The Safety of Silicone Gel-Filled Breast Implants: A Review of the Epidemiologic Evidence

Silicone implant surface microtopography modulates inflammation and tissue repair in capsular fibrosis

Excessive fibrous capsule formation around silicone mammary implants (SMI) involves immune reactions to silicone. Capsular fibrosis, a common SMI complication linked to host responses, worsens with specific implant topographies. Our study with 10 patients investigated intra- and inter-individually, reduced surface roughness effects on disease progression, wound responses, chronic inflammation, and capsular composition. The results illuminate the significant impact of surface roughness on acute inflammatory responses, fibrinogen accumulation, and the subsequent fibrotic cascade. The reduction of surface roughness to an average roughness of 4 μm emerges as a promising approach for mitigating detrimental immune reactions, promoting healthy wound healing, and curbing excessive fibrosis. The identified proteins adhering to rougher surfaces shed light on potential mediators of pro-inflammatory and pro-fibrotic processes, further emphasizing the need for meticulous consideration of surface design. The composition of the implant capsule and the discovery of intracapsular HSP60 expression highlight the intricate web of stress responses and immune activation that can impact long-term tissue outcomes.

Prevalence, clinical characteristics, and management of silicone lymphadenopathy: A systematic review of the literature

INTRODUCTION

Implant-based breast augmentations and reconstructions are one of the most common surgical procedures performed by plastic surgeons in the United States, which has rapidly increased in popularity since the 2000s. Silicone lymphadenopathy (SL) is a complication of breast implants that involves migration of silicone to nearby soft tissue/lymph nodes. Data on its clinical features and management is scarce.

METHODS

SL-related search terms were used to find articles in 3 databases. Of 598 articles, 101 studies met the inclusion criteria. Demographics, clinical presentation, workup, and management data were analyzed.

RESULTS

Of 279 cases of SL and 107 with information on initial diagnosis, 35 (33%) were incidental. The most common symptom was painless lymphadenopathy, followed by painful lymphadenopathy. 251 (95%) and 13 (5%) patients had silicone and saline implants, respectively. 149 (68%) patients had implant rupture. Axillary lymphadenopathy was the most affected region (136 cases, 72%), followed by internal mammary (40 cases, 21%), cervical/supraclavicular (36 cases, 19%), and mediastinal (24 cases, 13%) regions. 25% of patients underwent fine-needle aspiration, 12% core needle biopsy, and 59% excisional biopsy. 32% of cases underwent explantation and/or implant exchange. The most common indication for surgery was implant rupture. Histology showed multinucleated giant cells, large histiocytes, and silicone accumulation.

CONCLUSIONS

SL is a complication associated with breast implants. The majority of patients are asymptomatic, and most cases are managed conservatively. Minority need a biopsy and surgical interventions due to abnormal imaging, persistent symptoms, and/or implant rupture. Workup and management should be tailored to the patient.

Silicone prosthetics and anti-thyroid autoimmunity

INTRODUCTION

In esthetic surgery, the use of silicone implants is a topic of hot discussion.

MATERIAL AND METHODS

An analysis of 119 esthetic surgical interventions on the mammary gland was performed. A study of the immune and endocrine parameters after mammoplasty was carried out.

RESULTS

The phenomenon of an increase in the levels of autoantibodies to the TSH receptor was revealed. The phenomenon of pre-operative growth of prolactin and TSH levels has been confirmed. An increase in thyroid autoimmunity after silicone mammoplasty is interpreted as a result of a silicone adjuvant action. An increase in the incidence of ASIA syndrome in patients who underwent breast surgery was registered. However, it was observed in both patients with silicone and non-silicone breast surgeries and therefore could not be solely explained by the use of silicone. Within 12 months following silicone mammoplasty, the patients with an increase of anti-TSH receptor autoimmunity nevertheless did not show any clinical and laboratory signs of overt thyroid disease, thus staying in a pre-nosological state. PRACTICAL RECOMMENDATIONS: Based on these results, we recommend the following for esthetic surgery: (a) all patients planned for silicone implant surgery should be examined for autoantibodies to the TSH receptor and (b) patients who have undergone breast endoprosthesis, starting 6 months after the operation, need long-term follow-up for thyroid status with mandatory testing for the level of these autoantibodies.

