Untreated Silicone Breast Implant Rupture

Exploration of Point-of-Care Ultrasonography for Silicone Breast Implant Rupture Detection and Classification

Background and Objectives: The surge in breast-related surgeries in Korea underscores the critical need for an accurate early diagnosis of silicone breast implant-related issues. Complications such as BIA-ALCL and BIA-SCC add complexity to breast health concerns, necessitating vigilant monitoring. Despite advancements, discrepancies persist between ultrasonographic and pathologic classifications of silicone implant ruptures, highlighting a need for enhanced diagnostic tools. This study explores the reliability of ultrasonography in diagnosing silicone breast implant ruptures and determining the extent of silicone migration, specifically with a focus on guiding potential capsulectomy based on pathology. Materials and Methods: A comprehensive review of medical records encompassing 5557 breast implants across 2790 patients who underwent ultrasound-assisted examinations was conducted. Among the screened implants, 8.9% (249 cases) were diagnosed with silicone breast implant rupture through ultrasonography. Subsequently, 89 women underwent revisional surgery, involving capsulectomy. The pathological analysis of 111 periprosthetic capsules from these cases aimed to assess the extent of silicone migration, and the findings were juxtaposed with the existing ultrasonographic rupture classification. Results: The diagnostic agreement between preoperative sonography and postoperative findings reached 100% for silicone breast implant ruptures. All eighty prosthetic capsules exhibiting a snowstorm sign in ultrasonography demonstrated silicone migration to capsules upon pathologic findings. Conclusions: High-resolution ultrasonography emerged as a valuable and reliable imaging modality for diagnosing silicone breast implant ruptures, with a notable ability to ascertain the extent of free silicone migration to capsules. This diagnostic precision is pivotal in informing decisions about potential capsulectomy during revisional surgery. The study advocates for an update to the current binary ultrasonographic classification, suggesting a more nuanced categorization into three types (subcapsular, intracapsular, and extracapsular) based on pathology.

Rupture of 40-year-old silicone gel breast implants: a case report

BACKGROUND

Implant rupture is one of the complications of breast augmentation surgery. The rupture of silicone implants is often insidious, potentially causing problems at any time. This is a case report of the rupture of 145-cc breast implants manufactured by Dow Corning Corporation and their removal at 40 years after augmentation.

CASE PRESENTATION

A 70-year-old female patient was admitted for the removal of a lump in the upper and inner quadrants of the right breast. After a detailed examination, a rupture of the bilateral breast implants was diagnosed. Explantation without replacement was performed; the entire procedure proceeded smoothly. Immunohistochemical staining revealed siliconoma with lymphoid hyperplasia and calcification in the bilateral breasts with no signs of malignancy.

CONCLUSIONS

Silicone breast augmentation is one of the most popular aesthetic surgical procedures worldwide. Therefore, it is important to educate patients on the need for close monitoring of their implants after augmentation through magnetic resonance imaging or ultrasound to facilitate early detection of any changes before a rupture occurs. Early detection of the implant rupture, in turn, will facilitate early and effective management.

MRI for Evaluation of Complications of Breast Augmentation

Breast augmentation is one of the most common aesthetic procedures performed in the United States. Several techniques of breast augmentation have been developed, including the implantation of breast prostheses and the injection of autologous fat and other materials. The most common method of breast augmentation is to implant a prosthesis. There are different types of breast implants that vary in shape, composition, and the number of lumina. The rupture of breast implants is the leading cause of implant removal. The rupture rate increases substantially with the increasing age of the implant. Most implant ruptures are asymptomatic. Implant complications can be grouped into two categories: local complications in the breast and adjacent soft tissue, and systemic complications associated with rheumatologic or neurologic symptoms. The onset of local complications may be early (infection and periprosthetic collections including seromas, hematomas, or abscesses) or late (capsular contraction, implant rupture, gel bleed, or breast implant-associated anaplastic large cell lymphoma). Although mammography is the imaging modality for breast cancer screening, noncontrast breast MRI is the imaging modality of choice for evaluation of the integrity of breast implants and the complications of breast augmentation, for equivocal findings at conventional imaging, and as a supplement to mammography in patients with free injectable materials. The fifth edition of the Breast Imaging Reporting and Data System (BI-RADS) provides a systematic outline for MRI evaluation of patients with breast implants. Silicone- and water-selective sequences provide useful supplemental information to confirm intracapsular and extracapsular rupture. Breast MRI for evaluation of implant integrity does not require intravenous contrast material. The use of MRI contrast material in patients with breast augmentation is indicated when infection or malignancy is suspected. Radiologists should have a thorough understanding of the different techniques for breast augmentation, normal imaging features, and complications specific to breast augmentation. An invited commentary by Ojeda-Fournier is available online. ^©RSNA, 2022.

