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

The Problem of Diagnostic Criteria of Breast Implant Illness in Women After Breast Reconstruction: Review and Discussion of a Case

INTRODUCTION

There has been a rising trend in the use of silicone breast implants for breast reconstructions after breast cancer treatment, as well as in the aesthetic breast procedures. A cluster of non-specific symptoms related to the presence of silicone implant has been called breast implant illness (BII). However, there are no strict criteria of BII which would specifically define this term. The increasing interest in BII among patients and physicians urges verifying own cases of "on-demand" explantations.

MATERIAL AND METHODS

In this paper, we discussed a case of a patient with initial BII diagnosis, after breast reconstruction, and reviewed the literature on the BII symptoms and aetiology. A decision for aesthetic revision, not explantation, was made as the diagnosis of BII was questioned, and somatisation due to dissatisfaction with the aesthetic result of breast reconstruction was diagnosed.

RESULTS

Improving aesthetics by implant exchange and contralateral mastopexy caused a full recovery from patient's symptoms.

CONCLUSION

Based on our case, we point on the fact that BII diagnosis in patients after breast reconstruction is challenging. We suggest that while considering such a diagnosis and further proceedings, e.g. explantation, especially in patients after breast reconstruction, some exclusion criteria should be considered. Dissatisfaction with the result of the surgery can also lead to somatisation and the presence of real clinical symptoms, which should not be confused with the possible autoimmune reaction to silicone particles.

LEVEL OF EVIDENCE IV

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Breast Implant-Associated Immunological Disorders

Background

Breast implants are commonly placed postbreast cancer reconstruction, cosmetic augmentation, and gender-affirming surgery. Breast implant illness (BII) is a systemic complication associated with breast implants. Patients with BII may experience autoimmune symptoms including fatigue, difficulty concentrating, hair loss, weight change, and depression. BII is poorly understood, and the etiology is unknown. The purpose of this literature review is to characterize BII autoimmune disorders and determine possible causes for its etiology.

Methods

The PubMed, Google Scholar, Embase, Web of Science, and OVID databases were interrogated from 2010 to 2020 using a query strategy including search term combinations of "implants," "breast implant illness," "autoimmune," and "systemic illness."

Results

BII includes a spectrum of autoimmune symptoms such as fatigue, myalgias/arthralgias, dry eyes/mouth, and rash. A review of epidemiological studies in the past ten years exhibited evidence affirming an association between breast implants and autoimmune diseases. The most commonly recognized were Sjogren's syndrome, rheumatoid arthritis, systemic sclerosis, chronic fatigue syndrome, and Raynaud's syndrome. Explantation resulted in alleviation of symptoms in over 50% of patients, strengthening the hypothesis linking breast implants to BII. Studies have shown that silicone is a biologically inert material and unlikely to be the cause of these symptoms. This is supported by the fact that increased risk of autoimmune disease was also reported in patients with other implantable biomaterials such as orthopedic implants. Recent studies shed light on a possible role of bacterial biofilm and subsequent host-pathogen interactions as a confounding factor to this problem.

Conclusion

BII could be dependent on biofilm infection and the microenvironment around the implants. The true pathophysiology behind these complaints must be further investigated so that alternative treatment regimens other than explantation can be developed. Translational significance of these studies is not limited to breast implants but extends to other implants as well.

Understanding Breast Implant Illness: Etiology is the Key

Because breast augmentation is one of the most popular cosmetic procedures, the issue of implant-related complications has been widely debated ever since the FDA approved the use of implants in 1962. Although decades have passed, breast implant illness (BII) still represents a poorly defined and controversial complication. With ongoing nonscientific discussion in the mainstream media and on social media, revealing the etiology of BII is urgent because knowledge of this subject ultimately influences patients' decisions. Little or no scientific research is currently available on BII and no final conclusions regarding its etiology, clinical manifestations, diagnostic criteria, or treatment have been made. This review aims to give an overview of the hypotheses on the etiology of BII and seeks inspiration to improve the conditions of BII patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

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".

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.

Risk factors for developing capsular contracture in women after breast implant surgery: A systematic review of the literature

BACKGROUND

Capsular contracture is the most frequent complication in breast augmentation or reconstruction with breast implants. The exact mechanism for this complication is not completely understood. Yet, it is most likely to be a multifactorial condition. Several patient-, surgery-, and implant-specific risk factors have been related to cause capsular contracture. This review aims to provide a clear overview of all risk factors for capsular contracture.