A Practical Guide to Managing Patients With Systemic Symptoms and Breast Implants

Numerous studies have explored the possibility of an association between breast implants and systemic symptoms potentially linked to exposure to silicone. Some studies show no direct association whereas others provide insufficient scientific evidence to prove or disprove an association. Nonetheless, some patients with breast implants remain concerned about the possible role of their implants in systemic symptoms they may be experiencing. This paper provides a practical approach for plastic surgeons in managing patients with breast implants who present with systemic symptoms, including recommendations for patient counseling, clinical and laboratory assessment of symptoms, and/or referral. Integral components of patient counseling include listening attentively, providing unbiased information, and discussing the risks and benefits of options for evaluation and treatment. A thorough history and assessment of symptoms, including appropriate laboratory tests, may identify underlying conditions to expeditiously address patients’ health issues through a specialist referral. Diagnosing and treating disorders that are causing a patient’s symptoms, if unrelated to their implant, would avoid a potentially unnecessary surgery. Ultimately, better information is needed to reliably guide patients in an evidence-based fashion. Long-term follow-up of patients who are explanted to see what symptoms may or may not improve could be useful in educating patients. Control groups in studies prospectively following women with implants for development of systemic symptoms would also be useful because the symptoms reported are common in women without implants. Cases are presented to illustrate the recommendations for a practical approach toward management of women reporting systemic symptoms with breast implants.

Silicone granuloma: a cause of cervical lymphadenopathy following breast implantation

We report a case of a 54-year-old woman with saline-based breast implants who presented to the ear, nose and throat neck lump clinic with a 2-week history of bilateral neck lumps. She was found to have multiple palpable cervical lymph nodes bilaterally in levels IV and Vb. The ultrasonography demonstrated multiple lymph nodes with the snowstorm sign and a core biopsy confirmed a silicone granuloma (siliconoma). This granuloma was likely caused by bleeding gel from the silicone shell of her saline-based implants. This case demonstrates the importance of bleeding gel from saline-based implants, in the absence of implant rupture. Thus, head and neck specialists should consider siliconomas as a cause for cervical lymphadenopathy in patients with saline-based breast implants.

Medialization Laryngoplasty: A Review for Speech-Language Pathologists

Purpose The purpose of this study is to familiarize speech-language-pathologists with the current state of the science regarding medialization laryngoplasty in the treatment of voice disorders, with emphasis on current evidence-based practice, voice outcomes, and future directions for research. Method A literature review was performed in PubMed and Embase using the keywords vocal fold/cord and laryngoplasty, thyroplasty, augmentation, or laryngeal framework. Articles published between 2010 and 2020 were reviewed for data about clinical applications, technical approach, voice-related outcomes, and basic science or clinical innovations with the potential to improve patient care. A synthesis of data was performed from articles meeting the outlined search criteria. Conclusions As key members in the multidisciplinary care of voice disorders, speech-language pathologists need to be informed of current research in medialization laryngoplasty, a procedure commonly used for patients with glottic insufficiency. Advances in anesthetic technique, office-based procedures, and the development of materials with increased bio-tolerability over the past decade have led to innovations in treatment and improved patient outcomes. Recent applications of computational and bioengineering approaches have the potential to provide new directions in the refinement of currently available techniques and the improvement of patient-based treatment outcomes.

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".

The Effect of Omega-3 Fatty Acids on Capsular Tissue around the Breast Implants

BACKGROUND

One of the most common complications of the use of foreign material, in both reconstructive and cosmetic breast surgery, is capsular contracture. Historically, research on capsular contracture has focused mainly on reducing bacterial contamination through antibiotic solutions. Only secondary studies have focused on pharmacological control of the inflammation process, with particular attention paid to the main inflammation pathway, the arachidonic acid cascade. An important role in the arachidonic acid cascade is played by the omega-3 fatty acids, which are found mainly in oily fish and food supplements. The goal of the present study was to investigate the effects of omega-3 supplements on capsule contraction.