A Surgeon's Empirical Perspectives on Use of High-resolution Ultrasound in Preoperatively Detecting a Rupture in the Context of Breast Implant Crisis in Korea

BACKGROUND

We previously proposed a novel method for detecting a rupture of a breast implant using high-resolution ultrasound (HRUS). We therefore conducted this retrospective, observational study to describe its feasibility in making a preoperative diagnosis of rupture of the device in patients receiving an implant-based augmentation mammaplasty.

METHODS

We initially evaluated the medical records of the patients who had received primary or secondary augmentation mammaplasty using a breast implant at other hospitals for aesthetic or reconstructive purposes between August 31, 2017, and August 31, 2020. The patients underwent breast US using the Aplio i600 (Canon Medical System, Otawara, Tochigi, Japan) system with a 7-18 MHz linear transducer. Through a retrospective review of the patients' medical records, we analyzed their baseline and clinical characteristics. Then, we compared an agreement between preoperative diagnosis of rupture on HRUS and findings at reoperation.

RESULTS

A total of 29 patients with rupture (55 breasts) were evaluated for the performance of ultrasound in making a diagnosis of rupture. This showed that they were unaware of rupture but they were diagnosed with it on ultrasound. Preoperatively, there were no cases of rupture in 110 left breasts (80.9%) and 107 right breasts (78.7%), which exactly matched to the number of breasts without rupture on HRUS. Moreover, preoperatively, there were 26 (19.1%) and 29 cases (21.3%) of rupture in the left and right breast, respectively, which exactly matched to the number of breasts with rupture on HRUS.

CONCLUSIONS

In conclusion, patients who are suspected of having rupture of a breast implant should be stringently evaluated for presence of rupture and, if any, its scope using HRUS. Moreover, we propose that surgeons consider using HRUS in making a preoperative diagnosis of rupture of a breast implant.

LEVEL OF EVIDENCE III

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

Current Challenges in Breast Implantation

Breast implantation (BI) is the most common plastic surgery worldwide performed among women. Generally, BI is performed both in aesthetic and oncoplastic procedures. Recently, the prevalence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) or breast implant illness (BII) has aroused concerns. As a result, several countries, like Australia, Korea or the United Kingdom, introduced national registries dedicated to the safety and quality of BI surgeries. This narrative review aimed to focus on the clinical challenges, management and the current state of knowledge of BI. Both short and long-term outcomes of BI are determined by various alternatives and differences, which surgeons must consider during the planning and performing breast augmentation along with further complications or risk of reoperation. Proper preoperative decisions and aspects of surgical technique emerged to be equally important. The number of performed breast reconstructions is increasing, providing the finest aesthetic results and improving patient’s quality of life. Choice of prosthesis varies according to individual preferences and anatomical variables. A newly diagnosed cases of BIA-ALCL with lacking data on prevention, diagnosis, and treatment are placing it as a compelling medical challenge. Similarly, BII remains one of the most controversial subjects in reconstructive breast surgery due to unspecified diagnostic procedures, and recommendations.

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).

MemoryGel Breast Implants: Final Safety and Efficacy Results after 10 Years of Follow-Up

Background:

Mentor MemoryGel Breast Implants were approved by the U.S. Food and Drug Administration in November of 2006. Patients in the Core clinical study supporting this approval were followed for 10 years.

Methods:

This prospective, multicenter, clinical study included primary augmentation, revision augmentation, primary reconstruction, and revision reconstruction patients implanted with smooth or Siltex Texture MemoryGel Implants. Incidence, severity, and method of resolution for all postoperative complications were assessed on per-patient and per-implant bases. The primary effectiveness endpoints were overall mean change in chest circumference and bra cup size following the implantation procedure.

