Does the presence of an implant including expander with internal port alter radiation dose? An ex vivo model

BACKGROUND:

There is a lack of literature examining the dosimetric implications of irradiating breast implants and expanders with internal ports inserted at the time of mastectomy.

OBJECTIVE:

To determine whether the presence of breast expanders with port in saline or silicone implants affect the dose uniformity across the breast when irradiated with various photon and electron energies.

METHODS:

One tissue-equivalent torso phantom with overlying tissue expanders in saline or silicone implants were irradiated using tangential fields with 6 MV and 18 MV photons and 9 MeV and 12 MeV electrons. All dose measurements were performed using thermoluminescent dosimeters (TLDs). The TLDs were arranged around the port and the perimeters of either the expander, or saline or silicone implant. Comparisons of measured radiation doses, and between the expected and measured doses of radiation from the TLDs on each prosthesis, were performed. Data were analyzed using two-tailed t tests.

RESULTS:

There were no differences in TLD measurements between the expander and the saline implant for all energy modalities, and for the expected versus actual measurements for the saline implant. Higher than anticipated measurements were recorded for a significant number of TLD positions around the silicone implants.

CONCLUSIONS:

Radiation doses around saline implants or expanders with internal port were unaltered, whereas dose recordings for silicone implants were higher than predicted in the present laboratory/ex vivo study.     

Silicone breast prostheses: A cohort study of complaints,complications, and explantations between 2003 and 2015

Background

Complications after silicone implantation, with silicone extravasation being the most severe, remain a safety issue in breast implantation surgery. The purpose of our study was to determine the incidence of medium- and long-term postoperative complaints and complications and indications for explantation in patients with a silicone breast implant.

Changes over Time in Mammary Compliance Values After Breast Augmentation

Capsular contracture is the most troublesome and distressing complication after breast augmentation for both the surgeon and patient. The etiology of capsular contracture remains unclear. Clinical treatment for this complication is based on the surgeon’s evaluation, the condition of the breast, and a number of other factors. In a previous study, the authors investigated whether measurement of mammary compliance as a means of assessing capsular contracture was comparable with other methods described for the assessment of capsular contracture. The purpose of this study was to evaluate whether capsular contracture varies significantly over time. A prospective study was performed to measure mammary compliance in 60 female patients who received a total of 120 implants between 2000 and 2002. The implants used were anatomic prostheses filled with cohesive silicone gel and round double-lumen prostheses filled with silicone gel and saline solution. All the patients were followed up for at least 2 years. Statistical analysis of the data also was performed to assess significance. The results showed a general trend in mammary compliance values over time.     

Sentinel lymph node biopsy in a patient with ruptured poly implant prothese (PIP) implants: A case report

Introduction

Around 400,000 silicone gel breast implants produced by the French company poly implant prothese (PIP) were used worldwide. Following revelations that the company were using non- medical grade silicone for the production of their implants there has been growing concern over the increased rupture rate of these implants and the implications this may have on patients.

Presentation of Case

We report the case of a 57-year old lady with ruptured bilateral cosmetic PIP breast implants in whom a right breast lesion was detected on screening mammograms. Biopsies demonstrated a grade 1 tubular carcinoma. Histology from the sentinel lymph node biopsy showed axillary silicone granulomas but no evidence of metastatic disease.

Discussion

To our knowledge, this is the first reported case to describe SLNB in the presence of ruptured PIP implants, although SLNB in ruptured non-PIP implants has been previously described.

Conclusion

We conclude that SLNB can be utilised even in the context of concurrent PIP implant rupture and the presence of silicone granulomas in the axillary lymph nodes.     

Titanium-coated polypropylene mesh (TiLoop Bra®)—an effective prevention for capsular contracture?

Background

Silicone implants have been used in breast augmentation for more than 45 years. Complications, in particular, capsular contracture, still occur with a high incidence. Titanium-coated polypropylene mesh (TCPM; TiLoop Bra®, pfm medical, Cologne, Germany) provides new opportunities for implant-based breast reconstruction. We investigated the influence of the surface of silicone implants on the formation of capsular contracture by comparing textured silicone with TCPM-covered smooth silicone implants.

Methods

Twenty textured silicone gel-filled (group A) and twenty TCPM-covered smooth silicone gel implants (group B) (Silimed®, Rio de Janeiro, Brazil) were implanted in female Wistar rats. After 60 days, the implants and capsules were extracted, and histological and immunohistochemical staining was performed. The double-blind evaluation of the capsules was performed by two examiners.