METHODS

Female C57BL/6 mice were implanted with custom-made silicone gel implants and divided into two groups. The treated group received omega-3 oil daily while the control group received water daily by gavage. After mice were euthanized, samples of capsules were collected to evaluate thickness and transforming growth factor (TGF)-β expression.

RESULTS

The results showed that capsules in the omega-3 group were thinner and more transparent than those found in the control group. In addition, a significant downregulation of the TGF-β2 gene transcript was observed in the omega-3 group.

CONCLUSIONS

Omega-3 supplementation seems to be effective in reducing the occurrence of capsular formation, mainly through inhibition of the TGF-β pathway and impairment of collagen deposit. Omega-3 supplementation is a simple and promising method that could be used to prevent or at least reduce capsular contracture after silicone implant surgery.

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.

The bioengineered prosthetic breast reconstruction: advancements, evidence, and outcomes

Recent advancements in prosthetic breast reconstruction have provided the foundation for the bioengineered breast. These advancements include improved mastectomy techniques, autologous fat grafting, acellular dermal matrices (ADMs), and improved devices. Device-based breast reconstruction has evolved from subcutaneous, partial or total subpectoral, and now to prepectoral placement of devices. The evidence demonstrating the safety and efficacy of the bioengineered breast continues to increase. This manuscript will review the fundamental components of the bioengineered breast and provide an update of the current evidence.

Pilot for the Australian Breast Device Registry (ABDR): a national opt-out clinical quality registry for breast device surgery

PURPOSE

To establish a pilot clinical quality registry (CQR) to monitor the quality of care and device performance for breast device surgery in Australia.

PARTICIPANTS

All patients having breast device surgery from contributing hospitals in Australia. A literature review was performed which identified quality indicators for breast device surgery.

FINDINGS TO DATE

A pilot CQR was established in 2011 to capture prospective data on breast device surgery. An interim Steering Committee and Management Committee were established to provide clinical governance, and guide quality indicator selection. The registry's minimum dataset was formulated in consultation with stakeholder groups; potential quality indicators were assessed in terms of (1) importance and relevance, (2) usability, (3) feasibility to collect and (4) scientific validity. Data collection was by a two-sided paper-based form with manual data entry. Seven sites were recruited, including one public hospital, four private hospitals and two day surgeries. Patients were recruited and opt-out consent used.

FUTURE PLANS

The pilot breast device registry provides high-quality population-based data. It provides a model for developing a national CQR for breast devices; its minimum dataset and quality indicators reflect the opinions of the broad range of stakeholders. It is easily scalable, and has formed the basis for other international surgical groups establishing similar registries.

Extensive silicone lymphadenopathy after breast implant insertion mimicking malignant lymphadenopathy

Silicone implants are widely used in aesthetic and reconstructive breast surgery. Silicone lymphadenopathy is a well-known rare complication of implant insertion. Silicone leakage from a rupture or silicone bleeding can accumulate in lymph nodes. Foreign body reactions in the affected lymph nodes may be misdiagnosed as metastasis or malignant lymphadeno pathy upon initial presentation if silicone lymphadenopathy is not considered in the initial diagnosis. We report a case of siliconoma with extensive involvement of multiple lymph nodes mimicking malignant features to emphasize that clinicians should carefully evaluate each patient's medical history and disease status during differential diagnosis.

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.

Factors to Consider in Breast Reconstruction

Women considering breast ablative therapy are confronted with a variety of decisions that include the type of mastectomy (partial, total, skin sparing, nipple areolar sparing), the type of reconstruction (prosthetic, autologous, oncoplastic) and the need for adjuvant therapy (chemotherapy, radiation). The parameters for each are multifactorial and require significant thought and counseling. Therapeutic options are essentially individualized and dependent upon a variety of factors such as tumor size and location, lymph node involvement, comorbidities, expectations and body characteristics. The role of reconstructive surgery is now well appreciated and an integral component of the multidisciplinary care of the patient and is influenced by the opinions and recommendations of surgical, medical and radiation oncologists. This manuscript will review the role of reconstructive surgery and the many factors to consider.