Results:

Primary augmentation (n = 552), revision augmentation (n = 145), primary reconstruction (n = 251), and revision reconstruction (n = 60) patients were enrolled in the study. Kaplan-Meier estimated 10-year cumulative incidence rates for key complications at the subject level for Baker grade III/IV capsular contracture were as follows: primary augmentation, 12.1 percent; revision augmentation, 24.4 percent; primary reconstruction, 20.5 percent; and revision reconstruction, 36.9 percent. For infection, rates were as follows: primary augmentation, 1.6 percent; revision augmentation, 1.4 percent; primary reconstruction, 6.2 percent; and revision reconstruction, 0 percent. For explantation with or without replacement, rates were as follows: primary augmentation, 11.6 percent; revision augmentation, 24.1 percent; primary reconstruction, 33.4 percent; and revision reconstruction; 37.8 percent. For rupture, rates were as follows: primary augmentation, 24.2 percent; revision augmentation, 23.7 percent; primary reconstruction, 32.7 percent; and revision reconstruction, 38.7 percent. For any reoperation, rates were as follows: primary augmentation, 25.5 percent; revision augmentation, 43.6 percent; primary reconstruction, 49.0 percent; and revision reconstruction, 50.7 percent.

Conclusion:

The results of this study demonstrate that MemoryGel Implants are safe and effective for use in women undergoing breast augmentation or reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.

Safety and Effectiveness of Silicone Gel-Filled Breast Implants in Primary Augmentation Patients

Background

Results from the MemoryGel Breast Implants Core Clinical Study suggest these devices are safe and effective at 10 years after implantation. Although clinical trials are essential for measuring the safety and effectiveness of a device, real-world evidence can supplement clinical trials by providing information on outcomes observed in diverse clinical settings for a more heterogeneous population, without fixed treatment patterns, and without continuous patient monitoring, such that follow-up is more representative of normal clinical practice.

Objectives

The aim of this study was to measure real-world outcomes, including safety and effectiveness, in patients who underwent primary breast augmentation with smooth MemoryGel implants.

Methods

This was a case series looking at patients, age 22 years and older, who underwent primary breast augmentation at a single site between December 2006 and December 2016 and who had a minimum of 2 years of follow-up. Descriptive statistics were used to summarize baseline characteristics and outcomes. Kaplan-Meier models were used to estimate safety outcomes for capsular contracture (Baker grade III/IV), infection, and rupture.

Results

A total of 50/777 (6.4%) patients reported a complication, with an average time to complication of 3.9 years (range, 19 days-11.8 years) postprocedure. Kaplan-Meier estimates of the 10-year cumulative incidence of capsular contracture (Baker grade III/IV), infection, and rupture were 4.7%, 0.1%, and 1.6%, respectively.

Conclusions

Analyses of a large population from a single site provide further support for the long-term safety and effectiveness of MemoryGel breast implants in a primary augmentation cohort.

Level of Evidence: 4

Mechanical irritation by protruding bone: A possible cause of breast implant rupture

Although breast implants have been in clinical use for almost 6 decades and have undergone considerable development during this time, implant rupture is still a dreaded long-term complication. Some obvious external factors, such as trauma, can lead to implant rupture, but many studies have reported a high rate of “spontaneous” implant rupture. Herein, we present two cases with the aim of raising awareness of a new possible cause of “spontaneous” implant rupture: mechanical irritation by bony protrusions.

Role of US in evaluating breast implant integrity

PURPOSE

To assess the diagnostic accuracy and inter-observer variability of ultrasound (US) in recognizing signs of intra or extra-capsular rupture of silicone breast implants by using the magnetic resonance imaging (MRI) findings as the reference standard.

METHODS

150 patients for a total of 300 implants underwent breast US and subsequently MR examination searching for signs of intra or extra-capsular rupture. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for breast US having MRI findings as the reference standard. Cohen's kappa statistics was used in order to assess inter-observer agreement for US.

RESULTS

170/300 (57 %) implant ruptures were detected at US (intra-capsular n = 110, extra-capsular n = 60). By comparing US findings with MR results, overall sensitivity, specificity, accuracy, PPV, and NPV of 79, 63, 70, 65, and 77 %, respectively, were found for breast US. In case of intra-capsular rupture, sensitivity, specificity, accuracy, PPV, and NPV of 63, 63, 63, 45, and 77 %, respectively, were obtained; 100 % values were found for extra-capsular rupture US diagnosis.

