Mammography and breast implants

Recent recommendations by the American Cancer Society have focused attention on the value of screening mammography in the detection of occult breast cancers. This has resulted in a proliferation of "walk in" and mobile mammography screening clinics and a barrage of publicity aimed at women aged 40 and over. Among these are more than a half million women who have had an augmentation mammaplasty; at least another half million are still under 40 but entering this age group incrementally. Opinion is divided as to the value of this procedure because of uncertainty as to the amount of breast tissue obscured by the implant. Calibrated planimetry was used to measure the area of the implant and the glandular portion of the breasts in six sets of mammograms. Utilizing solid geometric calculations, it was found that the percentage of glandular tissue obscured by the implant varied from 22 to 83 percent. This wide variation casts serious doubt on the reliability of routine film screen mammography in these patients.     

Immediate breast reconstruction using biodimensional anatomical permanent expander implants: a prospective analysis of outcome and patient satisfaction

Immediate breast reconstruction is offered to the majority of women requiring a mastectomy for cancer treatment. Improvements in implant technology have seen the evolution of shaped, fixed-volume implants and permanent expanders. The theoretical benefits of biodimensional anatomical expander implants include better reconstructed breast form, the potential for achieving this at a single procedure, and the avoidance of a contralateral procedure as a result of improved ipsilateral cosmesis. The aim of the present study was to assess outcome after immediate breast reconstruction using the McGhan 150 permanent expander implant. A total of 107 consecutive patients (129 breast reconstructions) were studied over a 30-month period; 49 patients (68 reconstructions) had submuscular implant placement alone, and 58 patients (61 reconstructions) had an implant in conjunction with a latissimus dorsi flap. The mean patient age was 47 years (range, 22 to 72 years) and the mean follow-up was 18 months (range, 6 to 40 months). Outcome was assessed in the following four ways: geometric measurements, evaluation of photographs by four independent observers, linear numerical analogue scale, and a quality-of-life questionnaire. Geometric measurements after surgery showed median differences that were highly consistent with good symmetry. Transverse breast width difference between breasts was 0.35 cm, vertical breast height difference was 0.8 cm, sternal notch-to-nipple distance difference was 0.6 cm, midclavicular line-to-nipple distance difference was 0.5 cm, nipple-to-inframammary crease distance difference was 0.5 cm, midline-to-nipple distance difference was 0 cm, and projection difference was 0 cm. Photographic assessment by four observers who evaluated shape, cleavage, symmetry, and overall outcome produced correlation values of 0.73 to 0.81. More than 75 percent of each of these parameters was scored as good or excellent. A numerical analogue scale (from 1 to 10) assessing overall result by the surgeon and patient revealed good (7 to 8) or excellent (9 to 10) scores in 83 and 82 percent of respondents, respectively. Quality-of-life data showed that 81 and 88 percent of women felt "a little" or "not at all" less feminine, respectively, and 88 percent were satisfied with the appearance of their breasts. A total of 88 percent of women would also choose the same reconstructive procedure if faced with the same cancer diagnosis. Complication rates were low; infections occurred in 6.2 percent of reconstructions, hematoma occurred in 1.6 percent, and implant loss occurred in 3.9 percent. Only 24 of 107 patients (22 percent) elected to have a synchronous contralateral breast adjustment, and four of 107 (4 percent) chose to have a subsequent procedure for symmetry. Biodimensional expander implants used in immediate breast reconstruction are associated with high levels of patient and surgeon satisfaction. Optimum breast form can be achieved during a single operation with a low incidence of complications.     

