BREAST IMPLANTS

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BREAST IMPLANTS
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BREAST ANATOMY
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WHY IMPLANTS?

• To enhance breast size for women who feel their
  breasts are too small
• To correct a reduction in breast size after
  pregnancy
• To balance naturally occurring difference in
  breast size
• Reconstructive technique following breast surgery
  and/or mastectomy

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Pathophysiology

• Most reconstructive surgery is done after a
  mastectomy
• Main reason for mastectomy is removal of cancer
• 6-15 of women undergoing any form of cosmetic
  surgery suffer from Body Dysmorphic Disorder
• BDD has a high rate of co-morbidity with other
  psychiatric disorders, such as depression or OCD
• Many plastic surgeons screen for psychiatric
  disorders such as BDD

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HISTORY OF IMPLANTS

• Ivory, glass rubber balls
• 1895-Transplantation of lipoma from hip after
  removal of a fibroadenoma from breast
• Infection, hardening of the breast, lump
  formation, retinal, pulmonary and cerebral
  embolism
• 1899- Injection of parrafin into womens breasts
  by Austrian physician Robert Gensuny

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More History...

• 1920s- Fat transplants
• Lumpy, asymmetrical breasts after body reabsorbed
  fat
• 1940s-Silicone injections used by Japanese
  prostitutes during WWII in the form of shots
  directly into breast.
• Silicone dispersed and causing satellites
  throughout the entire breast resulting most often
  in mastectomy.

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Breast Implant Materials

• High molecular weight silicone
  elastomer shell filled with either
  medium MW silicone gel or
  plain saline
• Silicone
• Inert, hydrophobic, and non-toxic
• Many modifications over the past 40 years

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More History...

• 1950s-Surgical sponges (Surgifoam, Ivalon)
  implanted into breasts
• Polyvinylalcohol formaldehyde polymer
• Rough surface resulted in tissue in-growth
• Hard and distorted as the sponge shrank
• Encasing sponge in polyethylene sacs
• Sacs accumulated fluid and associated with
  infection and fistula.
• 1961- Dr. Thomas Cronin and Dr. Frank Gerow
  develop first modern breast implant
• Seams and fixation patches, shell was thick, gel
  was viscous
• Primary complication capsular contracture.
• 1962- First female recipient of breast implant

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More History. . .

• 1962 Polyurethane foam introduced for
  prevention of capsular contracture by allowing
  tissue in-growth
• Polyurethane may produce a toxic byproduct within
  the body, toluene diamine, known to be oncogenic
• Implants withdrawn from market in 1991
• 1974 Shell much thinner and gel less viscous
  with the aim of softening the breasts and
  decreasing the risk of capsular contracture.
• Late 1970s - Surgeons observed gel bleed with
  intact implants
• Development of connective tissue diseases and
  other autoimmune diseases???

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Materials

• Initially anchored to patient tissue
• Dacron patches
• Patches not required and eliminated

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Implant Shells

• 1st generation implants-Thick, smooth-surfaced
  shells
• 2nd generation implants-Thinner shells, for a
  more natural feel
• Higher rupture rates
• Other innovations- Textured surface to prevent
  excessive fibrous tissue growth and to help
  fixation of implant within the breast

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Implant Fillers

• Silicone gel and saline are the most common
  fillers
• 1995 in Europe-Trilucent implant was launched
• Gel derived from soybean oil
• Polyvinylpyrrolidone (PVP) gel tested

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Current Available Implants
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Augmentation vs. Reconstruction

• Augmentation surgery done on patients with
  healthy breasts.
• 2003- 280,400 women had breast augmentation
  surgery (147 increase over the past five years).
• Reconstructive surgery done after any type of
  breast surgery, mainly mastectomy.
• 2004- 63,000 women had reconstructive surgery
  following a mastectomy.

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Reconstructive Surgery

• Mastectomy
• Removal of breast, lymph nodes under the breast,
  lining under chest muscle, and, occasionally,
  part of chest wall muscles
• Results in weight shift that could lead to back
  and neck pains, especially in women with large
  breasts

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Reconstructive Surgery

• Reconstructive surgery is often done immediately
  following mastectomy
• Best candidates
• Complete elimination of the cancer
• No previous encounter with radiation therapy
• Types of Reconstructive Surgery
• Two-Stage Skin Expansion
• Single-Stage Skin Expansion
• Flap Reconstruction
• In certain circumstances reconstructive follows
  the same procedure as standard augmentation

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Augmentation Procedure Implant Placement

• Submuscular
• less likely to be felt through the skin
• less likely to have capsular contracture
• easier to image a breast mammogram
• longer surgery and recovery period
• more difficult for to perform replacement
  procedures if needed
• augmentation size is limited by the relatively
  noncompliant nature of the muscle cover

• Subglandular
• shorter surgery and recovery time
• easier to perform replacement procedures
• more noticeable edges and palpablity
• increases probability of capsular contracture
• difficulty to image a breast during a mammogram
  which is highly problematic for woman who have
  had breast cancer or at high risk
• sensory disturbance of the nipple-areolar complex
  occurs in 15 of patients