CONCLUSION

US can be used as the first examination in patients with breast implants. US intra-capsular rupture detection requires further evaluation by MRI; in case of extra-capsular rupture US diagnosis, surgical implant removal could be proposed without further investigations.

Sientra primary and revision augmentation rupture trending and analysis with magnetic resonance imaging

BACKGROUND

Rupture of silicone gel breast implants is a rare occurrence but remains one of the key surgical concerns. The objective of this article was to provide visibility and information on trends for the impact that patient and surgical characteristics play in the occurrence of rupture.

OBJECTIVES

Examine trends in surgical techniques to better understand the etiology of implant rupture.

METHODS

Analysis was based on Sientra's prospective, open-label, U.S.-based clinical study of High-Strength Cohesive silicone breast implants. Patient and surgical characteristics were compared between ruptured and intact implants.

RESULTS

The subset of data used for this analysis included 1792 implants in 935 primary and revision augmentation patients implanted by 31 plastic surgeons, with an average follow-up of 6.6 years. The results confirm that rupture remains a rare adverse event. Overall, the rupture prevalence for this study was 2.4%. Rupture prevalence was lower among textured devices (0.8%) compared to smooth devices (3.8%). The prevalence of rupture was 7.8% among devices placed with a transaxillary incision site compared to 1.6% and 3.0% when placed with an inframammary or periareolar incision site, respectively. Rupture was reported in 5.5% of the devices that received steroid pocket irrigation, compared to 1.8% of the devices that did not.

CONCLUSIONS

Although ruptures in the Sientra study with the High-Strength Cohesive silicone gel implants were an uncommon occurrence, the authors were able to identify strong trends for the association of certain surgical factors and characteristics. The results show among other factors that an inframammary approach and a textured device were found to be protective against rupture.

LEVEL OF EVIDENCE

2 Therapeutic.

Soft, Brown Rupture: Clinical Signs and Symptoms Associated with Ruptured PIP Breast Implants

Supplemental Digital Content is available in the text.

Background:

Preoperative signs and symptoms of patients with Poly Implant Prothese (PIP) implants could be predictive of device failure. Based on clinical observation and intraoperative findings 4 hypotheses were raised: (1) Preoperative clinical signs including acquired asymmetry, breast enlargement, fullness of the lower pole, decreased mound projection, and change in breast consistency could be indicative of implant rupture. (2) Device failure correlates with a low preoperative Baker grade of capsule. (3) Brown-stained implants are more prone to implant failure. (4) The brown gel could be indicative of iodine ingression through a substandard elastomer shell.

Methods:

Preoperative clinical signs were compared with intraoperative findings for 27 patients undergoing PIP implant explantation.

Results:

Acquired asymmetry (P = 0.0003), breast enlargement (P = 0.0002), fuller lower pole (P < 0.0001), and loss of lateral projection (P < 0.0001) were all significantly predictive of device failure. Capsule Baker grade was lower preoperatively for ruptured implants. The lack of palpable and visible preoperative capsular contracture could be secondary to the elastic nature of the capsular tissue found. Brown implants failed significantly more often than white implants. Analysis of brown gel revealed the presence of iodine, suggesting povidone iodine ingression at implantation.

Conclusions:

Preoperative signs can be predictive of PIP implant failure. Brown-stained implants are more prone to rupture. The presence of iodine in the gel suggests unacceptable permeability of the shell early in the implant’s life span. A noninvasive screening test to detect brown implants in situ could help identify implants at risk of failure in those who elect to keep their implants.

A retrospective analysis of ruptured breast implants

Background

Rupture is an important complication of breast implants. Before cohesive gel silicone implants, rupture rates of both saline and silicone breast implants were over 10%. Through an analysis of ruptured implants, we can determine the various factors related to ruptured implants.

Methods

We performed a retrospective review of 72 implants that were removed for implant rupture between 2005 and 2014 at a single institution. The following data were collected: type of implants (saline or silicone), duration of implantation, type of implant shell, degree of capsular contracture, associated symptoms, cause of rupture, diagnostic tools, and management.

Results

Forty-five Saline implants and 27 silicone implants were used. Rupture was diagnosed at a mean of 5.6 and 12 years after insertion of saline and silicone implants, respectively. There was no association between shell type and risk of rupture. Spontaneous was the most common reason for the rupture. Rupture management was implant change (39 case), microfat graft (2 case), removal only (14 case), and follow-up loss (17 case).