METHODS

A systematic literature review was performed focusing on patient-, surgery-, and/or implant-related factors related to capsular contracture in breast implants. PubMed, Embase, and Wiley/Cochrane Library databases were searched for relevant articles published from inception up to October 20, 2016. The included studies were assessed for the following main variables: study characteristics, patient characteristics, indication for surgery, type of surgery, implant characteristics, and other characteristics.

RESULTS

Data on the risk factors for the development of capsular contracture were retrieved from 40 studies. A presumptive increased risk in the development of capsular contracture is shown for the following variables: longer duration of follow-up, breast reconstructive surgery in patients with a history of breast cancer, subglandular implant placement, postoperative hematoma, and a textured implant surface. There is little, weak, or no evidence for the association of other factors with capsular contracture. This review also shows a large heterogeneity between studies and within the definition of capsular contracture.

CONCLUSION

This review provides an overview of the relationship between patient-, surgery-, and implant-specific risk factors in the development of capsular contracture.

Poly Implant Prothèse silicone breast implants: implant dynamics and capsular contracture

Background

The Poly Implant Prothèse (PIP) implants were withdrawn from the market in 2010 due to the use of low-grade silicone, causing a high risk for implant rupture. The aim of this study was to investigate the implant dynamics of PIP breast implants, as well as to determine the rate and predictors of implant gel bleeding, rupture, and capsular contracture in PIP implants.

Methods

Eighty women with a total of 152 PIP implants who underwent a reoperation in 2012 were enrolled in this study. Physical investigation included assessing the Baker score and demographics were retrospectively traced in medical records. The pre- and post-operative volumes of the implants were calculated and their state was determined intraoperatively by the surgeon.

Results

The implants were removed after a mean implant duration of 11 ± 2.1 years. Gel bleed and implant rupture occurred in respectively 42 and 25% of the implants. Intact implants had post-operative volume increase as well as decrease. There was a correlation between gel bleeding and more post-operative implant volume increase (P ≤ 0.05). Capsular contracture had a protective effect against post-operative implant volume increase (P ≤ 0.05), while a post-operative implant volume increase provided a protective influence in developing capsular contracture (P ≤ 0.05). Additionally, implant rupture led to a higher risk of capsular contracture (P ≤ 0.05).

Conclusions

We managed to illustrate that PIP implant shells were too permeable and that there is a correlation between gel bleeding and the increase of the post-operative implant volume. Implant rupture led to a higher risk for developing capsular contracture.

Level of evidence: Level III, risk / prognostic study.

Electronic supplementary material

The online version of this article (10.1007/s00238-018-1427-y) contains supplementary material, which is available to authorized users.

Silicone breast implants and connective tissue disease: no association

The association of silicone breast implants with connective tissue diseases (CTDs), including systemic sclerosis, systemic lupus erythematosus, rheumatoid arthritis, and fibromyalgia, as well as a hypothesized new "atypical" disease, which does not meet established diagnostic criteria for any known CTD, has been extensively studied. We have reviewed the epidemiologic literature regarding an association between cosmetic breast implants and CTDs, with particular emphasis on results drawn from the most recent investigations, many of which are large cohort studies with long-term follow-up, as well as on those studies that address some of the misinformation and historically widespread claims regarding an association between breast implants and CTDs. These claims have been unequivocally refuted by the remarkably consistent evidence from published studies, as well as numerous independent meta-analyses and critical reviews, which have demonstrated that cosmetic breast implants are not associated with a subsequent increased occurrence of individual CTDs or all CTDs combined, including fibromyalgia. Moreover, there is no credible evidence for the conjectured excess of "atypical" CTD among women with cosmetic breast implants, or of a rheumatic symptom profile unique to these women. No increased risk of CTDs is evident in women with extracapsular ruptures in two studies, which evaluated risk by implant rupture status, and no consistent association has been observed between silicone breast implants and a variety of serologic markers or autoantibodies. Thus, any claims that remain regarding an association between cosmetic breast implants and CTDs are not supported by the scientific literature but rather are a residual byproduct of the unprecedented large-scale product liability litigation in the USA.

Silicone and autoimmunity

BACKGROUND

Since the 1960s, silicone implants have been successfully used for breast augmentation and reconstruction. However, safety issues regarding the use of silicone have led to a moratorium by the US Food and Drug Administration between 1992 and 2006.