Chemical fingerprinting of silicone-based breast implants

With millions of women worldwide carrying them, silicone-based breast implants represent a large market. Even though silicone breast implants already have a history of use of more than 50 years, the discussion on their safety has not yet come to an end. To improve safety assessment, regulatory authorities should have the availability of a set of tests to be able to determine parameters of implant identity and quality. Therefore, the gels and envelopes of various brands and types of silicone-based breast implants have been subjected to infrared, Raman and NMR spectroscopy. We show that by using a combination of complementary spectroscopic techniques breast implants of various origins can be distinguished on typical chemical hallmarks. It was found that typical silicone-based implants display a surplus of vinyl signals in the gel, cyclosiloxane impurities are tolerable at low levels only and a barrier layer is present in the implant envelope. The techniques presented here and the results obtained offer a good starting point for market surveillance studies.

Anaplastic large cell lymphoma (ALCL) and breast implants: breaking down the evidence

Systemic anaplastic large cell lymphoma (ALCL) is a distinct disease classification provisionally sub-divided into ALCL, Anaplastic Lymphoma Kinase (ALK)(+) and ALCL, ALK(-) entities. More recently, another category of ALCL has been increasingly reported in the literature and is associated with the presence of breast implants. A comprehensive review of the 71 reported cases of breast implant associated ALCL (iALCL) is presented indicating the apparent risk factors and main characteristics of this rare cancer. The average patient is 50 years of age and most cases present in the capsule surrounding the implant as part of the periprosthetic fluid or the capsule itself on average at 10 years post-surgery suggesting that iALCL is a late complication. The absolute risk is low ranging from 1:500,000 to 1:3,000,000 patients with breast implants per year. The majority of cases are ALK-negative, yet are associated with silicone-coated implants suggestive of the mechanism of tumorigenesis which is discussed in relation to chronic inflammation, immunogenicity of the implants and sub-clinical infection. In particular, capsulotomy alone seems to be sufficient for the treatment of many cases suggesting the implants provide the biological stimulus whereas others require further treatment including chemo- and radiotherapy although reported cases remain too low to recommend a therapeutic approach. However, CD30-based therapeutics might be a future option.

Evaluation of the biocompatibility of silicone gel implants - histomorphometric study

CONFLICT OF INTEREST

NONE DECLARED Breast implants are medical devices that are used to augment breast size or to reconstruct the breast following mastectomy or to correct a congenital abnormality. Breast implants consist of a silicone outer shell and a filler (most commonly silicone gel or saline). Approximately 5 to 10 million women worldwide have breast implants. Histomorphometric study to evaluate the biological tissue compatibility of silicone implants suitable for plastic surgery and the adverse effects and risks of this material. Thirty Wistar white rats received subcutaneous implants and the revestiment of silicone gel Silimed ®®, and randomized into six groups of five animals each, according to the type of implanted material and the time of sacrifice. Eight areas of 60.11mm2 corresponding to the obtained surgical pieces were analyzed, counting mesenchymal cells, eosinophils, and foreign body giant cells, observing an acceptable biocompatibility in all implants, for subsequent statistical analysis by Tukey test. Silicone gel showed inflammation slightly greater than for other groups, with tissue reactions varying from light to moderate, whose result was the formation of a fibrous capsule around the material, recognized by the organism as a foreign body. Despite frequent local complications and adverse outcomes, this research showed that the silicone and top layer presented an acceptable chronic inflammatory reaction, which did not significantly differ from the control group. In general, it is possible to affirm that silicone gel had acceptable levels of biocompatibility, confirmed the rare presence of foreign body giant cells, and when of the rupture, formed a fibrous capsule around the material, separating the material of the organism.