Conclusions

Saline implants have a shorter average duration of rupture, but diagnosis is easier and safer, leading to fewer complications. Previous-generation silicone implants required frequent follow-up observation, and it is recommended that they be changed to a cohesive gel implant before hidden rupture occurs.

Correlation between MRI results and intraoperative findings in patients with silicone breast implants

Background

Silicone gel breast implants may silently rupture without detection. This has been the main reason for magnetic resonance imaging (MRI) of the augmented or reconstructed breast. The aim of the present study was to investigate the accuracy of MRI for implant rupture.

Methods

Fifty consecutive patients with 85 silicone gel implants were included in the study. The mean age of the patients was 51 (range 21–72) years, with a mean duration of implantation of 3.8 (range 1–28) years. All patients underwent clinical examination and breast MRI. Intraoperative implant rupture was diagnosed by the operating surgeon.

Results

Nineteen of the 50 patients suffered from clinical symptoms. An implant rupture was diagnosed by MRI in 22 of 85 implants (26%). In seven of 17 removed implants (41%), the intraoperative diagnosis corresponded with the positive MRI result. However, only 57% of these patients were symptomatic. Ultrasound imaging of the harvested implants showed signs of interrupted inner layers of the implant despite integrity of the outer shell. By microsurgical separation of the different layers of the implant shell, we were able to reproduce this phenomenon and to produce signs of implant rupture on MRI.

Conclusion

Our results show that rupture of only the inner layers of the implant shell with integrity of the outer shell leads to a misdiagnosis on MRI. Correlation with clinical symptoms and the specific wishes of the patient should guide the indication for implant removal.

Povidone-iodine combined with antibiotic topical irrigation to reduce capsular contracture in cosmetic breast augmentation: a comparative study

BACKGROUND

Antibacterial lavage with topical antibiotics may reduce the occurrence of capsular contracture (CC) in breast augmentation.

OBJECTIVES

The authors investigate the efficacy of povidone-iodine combined with antibiotic irrigation in reducing the CC rate.

METHODS

The charts of 330 consecutive women who underwent cosmetic breast augmentation during 2 different periods (group A: 2004-2009, n = 165; group B: 2009-2010, n = 165) were retrospectively reviewed. All patients in the series underwent augmentation with the same surgeon (A.S.) via the inframammary approach and dual-plane pocket. In group A, patients received a single perioperative dose of 1.5 g of intravenous cephalothin and 750 mg of oral cephalexin twice a day for 7 days after discharge. In group B, patients perioperatively received 750 mg of intravenous cefuroxime, and each implant and pocket were irrigated with 25 mL of a 10% povidone-iodine solution mixed with 750 mg of cefuroxime and 80 mg of gentamicin diluted in 15 mL of 0.9% sodium chloride solution. After discharge, patients received 500 mg of oral levofloxacin once a day for 5 days. Postoperative complications included occurrence of infection, hematoma, seroma, and CC.

RESULTS

Mean (SD) postoperative follow-up in groups A and B was 24 (+/- 13) months and 22 (+/- 3) months, respectively. The postoperative superficial wound infection rate was 1.8% and 1.2%, the seroma rate was 1.8% and 1.2%, and the hematoma rate was 0.6% and 1.2% in groups A and B, respectively. Ten CC cases (Baker grade 3 or 4) in group A and 1 in group B were reported (6% vs 0.6%; P = .006).

CONCLUSIONS

Povidone-iodine and antibiotic irrigation in cosmetic breast augmentation yielded a lower CC rate than standard perioperative antibiotics in this series of patients.

Implant ruptures after augmentation mammoplasty

This article discusses eleven cases of implant ruptures in nine patients that occurred 3-10 years after primary surgery. The implant ruptures were diagnosed by visual inspection, palpation, ultrasound and MRI of the breast. We describe rupture symptoms and treatment tactics depending on the characteristics of the rupture, the nature of the filler (liquid silicone, soft cohesive gel (Soft Touch™) or high cohesive silicone gel), the current condition of the soft tissues and presence of any complications. We present recommendations allowing early detection of an asymptomatic rupture.

LEVEL OF EVIDENCE V

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 .