DESIGN

To date, although the moratorium has been removed and women overwhelmingly prefer silicone over saline implants, local and systemic adverse effects still remain a concern.

RESULTS

Silicone-elicited inflammatory fibro-proliferative response and capsular contracture is irrefutable. Studies on silicone breast implants have not supported a relationship to carcinogenesis, whereas that to autoimmunity mainly to nondefined autoimmune phenomena seems very plausible. These silicone-related autoimmune adverse events termed 'siliconosis' are probably limited to a small minority of implanted patients.

CONCLUSIONS

Risk factors, such as characteristic environmental exposure and/or genetic predisposition, still require further elucidation. Similarly to antibacterial agents, texturized implants and Zafirlukast that were found to be beneficial in inhibiting fibro-proliferative response and capsular contracture, elucidating autoimmune-related risk factors might subsequently enable physicians to accurately predict long-term health status of silicone implant recipients.

[Etiology and pathophysiology of fibromyalgia syndrome and chronic widespread pain]

OBJECTIVE

To write a systematic review on the etiology and pathophysiology of the fibromyalgia syndrome (FMS) and of chronic widespread pain (CWP).

METHODS

An interdisciplinary level-3 guideline (i.e. systematic literature search and assessment, logic analysis, formal consensus procedure) for the diagnosis and therapy of FMS was created in cooperation with 10 medical and psychological societies and 2 patient self-help organizations. A literature search was performed covering all available review articles on the etiology and pathophysiology of FMS and CWP using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/2006). For the assignment of evidence classes the system of the Oxford Centre for Evidence-Based Medicine was applied. Consensus was achieved by a multi-step nominal group procedure.

RESULTS

FMS aggregates in families (evidence level 2c). Physical and psychological stress at the workplace are risk factors for the development of CWP and FMS. Affective disorders are risk factors for the development and maintenance of FMS. Operant learning mechanisms and sensitization are risk factors for the chronification of FMS (evidence levels 2b). Several factors are associated with the pathophysiology of FMS, but the causal relationship is unclear. This includes alterations of central pain pathways, hyporeactivity of the hypothalamus-pituitary-adrenal axis, increased systemic pro-inflammatory and reduced anti-inflammatory cytokine profiles and disturbances in the dopaminergic and serotonergic systems.

CONCLUSIONS

FMS is the common final product of various etiological factors and pathophysiological mechanisms.

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.

Magnetic resonance imaging and explantation investigation of long-term silicone gel implant integrity

BACKGROUND

Information about silicone gel implant longevity is sparse. Magnetic resonance imaging studies have superseded explantation studies in the search for data on their long-term integrity. Unfortunately, the majority of studies are based predominantly on second-generation implant cohorts. Although magnetic resonance imaging is acknowledged to be the best imaging modality, the results of any study are entirely dependent on its ability to differentiate ruptured from intact implants.

METHODS

A single, textured, third-generation implant type was chosen, to reduce the number of variables. The largest cohort of patients in our database had subglandular Mentor Siltex gel implants (Mentor Medical Systems, Santa Barbara, Calif.). They were contacted and offered a magnetic resonance imaging scan. All patients with at least one radiologically ruptured implant were then offered explantation.

RESULTS

One hundred forty-nine patients with bilateral subglandular implants (median +/- SD age, 8.9 +/- 2.3; range, 4.8 to 13.5 years) were imaged and reported by two independent radiologists. Twenty-three patients were reported to have 33 radiologically ruptured implants. Twenty-one patients (30 radiologically ruptured implants) agreed to explantation. Statistical analysis using maximum likelihood estimation of survival curve for cross-sectional data suggests that implant rupture starts at 6 to 7 years and that by 13 years approximately 11.8 percent of implants will have ruptured.

CONCLUSION

Although these results cannot necessarily be extrapolated to other implant types and manufacturers, they provide further information about the natural history of implant integrity, better enabling us to counsel prospective and current implant recipients.

A Nationwide Study of Connective Tissue Disease and Other Rheumatic Conditions Among Danish Women With Long-Term Cosmetic Breast Implantation

PURPOSE

Numerous epidemiologic studies have demonstrated that breast implants are not associated with connective tissue diseases (CTDs). However, many CTDs are rare, and continued follow-up of women with breast implants is warranted.