Results

We were able to detect a thinner, but stiffer, capsule and a less development of an inner synovia metaplasia layer as well as a lower vascularity in capsules around TCPM-covered silicone implants. We found a higher percentage of myofibroblasts within the capsule structure and more inflammatory cell infiltration.

Conclusions

The quality of capsule structure around both tested implants differs significantly. Although capsules around TCPM-covered implants presented were thinner, they integrated with the mesh in a rigid cage structure capsule with higher infiltration of inflammatory cells caused by a significant foreign body reaction. TCPM-covered silicone implants showed no apparent advantage in the reduction of capsular contracture. On the other hand, the indication for using this material as a supportive soft tissue structure can be confirmed. Level of Evidence: not ratable, experimental study.     

The effect of timing of postmastectomy radiation on implant-based breast reconstruction: a retrospective comparison of complication outcomes

Background

The optimal timing of postmastectomy radiation for women undergoing delayed permanent implant exchange continues to remain controversial. The objective of our study is to compare complication rates when tissue expanders are exchanged for permanent implants pre- vs postradiation.

Methods

A retrospective review of 54 consecutive patients who underwent implant-based breast reconstruction and received postmastectomy radiation was conducted. Complications including infection, implant loss, and capsular contracture (measured in Baker score) were compared between the 2 groups.

Results

Of the patients studied, 32 patients had radiation before placement of permanent implants, whereas 22 patients received radiation after implant placement. There was no difference in individual complication rates between the 2 groups.

Conclusions

In our study of 54 patients, the timing of radiation did not affect individual complication rates for patients who underwent implant-based breast reconstruction after immediate tissue expander placement.     

The impact of preoperative breast implant size selection on the 3-year reoperation rate

Background

Revision surgery following primary augmentation mammoplasty is commonly performed. There are several long-term and short-term published studies on the incidence of revisionary surgery in primary mammoplasties. The current study is a single surgeon’s experience with reoperations following consecutively performed primary augmentation mammoplasties and an assessment of the role of the process of breast augmentation. A retrospective data analysis was performed to evaluate a single surgeon’s 3-year reoperation rate in primary augmentation mammoplasties.

Methods

A retrospective analysis of data using the Excel Spread was performed. Data of patients having had consecutive primary augmentation mammoplasties, performed between January 2008 and December 2010, were collected to evaluate the efficacy of a structured process of primary augmentation mammoplasties and its impact on a 3-year reoperation rate. Patients with asymmetrical breast or chest requiring different size implants were excluded. Patients presenting with ptosis requiring mastopexy in primary augmentation mammoplasty were also excluded from the study.

Results

A total of 507 primary bilateral augmentation mammoplasties were performed by the author between January 2008 and December 2010. All patients had muscle splitting biplane technique and all had round silicone cohesive gel silicone implants during the study period. All implants were inserted using inframammary crease incision. Mean size of implant in primary augmentation mammoplasty was 346.9 cc (range 200–700). Data showed 10 (1.97 %) patients had a reoperation following primary augmentation mammoplasty.

Conclusions

This retrospective study showed a low 3-year reoperation rate. A clear understanding of the process of breast augmentation, good informed consent and careful selection of implant size in primary and revision augmentation mammoplasty can potentially reduce reoperations. Level of Evidence: Level IV, Prognostic/risk study.     

Breast reduction surgery in Ontario: Changes in practice, 1992 to 2008

BACKGROUND:

Symptomatic mammary hypertrophy impacts physical function and patient quality of life. Breast reduction mammoplasty, a surgical procedure performed to reduce breast size, has been used for many years to reduce these symptoms.

OBJECTIVE:

To evaluate variations in the surgical practice of breast reduction mammoplasty among women ≥15 years of age (approximately 6.4 million population in 2008) over a 17-year period in Ontario.

METHOD:

A population-based, cross-sectional time series analysis was conducted to examine temporal trends in 87,049 breast reduction surgeries performed between January 1, 1992 and December 30, 2008.

RESULTS:

Breast reduction rates have been relatively stable over time, with 83 per 100,000 of the female population undergoing breast reduction surgery annually. However, a significant decrease in the rate of inpatient surgeries were observed over the study period (from 69.3 per 100,000 in 1992 to 25.7 per 100,000 in 2008). At the beginning of the study period, the highest annual rates of this procedure were observed among women 21 to 30 years of age (116.6 procedures per 100,000); however, by the end of the observation period, this shifted to women 31 to 50 years of age (109.9 procedures per 100,000). Furthermore, the annual procedure rate among women ≥51 years of age almost doubled, rising from 36.4 procedures per 100,000 in 1992 to 66.6 procedures per 100,000 in 2008. This was likely related to changing demographics and social factors.