Internal mammary silicone lymphadenopathy diagnosed by robotic thoracoscopic lymphadenectomy

Internal mammary lymphadenopathy can be caused by a variety of disease processes and is a difficult diagnostic dilemma. We report a case of internal mammary lymphadenopathy, in a patient with a significant history of malignancy, requiring a tissue diagnosis. Robotic thoracoscopic lymphadenectomy was used to facilitate excisional biopsy. Pathology was significant for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.

PIP silicone breast implants: rupture rates based on the explantation of 676 implants in a single surgeon series

INTRODUCTION

To determine the true rupture rates of PIP implants from a large single surgeon cohort and to assess whether rupture rates varied depending on time of implant insertion. In addition, the efficacy of ultra sound scanning (USS) in determining rupture is examined.

DESIGN

Predominantly prospectively based analysis of patient records, investigations and surgical findings.

PARTICIPANTS

338 patients (676 implants) were included in the study and they all had removal of their implants. The senior author operated on all patients at some stage of their treatment. 160 patients were imaged pre-operatively with USS. Patients had implants inserted between 1999 and 2007 for cosmetic breast augmentation.

RESULTS

A total of 144 ruptured implants were removed from 119 patients, giving a rupture rate of 35.2% per patient and 21.3% per implant over a mean implantation period of 7.8 years. A statistical difference (P < 0.001) in rupture rates between implants inserted prior to 2003 and those inserted from 2003 was demonstrated, with higher failure rates in the latter group. There was a significant difference in rupture rates depending on pocket placement of the implants. The sensitivity and specificity of USS at detecting rupture was 90.6% and 98.3% respectively. A proportion of patients (29.4%) demonstrated loco-regional spread of silicone to the axilla on scanning.

CONCLUSIONS

Our paper has confirmed high rates of PIP implant failure in the largest published series to date. The significant difference in rupture rates between implants inserted prior to 2003 and those after this time supports the view that industrial silicone was used in the devices after 2003. Implants are more likely to rupture if inserted in the sub muscular plane compared to the sub glandular plane. USS is highly effective at detecting rupture in PIP implants and loco-regional spread is high compared to other devices. We believe this paper provides hard data enabling more informed decision making for patients, clinicians and providers in what remains an active issue affecting thousands of women.

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

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

The effect of study design biases on the diagnostic accuracy of magnetic resonance imaging for detecting silicone breast implant ruptures: a meta-analysis

BACKGROUND

The U.S. Food and Drug Administration has recommended that all silicone breast implant recipients undergo serial screening to detect implant rupture with magnetic resonance imaging. The authors performed a systematic review and meta-analysis to examine the effect of study design biases on the estimation of magnetic resonance imaging diagnostic accuracy measures.

METHODS

Studies were identified using the MEDLINE, EMBASE, ISI Web of Science, and Cochrane library databases. Two reviewers independently screened potential studies for inclusion and extracted data. Study design biases were assessed using the Quality of Diagnostic Accuracy Studies tool and the Standards for Reporting of Diagnostic Accuracy Studies checklist. Meta-analyses estimated the influence of biases on diagnostic odds ratios.

RESULTS

Among 1175 identified articles, 21 met the inclusion criteria. Most studies using magnetic resonance imaging (10 of 16) and ultrasound (10 of 13) examined symptomatic subjects. Magnetic resonance imaging studies evaluating symptomatic subjects had 14-fold higher diagnostic accuracy estimates compared with studies using an asymptomatic sample (relative diagnostic odds ratio, 13.8; 95 percent confidence interval, 1.83 to 104.6) and 2-fold higher diagnostic accuracy estimates compared with studies using a screening sample (relative diagnostic odds ratio, 1.89; 95 percent confidence interval, 0.05 to 75.7).

CONCLUSIONS

Many of the published studies using magnetic resonance imaging or ultrasound to detect silicone breast implant rupture are flawed with methodologic biases. These methodologic shortcomings may result in overestimated magnetic resonance imaging diagnostic accuracy measures and should be interpreted with caution when applying the data to a screening population.

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.

Breast implant complication review: double capsules and late seromas

BACKGROUND

The problem of double capsules and late seromas is a relatively new phenomenon in breast augmentation surgery.