METHODS

We extended by 5 years the follow-up of our earlier population-based cohort study of Danish women with cosmetic breast implants (n = 2761) and comparison groups of women with other types of cosmetic surgery (n = 8807). All women were followed from January 1977 through December 2001. Hospitalization and outpatient data for CTD and ill-defined and other rheumatic conditions in the implant and comparison groups were compared with those in the general Danish population. Additionally, CTDs and fibromyalgia were confirmed through medical chart review, and direct comparisons of the breast implant cohort with the comparison cohort were performed.

RESULTS

When compared with general population rates, CTDs were not statistically significantly elevated in either the implant or the comparison cohorts. However, unspecified rheumatism was similarly increased in the implant (standardized rate ratio = 1.9; 95% confidence interval = 1.6 to 2.2) and comparison (standardized rate ratio = 1.5; 95% confidence interval = 1.4 to 1.7) cohorts. In analyses of diagnoses validated by chart review, women with cosmetic breast implants compared with those having other types of plastic surgery or consultation for plastic surgery had no statistically significant excess for any specific confirmed CTD or combined CTDs (hazard ratio = 1.3; 95% CI = 0.9 to 1.9). In addition, there was no relation between breast implants and confirmed fibromyalgia (hazard ratio = 1.2; 95% CI = 0.6 to 2.1).

CONCLUSIONS

This extension of our earlier cohort study further supports the consensus of epidemiologic research that breast implants are unrelated to the development of CTD.

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.

Silicone breast implants and connective tissue disease: an updated review of the epidemiologic evidence

Numerous meta-analyses, weight-of-the-evidence, and critical reviews have summarized data from case-control and cohort studies, published through 1999, which have been conducted to evaluate the potential association between cosmetic silicone breast implants and the occurrence of well-defined connective tissue diseases, as well as a hypothesized new atypical disease, which does not fulfill established diagnostic criteria for any known connective tissue disease. These reviews have unanimously concluded that there is no evidence of an association between breast implants and any of the traditional connective tissue diseases evaluated individually or combined or atypical connective tissue disease. We have performed an updated review of the results of epidemiologic studies published since 1999. Two long-term follow-up studies of women with breast implants in Denmark and a retrospective cohort study in Australia found no excess of definite connective tissue disease, including rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus and Sjogren's syndrome, among women with cosmetic breast implants compared with breast reduction or other plastic surgery controls or women in the general population. No consistent evidence was observed of increased risk of definite connective tissue disease in women with extracapsular ruptures in 2 studies which evaluated risk by rupture status among women with cosmetic breast implants. The results of several studies provide no evidence of a higher frequency of undefined connective tissue disease among women with cosmetic breast implants or of a rheumatic symptom profile unique to these women and/or indicative of a specific atypical connective tissue disease. In conclusion, the most recent epidemiologic investigations have been remarkably consistent with earlier epidemiologic studies in finding no evidence of an excess of any individual connective tissue disease or all connective tissue diseases combined, including both established and atypical or undefined connective tissue disease, among women with cosmetic silicone breast implants. Thus, the conclusions reached in earlier independent reviews have not changed based on data published during the subsequent years.

Breast Implants and Fibromyalgia

Although the collective epidemiologic literature does not support an association between silicone breast implants and any well-defined or atypical connective tissue disease, a recent study raised concern regarding an increased risk for fibromyalgia among women with extracapsular ruptured implants. In this review, we examine the results of 6 epidemiologic studies which have evaluated the occurrence of fibromyalgia among women with breast implants. Two large nationwide follow-up studies of women with breast implants in Sweden and Denmark reported relative risks for fibromyalgia of 1.0 (95% confidence interval [CI] 0.3 to 3.0) and for unspecified rheumatism (including fibromyalgia and myalgia) of 1.2 (95% CI 0.9 to 1.5), respectively. Similarly, both a case-control and a cross-sectional study conducted within rheumatic disease clinics reported no association between silicone breast implants and the subsequent development of fibromyalgia. The single positive finding, that of a greater than 2-fold excess of self-reported fibromyalgia among women with magnetic resonance imaging-diagnosed extra-capsular ruptures in one study, can be explained by selection bias and the use of an inappropriate reference group in the analyses. In the most recent study of indefinite connective tissue disease (including fibromyalgia) by rupture status, no association was found among unselected Danish women with ruptured implants (relative risk 1.0; 95% CI 0.3 to 3.0), and none of the women with extracapsular rupture reported fibromyalgia. Thus, the weight of the epidemiologic evidence is remarkably consistent and reassuring in failing to support an association between breast implants and subsequent fibromyalgia.