Biocompatibility of radiolucent breast implants

Current implants for breast augmentation containing silicone gel, saline, or both are radiopaque on mammographic examination and can totally obscure microcalcifications and soft-tissue masses. The effect of these implants on the detection of early breast cancers in patients who have undergone augmentation mammaplasty remains unproven and controversial. Implants filled with medium-chain triglycerides (peanut oil) are radiolucent on mammographic examination and allow visualization of both soft-tissue masses and microcalcifications. To investigate the biocompatibility of radiolucent implants, 10 cc of sterile, nonpyrogenic peanut oil was injected subcutaneously into rats using silicone gel as a control. Twenty-one rabbits had two 125-cc silicone shell implants inserted on either side of the chest wall. The right-sided shell was filled with 125 cc of sterile saline, and the left-sided shell was filled with 125 cc of sterile, nonpyrogenic peanut oil. Results were determined by both histologic and radiographic examination. Rats injected with peanut oil equivalent to 7 percent of their body weight rapidly absorbed the freely injected oil without detriment. Histologic examination of the lungs, liver, kidneys, and tissues adjacent to the injection sites demonstrated no abnormalities. There was no evidence of allergic, toxic, inflammatory, or neoplastic response. Eighteen of 21 rabbits survived more than 3 months. Radiographs showed the oil-filled implants to be radiolucent, whereas the saline-filled controls obscured the surrounding soft and bony tissues. Histologic examination demonstrated a fibrous capsule surrounding both types of implants. Histologic examination of the lungs, liver, and kidneys showed no significant abnormalities. These and previous studies have shown peanut oil to be biocompatible when freely injected either intramuscularly or subcutaneously. This study demonstrates that a radiolucent, peanut oil-filled implant is biocompatible in animals and that further long-term studies for its use in humans are merited.     

Long-term complications of polyurethane-covered breast implants

The authors's personal experience using an earlier manufactured polyurethane-covered gel prosthesis is presented. Very long-term follow-up did not validate the author's initial enthusiasm. It is to be hoped that the newer polyurethane-covered implants will give more satisfactory long-term results.     

Anti-soya antibodies and trilucent breast implants

In light of the media attention surrounding the withdrawal of Trilucent breast implants in March of 1999, we undertook a study of 20 women with these implants to compare the level of serum antibodies to soya oil and protein with that of a control group. Two control groups were chosen: 20 women without breast implants and 20 women with silicone-containing breast implants. Serum antibodies to soya protein were detected with an enzyme-linked immunoabsorbent assay technique, because direct assay to soya oil is not possible owing to insolubility of the soya oil component. No antibody formation was detected in the patients with Trilucent breast implants or in either of the control groups, lending support to the view that these implants are unlikely to give rise to a systemic immune response.     

Antinuclear antibodies and breast implants.

Anecdotal reports have linked silicone breast implants to autoimmune diseases, with scleroderma being mentioned most often. In view of other environmental influences--such as silica mining and the toxic oil syndrome--thought to predispose to scleroderma, more systematic immunologic information on women with silicone implants is needed to assess any possible relation to autoimmunity. A cross-sectional survey was carried out with 150 women, of whom 131 had implants. Group 0 consisted of 19 volunteer women without breast implants who felt healthy, group I was 38 volunteer women with breast implants who felt healthy, group II was 82 women with implants who had various symptoms, and group III was 11 women with implants who had autoimmune disease. Scleroderma was overrepresented in group III (6 of 11). Antinuclear antibodies were determined on Hep-2 cells, using serum dilutions of 1:16, 1:64, and 1:256. A positive test was indicated by 1+ or more fluorescence at 1:256. Antinuclear antibody tests were positive in 0% of group 0, 18% of group I (P < .05 versus group 0), 26% of group II, and 64% of group III. There was no correlation between antinuclear antibody positivity and type of implant, indication for implantation, time since first implantation, total number of implants, and report of implant leak or rupture. Women with breast implants may be at risk for the development of antinuclear antibodies. Proof of such an association will require large-scale prospective studies and epidemiologic analyses.     

The diagnosis of ruptured breast implants

This study is a retrospective review of 18 patients treated by the authors and 14 reported patients with ruptured breast implants. A history of trauma was absent in 11 patients; 17 patients had closed capsulotomies. The physical findings of ruptured implants were nodules, decreased breast size, asymmetry, tenderness, and a softer texture. Mammograms were 90 percent accurate when silicone had migrated. In seven of eight false-negative mammograms, silicone was contained within the fibrous capsule. Mammography signs of rupture are summarized. The diagnosis of ruptured implants should be facilitated by recognition of the clinical presentations and radiographic signs.