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Augmentation ProcedureSaline vs. Silicone

• Saline
• can be inserted unfilled into breast and then
  filled with a removable tube resulting in a
  smaller incision
• mandatory replacement if ruptures
• replacement is easy and will be paid for by the
  major implant company
• normally implanted submuscular to prevent
  rippling
• higher rupture rate
• firmer consistency compared with silicone
• less expensive

• Silicone
• must be inserted as a filled implant, requiring a
  larger incision
• due to silicones more rigid nature, insertion is
  more likely to result in fracture of the material
• does not require replacement if ruptures
• more natural feel
• are less palpable
• produce less skin wrinkling
• higher maintenance of shape
• not as accessible to the public

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Complications

• Immediate adverse effects
• Haematoma
• Seroma
• Wound dehiscence
• Surgical site infection
• Periprosthetic infection
• Perforation of the skin
• Change in tactile sense

• Short-term adverse effects
• Visible skin wrinkles
• Palpable implant folds
• Asymmetry or displacement of the implant
• Ptosis
• Swelling of the breast
• Disconfiguration of the breast at time of
  muscular contraction
• Hypertrophic scar
• Periprosthetic infection
• Capsular contracture
• Prolonged pain of the breast
• Implant rupture

• Long-term adverse effects
• Late infection
• Capsular contracture
• Silicone granuloma

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Infection

• Leading cause of morbidity
• Occurs approximately in 2.5 of breast
  augmentation surgery
• Potential sources are a contaminated implant,
  contaminated saline, the surgical environment,
  the patients skin or mammary ducts, or seeding
  of the implant from remote infection
• Two Types Acute Infection and Late Infection

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Risk factors for Infection

• Poor surgical procedure
• Pre-existing tissue scarring and skin atrophy
• Exposure to radiation therapy
• Immediate implant placement following mastectomy

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Acute Infection

• 1.7 of breast augmentation surgeries
• Usually associated with fever, rapidly evolving
  pain, and marked breast erythema
• Not related to type of implant
• Toxic shock syndrome is one lethal form
• Staphylococcus aureus bacteria growth

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Late Infection

• Occurs approximately 0.8 of breast augmentation
  procedures
• Usually results from secondary bacteria or an
  invasive procedure at a location other than
  breasts

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Management of Infection

• Aspiration guided by ultrasonography may be done
  if fluid is present
• Surgical removal of the implant is mandatory in
  most cases
• A 10-14 day course of systemic antibiotics to
  remove causative pathogens

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Capsular Contracture

• Capsular contracture is the leading long-term
  complication
• The acellular collagenous sheath, which forms
  around an inert foreign material, contracts
  around the implant forming a hard spherical mass
• Incident rate is 1.66 per 1000 implant-months and
  2.83 per 1000 person-months

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Capsular Contracture Causes

• May be caused by a low grade or subclinical
  infection that could be prevented by antibiotics
• Might be prevented by antibiotics at the site of
  the implant
• Current studies show a 50 reduction in capsule
  formation when treated with antibiotics
• Higher occurrence associated with small surgical
  pocket, subglandular placement, silicone gel,
  presence of Dacron patch, thinner shell, smooth
  implant surface, and increased duration of
  implantation

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Implant Rupture

• Risk factors
• older implants
• subglandular implant location
• capsular contracture
• local symptoms
• certain implant type
• the smooth-shell single-lumen gel-filled implants
  has a higher risk of rupture than the
  polyurethane or the double-lumen implants
• certain manufacturers
• in comparison to Dow Corning, Surgitek has
  significantly higher rupture rates, while McGhan,
  Mentor, and Cox Uphoff had significantly lower
  rupture rates

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Implant Rupture Age
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Implant Rupture Contracture
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Implant Rupture Symptoms

• No significant relation between presence or
  absence of systemic or local symptoms to rupture

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Silicone Granuloma

• A natural host response to wall off a foreign
  substance.
• Rare complication
• May cause ulcers, pain, swelling, numbness and
  tightness of the skin
• Requires extensive dissection to remove.

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The Ban on Silicone filled Implants

• In 1992, the FDA banned the use of silicone
  breast implants, except for those undergoing
  reconstructive surgery or participating in a
  controlled clinical trial.
• There was not sufficient evidence from the
  manufacturers.
• The moratorium advised against approving silicone
  implants.
• In 1994, Dow Corning, the leading manufacturer of
  silicone implants, set aside 4.25 billion
  settlement for women with implants.
• Since 1992 many studies have been conducted
  concerning the connection between silicone breast
  implants and connective tissue diseases. All of
  these studies came to the same conclusion There
  is no connection between silicone breast implants
  and the development of a connective tissue
  disease.
• In April 2005, the moratorium due to the
  substantial new research recommended that the ban
  on silicone implants be lifted.