METHODS

The author's experience with double capsules in 14 patients is outlined. The author reviewed all primary bilateral breast augmentations and primary bilateral mastopexy-augmentations after the moratorium in 1992. There were 209 patients with saline implants, 160 patients with CML and CMH Microcell textured surface implants, 105 patients with Biocell textured surface silicone gel breast implants, and 152 patients with smooth round silicone gel breast implants. Complications and revisions were reviewed to see if any patterns emerged.

RESULTS

Fourteen patients were found to have double capsules. Double capsules were only seen with the Biocell textured surface implant. Three patients developed late seromas (more than a year after their original surgery), with two patients requiring urgent drainage of an expanding seroma/hematoma. Seven patients were found to have double capsules as an incidental finding for procedures, such as asymmetry and bottoming out, and five patients were found to have double capsules when surgery was performed for capsular contracture. The review of complications and revisions showed that the silicone gel implants were far better than saline implants. Highly cohesive Microcell textured CMH and CML implants had by far the best capsular contracture profile. Biocell texturing increased the capsular contracture rate.

CONCLUSIONS

Double capsules and late seromas are a relatively new problem in breast augmentation surgery. The problem was not seen in smooth saline or smooth silicone gel breast implants but only in aggressively textured implants.

Breast implant surface development: perspectives on development and manufacture

Capsular contracture poses a significant clinical and scientific research challenge for breast surgeons. Some researchers have pointed to the surface features of implant devices as being responsible for the potential tightening and hardening of the surrounding capsule. In this article, the authors review the history and development of breast implant design, specifically the data supporting improvements that have potential to mitigate the incidence of capsular contracture. The literature suggests that development of new implant surfaces designed to reduce a patient's foreign body response will improve the safety profile of implant devices and increase patient satisfaction in the long-term.

Prospective cohort study of breast implants and the risk of connective-tissue diseases

BACKGROUND

A 2000 meta-analysis indicated no overall association between breast implants and risk of connective-tissue diseases (CTDs). However, a large retrospective cohort study we previously conducted suggested, instead, a small increased risk of CTDs. Because of limitations inherent to the retrospective cohort study design, we sought clarification by conducting a prospective cohort study of the association of breast implants with CTD risk.

METHODS

Participants were 23 847 US women (mean age 56.6 years), 3950 of whom had breast implants and 19 897 did not. Women reported their breast implant status at baseline in 2001 and were followed for a median of 3.63 years. During follow-up, women reported incident CTD, confirmed using a CTD screening questionnaire (CSQ) and medical records.

RESULTS

In multivariate analyses, the rate ratios for self-reported CTD (113 vs 377 cases in the implanted and non-implanted group, respectively) were 1.60 [95% confidence interval (CI) 1.28-2.00], for CSQ-confirmed CTD (77 vs 226 cases), 1.80 (1.37-2.38) and for medical record confirmed CTD (21 vs 74 cases), 1.39 (0.82-2.35).

CONCLUSIONS

Although this prospective cohort study represented a stronger design than the retrospective cohort study, the present data should still be viewed cautiously because of remaining methodological limitations, including the potential for differential self-reporting of CTD and CTD symptoms among women with and without breast implants, the difficulty of obtaining medical records for women reporting CTD and the low and possibly differential confirmation of self-reported disease against medical records. A reasonable conclusion is the lack of a large increase in CTD risk (e.g. ≥2-fold) associated with breast implants.

Aesthetic breast augmentation and thoracic deformities

To ensure the best results from aesthetic breast augmentation, preoperative evaluation and adequate patient information are essential. However, assessment of the underlying thoracic shape often is neglected. Patients with obvious deformities are aware of the problematic reconstruction, whereas patients with mild or moderate deformities often are not aware of their condition and fail to see that standard breast augmentation will lead to unsatisfying results. The authors reviewed their charts for patients with breast augmentation and mild to moderate thoracic deformities, then compiled the therapeutic possibilities and the outcome. Of the 548 patients who underwent breast augmentation, 7.1% (n = 39) exhibited low- or midgrade thoracic wall deformities. Almost none of the patients were aware of their deformity. The patients were augmented with silicone-filled, textured round implants. Placement and volume were adapted to the anatomic situation. A reoperation was not performed in any case, and both patient and physician satisfaction was high. The percentage of patients with thoracic deformity in this group was high compared with an overall incidence of less than 2%. This emphasizes the need for cautious physical examination and preoperative documentation. By individualized surgical planning and diligent implant selection, optimal results and patient satisfaction can be achieved.