An adipoinductive role of inflammation in adipose tissue engineering: key factors in the early development of engineered soft tissues

Tissue engineering and cell implantation therapies are gaining popularity because of their potential to repair and regenerate tissues and organs. To investigate the role of inflammatory cytokines in new tissue development in engineered tissues, we have characterized the nature and timing of cell populations forming new adipose tissue in a mouse tissue engineering chamber (TEC) and characterized the gene and protein expression of cytokines in the newly developing tissues. EGFP-labeled bone marrow transplant mice and MacGreen mice were implanted with TEC for periods ranging from 0.5 days to 6 weeks. Tissues were collected at various time points and assessed for cytokine expression through ELISA and mRNA analysis or labeled for specific cell populations in the TEC. Macrophage-derived factors, such as monocyte chemotactic protein-1 (MCP-1), appear to induce adipogenesis by recruiting macrophages and bone marrow-derived precursor cells to the TEC at early time points, with a second wave of nonbone marrow-derived progenitors. Gene expression analysis suggests that TNFα, LCN-2, and Interleukin 1β are important in early stages of neo-adipogenesis. Increasing platelet-derived growth factor and vascular endothelial cell growth factor expression at early time points correlates with preadipocyte proliferation and induction of angiogenesis. This study provides new information about key elements that are involved in early development of new adipose tissue.

Economic analysis of screening strategies for rupture of silicone gel breast implants

BACKGROUND

In 2006, the U.S. Food and Drug Administration recommended screening of all women with silicone gel breast implants with magnetic resonance imaging 3 years after implantation and every 2 years thereafter to assess their integrity. The cost for these serial examinations over the lifetime of the breast implants is an added burden to insurance payers and to women. The authors performed an economic analysis to determine optimal screening strategies by considering the diagnostic accuracy of the screening tests, costs of the tests, and subsequent implant removal.

METHODS

The authors determined aggregate/pooled values for sensitivity and specificity of the screening tests of ultrasound and magnetic resonance imaging in detecting silicone breast implant ruptures from the data obtained from published literature. They compiled costs, based on Medicare reimbursements for 2011, for the following elements: imaging modalities, anesthesia, and three surgical treatment options for detected ruptures. A decision tree was used to compare three alternate screening strategies of ultrasound only, magnetic resonance imaging only, and ultrasound followed by magnetic resonance in asymptomatic and symptomatic women.

RESULTS

The cost per rupture of screening and management of rupture with ultrasound in asymptomatic women was $1090; in symptomatic women, it was $1622. A similar cost for magnetic resonance imaging in asymptomatic women was $2067; in symptomatic women it was $2143. A similar cost for ultrasound followed by imaging in asymptomatic women was $637; in symptomatic women, it was $2908.

CONCLUSION

Screening with ultrasound followed by magnetic resonance imaging was optimal for asymptomatic women, and screening with ultrasound was optimal for symptomatic women.

A clinical study of late seroma in breast implantation surgery

BACKGROUND

The use of mammary implants may lead to a variety of early and delayed complications. The most common delayed complications are capsular contracture and implant failure. Late seroma has seldom been reported. In a long-term prospective observational study, cases of late seroma were assessed and recorded.

METHODS

Between March 2005 and November 2009, suspected cases of late seroma in patients who had undergone breast augmentation or reconstruction with textured implants were evaluated clinically and with instrumental analyses. An ultrasound-guided needle aspiration of the fluid was performed.

RESULTS

In this study, 13 cases of late seroma (8 augmentations and 5 reconstructions) were observed. The overall incidence of this complication was 1.68%. Chemical analyses confirmed the diagnosis of seroma, which recurred in all the patients within days of evacuation. For 12 patients, a reoperation was performed, during which the implant was removed, a total capsulectomy was performed, and in cases of subglandular breast augmentation, the implant pocket was changed to a submuscular placement before a new prosthesis was inserted. One patient underwent a second ultrasound-guided needle aspiration. No seroma recurrence was observed in any of the patients during the follow-up period.

CONCLUSION

In case of unexpected breast enlargement after prosthesis implantation, the physician should first rule out infection, then investigate possible friction irritation from either a fold in the device or rubbing of a textured implant. According to the authors' experience and another report, this complication occurs in 1% to 2% of cases. The inclusion of this complication in the informed consent form should be considered. Long-term studies designed to investigate the underlying causes of late seroma are warranted for the prevention and treatment of this complication.

