implanted with Style 410 implants between 1995 and 1999 at Akademikliniken Hospital in Stockholm were eligible to participate in the study. One hundred forty-four of 302 potential subjects received a physical examination, underwent magnetic resonance imaging screening for silent rupture, and completed a quality-of-life survey. The majority of subjects were Caucasian (96 percent), with a median age of 39 years. The study population consisted of subjects with cosmetic augmentation (86 percent) or revision of previous breast implantation (14 percent). Median time elapsed between physical examination and magnetic resonance imaging was 2 days.

RESULTS

The 144 subjects provided 286 implants for magnetic resonance imaging assessment, with a median implantation time of 6 years (range, 5 to 9 years). Overall, 99.0 percent of implants showed no evidence of rupture, 0.3 percent showed evidence of rupture, and 0.7 percent were indeterminate. The most common complication noted at physical examination was capsular contracture (5.6 percent). All other complications occurred in less than 3 percent of subjects. Quality-of-life results found an improvement in overall sense of well-being for 87 percent of subjects. Most compelling is that 97 percent stated an overall feeling that their breast implantation had been advantageous.

CONCLUSIONS

The authors' findings support the long-term safety and effectiveness of Inamed Style 410 cohesive breast implants and demonstrate a low prevalence of rupture.

Prevalence of Rupture in Inamed Silicone Breast Implants

BACKGROUND

Silicone breast implants have been used for decades and are arguably the most studied implantable device. However, the vast body of scientific literature has been unable to establish a definitive rupture rate. Various studies have evaluated implant rupture, but the meaningfulness of these data was confounded by the inclusion of different generations of implants and multiple manufacturers' implants and the selection of subjects who were already suspected of having ruptured implants. The authors' study was designed to acquire long-term rupture data specific to Inamed's third-generation silicone breast implants using magnetic resonance imaging technology.

METHODS

A total of 106 women with at least one Inamed silicone breast implant (styles 40, 110, and 120) were enrolled in this multicenter, cross-sectional study. The majority received implants for cosmetic augmentation (n = 77, 72.6 percent), with a smaller number having undergone breast reconstruction (n = 11, 10.4 percent) or revision of previous breast implant operations (n = 18, 17.0 percent). Most subjects were Caucasian (n = 99, 93.4 percent) with a median age at implantation of 34 years (range, 18 to 70 years). Enrolled subjects underwent a physical examination and magnetic resonance imaging screening at one of five sites to determine the prevalence of asymptomatic rupture.

RESULTS

A total of 199 implants were evaluated, with a median implantation time of 10.9 years (range, 9.5 to 13.2 years). Overall, 183 implants (92.0 percent) showed no evidence of rupture, 12 (6.0 percent) showed evidence of rupture, and four (2.0 percent) were indeterminate. All indeterminate evaluations were considered ruptures, providing a worst-case rupture prevalence of 8.0 percent.

CONCLUSION

The study results establish a rupture prevalence rate of 8.0 percent at 11 years for Inamed's silicone breast implants.

The Diagnosis of Silicone Breast-Implant Rupture

The objective was to evaluate the usefulness of clinical examination in the evaluation of breast-implant integrity, using the diagnosis at magnetic resonance imaging (MRI) as the "gold standard." Fifty-five women with 109 implants underwent a breast examination either just before or shortly after an MRI examination. Twenty-four of 109 implants were clinically diagnosed with possible rupture or rupture. Eighteen of the 24 implants were ruptured according to the MRI examination (75%). Eighty-five implants were clinically classified as intact, and 43 of these were actually ruptured at MRI (51%). The sensitivity of the clinical examination for diagnosing rupture was thus 30% and the specificity 88%. The positive predictive value of a clinical diagnosis of rupture was 75%, and the negative predictive value was 49%. In this study, we found that when a clinical examination is used as the sole diagnostic tool to identify implant rupture, neither the sensitivity nor the specificity is acceptable.

The diagnosis of breast implant rupture: MRI findings compared with findings at explantation

STUDY OBJECTIVE

The aim of this study was to evaluate the accuracy of Magnetic Resonance Imaging (MRI) as performed according to a strict study protocol in diagnosing rupture of silicone breast implants.

MATERIAL AND METHODS

The study population consisted of 64 women with 118 implants, who had participated in either one or two study MRI examinations, aiming at determining the prevalence and incidence of silent implant rupture, respectively, and who subsequently underwent explantation. Implant rupture status was determined by four independent readers and a consensus diagnosis of either rupture (intracapsular or extracapsular), possible rupture or intact implant was then obtained. Strict predetermined rupture criteria were applied as described in this report and findings at surgery were abstracted in a standardised manner and results compared.

RESULTS

At MRI, 66 implants were diagnosed as ruptured, nine as possibly ruptured and 43 as intact. Among the ruptured implants, 27 were categorized as extracapsular. At surgery, on average 297 days after the MRI, 65 of the 66 rupture diagnoses were confirmed, as were 20 of the cases with extracapsular silicone. Eight of the nine possibly ruptured implants were in fact ruptured at surgery. Thirty-four of the 43 intact implants were described as intact at surgery. When categorising possible ruptures as ruptures, there were one false positive and nine false negative rupture diagnoses at MRI yielding an accuracy of 92%, a sensitivity of 89%, and a specificity of 97%. Correspondingly, the predictive value of a positive MRI examination was 99% and the predictive value of a negative MRI examination was 79%.