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

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

Imaging in patients with breast implants-results of the First International Breast (Implant) Conference 2009

BACKGROUND: The First International Breast (Implant) Conference was held by the EAoS® (European Academy of Senology) in cooperation with the German Society of Senology during its 29th annual meeting in Düsseldorf, Germany, on 13 June 2009. METHODS: It was performed as a whole-day interactive workshop in which the standards of implant surgery within reconstructive and aesthetic breast surgery were discussed and defined by telecommunication dialogue voting. RESULTS: This article describes the conference results concerning pre- and post-procedural imaging in patients with breast implants. Both before and after augmentation, imaging is mandatory and provides essential information concerning tissue and implant integrity. Whereas mammography is the first-line method before surgery, ultrasound is the mainstay of post-procedural imaging. Cancer screening in augmented breasts generally follows the same guidelines as for non-augmented breasts. CONCLUSION: Whereas agreement about the indications for mammographical and sonographical evaluations is largely unanimous, there was substantial disagreement as far as the application of magnetic resonance imaging is concerned. There is an obvious demand for an evidence-based evaluation of this modality and the implementation of appropriate guidelines.

Thoracic and abdominal devices radiologists should recognize: pictorial review

OBJECTIVE

Surgical, interventional, and diagnostic devices are continually being developed and often have unexpected radiographic appearances. The purpose of this article is to familiarize the radiologist with several devices that may be placed in the thorax and abdomen.

CONCLUSION

The radiologist's familiarity with the radiographic appearance of devices placed in the chest and abdomen is essential for accurate image interpretation and identification of postprocedure complications.

Thoracic and abdominal devices radiologists should recognize: self-assessment module

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of thoracic and abdominal devices.

Post-mastectomy breast reconstruction: a history in evolution

Although the need for mastectomy has been evident for many years, postmastectomy reconstruction has been recognized as an achievable outcome for only a little over a century. A review of the evolution of both autologous and prosthetic options for reconstruction was undertaken. The earliest attempts at reconstruction used autologous techniques that were either unsuccessful, not reproducible, or were associated with significant morbidity. Prosthetic techniques became sought after, with silicone prostheses widely used until concerns about potential adverse effects led to the investigation of alternate options. With these concerns shown to be unfounded, silicone and saline prostheses evolved with successive generations of implants. Concurrent advances in reconstructive surgery led to a revival in autologous techniques for breast reconstruction, with microsurgical free-tissue transfer potentiating a new range of potential donor sites. The abdominal wall became the donor site of choice, and with the advent of perforator flaps, morbidity associated with flap harvest was minimized. In cases where the abdominal wall is unsuitable, flaps such as the superior and inferior gluteal artery perforator flaps, the musculocutaneous gracilis flap, and the "stacked" deep inferior epigastric artery perforator flap are frequently used options. The development of minimally invasive techniques for implant placement and flap harvest, such as endoscopy, continue to evolve, and research in tissue engineering offers a vision for a future without the need for a donor site.

Breast augmentation motivations and satisfaction: a prospective study of more than 3,000 silicone implantations

More than 3,000 participants from three large, multi-center, US clinical studies of silicone implants (Allergan, Santa Barbara, CA) were asked to rate their motivations for breast augmentation surgery prior to implantation. A 5-point scale was used to rate the level of importance, ranging from "not at all important" to "extremely important." Prior to implantation and 1 year after implant surgery, women also rated their level of satisfaction with various aspects of their breasts. This article reviews the data collection methods and current results of these studies, identifying the patient's motivation for breast augmentation surgery and reported post-operative satisfaction.