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.

Systemic inflammatory reaction after silicone breast implant

BACKGROUND

Systemic inflammation after augmentation mammaplasty with modern silicone implants is not currently recognized. In a prospective controlled study, C-reactive protein and other variables were monitored, aiming to test this hypothesis in a young cohort of patients.

METHODS

Females (18-30 years old, BMI = 18.5-30 kg/m(2), N = 52) were consecutively recruited for breast implant (n = 24, Group I) and for abdominal liposuction (n = 28, Group II/Controls). Patients were interviewed at baseline and followed until 6 months after operation. Variables included demographic and clinical information, surgical outcome, inflammatory markers and autoantibodies.

RESULTS

Operations were well tolerated, without surgical or infectious complications. Mean prosthesis size was 258 ± 21 ml (range = 220-280) and mean aspirate of liposuction was 1972 ± 499 ml (range = 1200-3000). Preoperative, 2-month, and 6-month C-reactive protein concentrations for breast implant patients were 1.3 ± 1.2, 4.8 ± 3.0, and 4.3 ± 6.4 mg/l and for liposuction 3.5 ± 2.7, 3.5 ± 2.1, and 2.2 ± 2.2 mg/l, respectively. Change at 2 months was significant (p = 0.001). Autoantibody investigation failed to reveal remarkable aberrations, except for anticardiolipin elevation, which was nearly symmetrical in the two groups.

CONCLUSION

C-reactive protein levels increased after operation and correlated with proinflammatory and procoagulatory indices. A mild increase in anticardiolipin IgM occurred but differences between populations were lacking. Despite excellent cosmetic outcomes and lack of complications, acute phase reaction could signal ongoing immunogenicity of silicone and long-term monitoring is recommended.

Imaging of breast implants-a pictorial review

The number of women with breast implants is increasing. Radiologists must be familiar with the normal and abnormal findings of common implants. Implant rupture is a well-known complication after surgery and is the main cause of implant removal. Although mammography and ultrasonography are the standard first steps in the diagnostic workup, magnetic resonance imaging (MRI) is the most useful imaging modality for the characterisation of breast implants because of its high spatial resolution and contrast between implants and soft tissues and absence of ionising radiation. MRI has the highest sensitivity and specificity for implant rupture, thanks to its sequences that can suppress or emphasise the signal from silicone. Regardless of the technique used, the overall aim of imaging breast implants is to provide essential information about tissue and prosthesis integrity, detect implant abnormalities and detect breast diseases unrelated to implants, such as breast cancer.

Axillary silicone lymphadenopathy presenting with a lump and altered sensation in the breast: a case report

Introduction

Silicone lymphadenopathy is a rare but recognised complication of procedures involving the use of silicone. It has a poorly understood mechanism but is thought to occur following the transportation of silicone particles from silicone-containing prostheses to lymph nodes by macrophages.

Case presentation

We report of a case involving a 35-year-old woman who presented to the breast clinic with a breast lump and altered sensation below her left nipple 5 years after bilateral cosmetic breast augmentations. A small lump was detected inferior to the nipple but clinical examination and initial ultrasound investigation showed both implants to be intact. However, mammography and magnetic resonance imaging of both breasts revealed both intracapsular and extracapsular rupture of the left breast prosthesis. The patient went on to develop a flu-like illness and tender lumps in the left axilla and right mastoid regions. An excision biopsy of the left axillary lesion and replacement of the ruptured implant was performed. Subsequent histological analysis showed that the axillary lump was a lymph node containing large amounts of silicone.

Conclusion

The exclusion of malignancy remains the priority when dealing with lumps in the breast or axilla. Silicone lymphadenopathy should however be considered as a differential diagnosis in patients in whom silicone prostheses are present.

Squamous metaplasia on the breast implant capsule

The development of squamous metaplasia or carcinoma is a rare occurrence in the setting of a ruptured or leaking silicone breast implant capsule. However, the oncogenic process in such a context is yet another intriguing example of how chronic inflammation plays an integral role in the tumorigenic process. Recent papers have shed light on how inflammation involving M2-tpe macrophages, lymphocytes, and other inflammatory cells at first provide the cytokines necessary to fend off an inciting foreign-body attack such as silicone from a ruptured or leaking implant. Although such a response is beneficial in keeping infection or foreign material in check, there are instances when the response may be exaggerated. It is thought that the extent and length of the response, the balance between pro-inflammatory/ anti-apoptotic and anti-inflammatory/pro-apoptotic, as well as genetic factors play important roles in determining the final result of an inflammatory insult.