CONCLUSIONS

We conclude that MRI is highly accurate for identification of silicone breast implant rupture, with a high sensitivity and specificity when evaluation of images are based on presence of well-defined rupture criteria.

Talc and Capsular Contracture

Capsular contracture, constrictive tightening of scar tissue around implants, was historically the primary reason for reoperating breast-implanted women. Yet, capsular contracture remains of unknown etiology. Contamination with foreign material is one of several suspected causes. Talc, a known fibrogenic agent, was recently found in peri-implant scars. A comparison of 192 explanted women was designed to investigate the role of talc in the induction of capsular contracture. This study included women implanted with silicone gel-filled implants for whom tissue samples were available. Patients were evaluated for the occurrence of capsular contracture and the presence of intracellular talc particles in peri-implant tissues. There was a significant association between talc and capsular contracture (odds ratio = 18.0, 95% confidence interval = 5.9-55, P < 1 x 10(-9)). This study indicates that talc was a major risk factor for capsular contracture in women augmented before 1992.

Silicone Gel Breast Implant Rupture Presenting as a Fluctuant Back Mass After Latissimus Dorsi Breast Reconstruction

The authors describe a patient who presented with acute onset of a lower back fluctuant mass 12 years after breast reconstruction with a latissimus dorsi musculocutaneous flap and silicone gel implant. Aspiration and subsequent surgical exploration revealed this mass to be free-flowing silicone gel within a cavity that was confluent with the breast implant capsule through an axillary tunnel. Excision of the back cavity, explantation with subtotal capsulectomy, and implant replacement resolved the problem. Although distant migration of extracapsular silicone gel from the breast to the axilla, arm, abdomen, and groin has been described, the authors think this represents the first reported case of distant migration of silicone gel to the lower back.

Autogenous augmentation mammaplasty with microsurgical tissue transfer

Many patients dream of reducing their abdominal or gluteal fat tissue and, in the same procedure, enlarging their breasts without the need for implants and their related problems. Following this demand, a new "natural" alternative to breast augmentation with autogenous tissue is presented. Since 1993, 16 patients have undergone either unilateral or bilateral breast augmentation with free fat transfer. These 20 augmentation mammaplasties consisted of nine deep inferior epigastric perforator flaps, eight superior gluteal artery perforator flaps, and three superficial inferior epigastric artery flaps. The postoperative results were judged aesthetically by independent examiners and by the patients according to Netscher's score. The additional operations for final shaping of the breasts and the postoperative complications at the donor and recipient sites are reported. The augmented breasts improved the aesthetic proportions more than 100 percent. All flaps survived, and except for minor postoperative complications such as small areas of wound dehiscence, the breasts could be shaped aesthetically in a second-stage procedure several weeks later. Breast augmentation with autogenous tissue offers a natural alternative to alloplastic augmentation mammaplasty.

Self-reported diseases and symptoms by rupture status among unselected Danish women with cosmetic silicone breast implants

Epidemiologic evidence does not support an association between silicone breast implants and connective tissue or other rheumatic diseases. However, a recent study has suggested that women with ruptured implants may be at increased risk of developing fibromyalgia. An analysis of adverse health outcomes according to breast implant rupture status was conducted in 238 unselected Danish women with cosmetic silicone breast implants. Ninety-two of the women had definite implant rupture, and 146 had intact implants as determined by magnetic resonance imaging. Before undergoing imaging, the women provided blood samples and completed a self-administered questionnaire. Women with ruptured implants overall, and the subgroup with extracapsular ruptures (n = 23), were compared with women with intact implants regarding a number of self-reported diseases and symptoms and the presence of specific autoantibodies, such as antinuclear antibodies, rheumatoid factor, and cardiolipin immunoglobulin G and M antibodies. Overall, there were no differences in the occurrence of self-reported diseases or symptoms or in the presence of autoantibodies between women with intact implants and women with ruptured implants, including extracapsular rupture. The only exception was capsular contracture, which was reported six times more frequently by women with extracapsular ruptures than by women with intact implants (OR, 6.3; 95 percent CI, 1.7 to 23.5). In conclusion, this study of unselected women with silicone breast implants could establish no association between silicone implant rupture and specific diseases or symptoms related to connective tissue disease or other rheumatic conditions, except for an excess of capsular contracture among women with extracapsular rupture.

An association of silicone-gel breast implant rupture and fibromyalgia

Silicone-gel breast implant rupture is common. Silicone-gel from ruptured implants may escape the scar capsule that forms around breast implants and become "extracapsular silicone." Our previously published study found that women with extracapsular silicone gel were at higher risk of reporting that they were diagnosed with fibromyalgia. There has been a limited number of studies addressing this association in the literature. Some studies addressing the issue of silicone breast implants and connective tissue disease specifically exclude patients with fibromyalgia from the sample or do not include the syndrome in the analysis. Case series describing fibromyalgia in patients with implants have been published, but many of these papers lack information on extracapsular silicone and are not representative because the patients are typically from referral populations. In addition, most studies do not have control groups of women without implants for comparison or do not distinguish between saline and silicone implants. Additional observational studies of women from nonreferral populations are necessary to validate an association. These studies should provide information on how the rupture is diagnosed, state whether the rupture extended beyond the capsule, and provide an appropriate control group for comparison. The findings from such studies may be important to physicians as they describe potential risks associated with implants to their patients. These findings should also be important for regulatory decision making on silicone-gel breast implants.