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.

A long-term study of outcomes, complications, and patient satisfaction with breast implants

BACKGROUND

Breast implants have been used worldwide for more than 40 years. Despite extensive clinical experience, there is continued concern about the safety of these devices. The purpose of this study was to compare the efficacy, complication rates, frequency of reoperation, and degree of patient satisfaction with different types of implants.

METHODS

This is a consecutive, population-based study consisting of all patients receiving implants at a multidisciplinary breast center between 1979 and 2004 (25 years). A prospective implant database was constructed and maintained in Excel, and statistical analysis was performed using SAS 8.2. Various outcomes, including infections, hematomas, undesirable waviness, capsular contracture, deflation, rupture, reoperation, and patient satisfaction, were monitored.

RESULTS

Data were collected on 3495 implants in 1529 women. The longer implants were in place, the greater the cumulative risk of developing contracture; hematoma significantly increased the risk of contracture; smooth and textured implants had similar contracture rates; polyurethane foam-covered implants had a reduced risk of contracture persisting for at least 10 years after implantation. There was a relatively high rate of reoperation and a relatively short interval between primary surgery and reoperation; the most common indication for reoperation was capsular contracture. Implant recipients expressed a high overall level of satisfaction.

CONCLUSIONS

Breast implants are associated with a significant rate of local complications and reoperation. There are marked differences in outcomes as a function of implant surface type and surgical indication. Despite relatively frequent complications and reoperations, implant recipients are largely satisfied.

Spontaneous autoinflation and deflation of double-lumen breast implants

A rare late complication of textured, double-lumen breast implants developed 15 years after routine augmentation mammaplasty. The patient required secondary surgery for removal of the implants in both breasts because of their spontaneous autoinflation and deflation. Mammography showed autoexpansion of the right breast implant and deflation of left breast implant in the outer lumen without evidence of silicone leakage 15 years after implantation. The spherical shape of the right implant was filling with red-brown fluid. The deflated left implant had a thick capsule. Both implants were characterized during surgery and removed. Few reports have described spontaneous autoinflation of breast implants. Several causes of implant autoinflation have been proposed, such as valve defects, osmotic swelling, and inorganic salts produced by the texturization process or injection of saline with nonstandard salt concentrations. However, the exact mechanism remains unknown.

Analysis of 30 breast implant rupture cases

Breast implants used for augmentation mammoplasty or breast reconstruction could rupture from various causes such as trauma or spontaneous failure. The objectives of this study were to investigate the relationships between the causes of implant rupture and the degree of capsular contracture, and then to evaluate the relative efficacies of specific signs on magnetic resonance imaging (MRI) known to be beneficial for diagnosing the rupture. A retrospective review identified patients with prosthetic implant rupture or impending rupture treated by the senior author. The 30 cases of implant rupture available for review were classified into two groups: intracapsular and extracapsular ruptures. The 30 cases of breast implant ruptures were analyzed with respect to the clinical symptoms and signs, the causes of rupture, the degree of capsular contracture, and therapeutic plans. Among the 30 cases, 14 patients who had undergone MRI during the diagnostic period were analyzed with respect to the relationships between MRI readings and operative findings. Spontaneous rupture of membranes was most common (80%), followed by failure because of trauma (7%) and valve or implant base (4%). The symptoms during implant rupture were contour deformity, palpated mass-like lesions, pain, and focal inflammation. According to the analysis of specific MRI signs, the sensitivity and specificity of the linguine sign were 87% and 100%, respectively, for intracapsular rupture. For extracapsular rupture, the sensitivity and specificity of the linguine sign were, respectively, 67% and 75%. The sensitivity and specificity of the rat-tail sign and tear drop sign were 14% and 50%, respectively. Breast implant rupture was correlated with the degree of capsular contracture in our study. Among the various specific MRI signs used in diagnosing the rupture, the linguine sign was reliable and had a high sensitivity and specificity, especially in cases of intracapsular rupture. On the other hand, the rat-tail and tear drop signs were nonspecific signs for diagnosing the rupture of breast implant.

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.