CONCLUSION:

These data suggest that breast reduction mammoplasty will continue to be requested, with an increased proportion of patients who are older and desire improved quality of life and physical function.     

Breast Implant Stability in the Subfascial Plane and the New Shaped Silicone Gel Breast Implants

The author presents his experience with breast augmentation using a next-generation, form-stable, anatomically shaped silicone gel breast implant. Rotation is a potential complication for anatomically shaped breast implants. Anatomically shaped saline implants have been reported to have a rotation rate as high as 14%, while lower rotation rates of 1–2.6% for anatomic cohesive gel silicone implants have been reported. Currently, these implants are limited in the United States to US FDA-approved clinical trials. The author reviews the appropriate surgical techniques to prevent rotation when using these devices. A recent innovation, placement of the superior pole of the implant underneath the superficial fascia of the pectoralis major muscle, is described. Primary and secondary breast augmentations in 241 procedures using the Allergan Style 410 implant resulted in a 0.0% rotation rate. Overall, the anatomic form-stable silicone gel breast implants, when placed subfascially, improve common complications such as capsular contracture and implant rupture with improved aesthetic outcomes and patient satisfaction.     

The natural history of a newly developed flexion contracture following primary total knee arthroplasty

Purpose

We investigated the incidence, natural history, and functional consequences of a newly developed flexion contracture after total knee arthroplasty (TKA).

Methods

Forty patients with full knee extension preoperatively who developed a postoperative flexion contracture were match-paired 1:2 with 80 patients who had full extension. The incidence of a newly developed flexion contracture, ROM, and Knee Society scores (KSS) at six weeks, four months, and one year were analysed.

Results

The incidence of a new flexion contracture at six weeks was 14 %, but diminished to 5 % and 0.3 % at four months and one year, respectively. One year after surgery, there was no difference in the KSS (p = 0.5).

Conclusions

This study showed that the majority of patients who developed a new flexion contracture after TKA have full knee extension one year postoperatively. Moreover, knee extension and KSS at one year are equivalent to those patients who did not developed a flexion contracture.     

Preliminary (3 years) experience with smooth wall silicone gel implants for primary breast augmentation

The goal of this study is to obtain data concerning the incidence of capsular contracture and reoperation rates in patients having primary breast augmentation utilizing modern low-bleed smooth-wall silicone gel implants. Data were collected retrospectively and consisted of 44 patients who underwent primary breast augmentation using smooth silicone gel implants (Mentor Corporation) in the period between 2001 and 2003. Of the 131 patients identified, 44 patients fit the criteria of primary breast augmentation. Secondary cases and primary augmentation with mastopexy were excluded from this study. This group of patients is still followed, and the data are being updated periodically. A total of 44 patients underwent primary breast augmentation. Average age was 32 years (range, 19-57). Average follow-up was 34 months (range, 28-40). Average operative time was 52 minutes. The inframammary incision was used in 65% of patients and the areolar incision in 35%. The subglandular position was used in 35% of patients versus the submuscular position in 65%. Nine patients (20%) developed capsular contracture. Six patients (13.6%) had Baker 3 capsular contracture, which required revision. Four of the 9 patients with capsular contracture had implants placed in the submuscular space and 5 in the subglandular position. Relative to the implant position, 4 patients (9%) with implants placed in the submuscular position developed capsular contracture. Relative to the subglandular position, 5 patients (11.3%) with implants placed in the subglandular position developed capsular contracture. Eight patients (19%) required implant revision, 6 patients for capsular contracture, and 2 patients requested size change. Preliminary data from this study indicate that the use of the new generation of gel implants yields less capsular contracture, as well as decreased revision rates. Subglandular placement of gel implants did not significantly increase the risk of capsular contracture. Longer follow-up and multicenter studies are still needed to confirm these findings. This cumulative data could challenge the current status of gel implant moratorium imposed by the incidence of capsular contracture and revision rates.     

Mammoplasty for symmetry in breast reconstruction and histologic assessment

Background

In breast reconstruction, complementary surgery on the contralateral breast is sometimes necessary to obtain a satisfactory aesthetic result. This complementary mammoplasty for symmetry gives the surgeon the opportunity to verify the state of the mammary glandular tissue to rule out a possible occult tumour in the contralateral breast. Our objective was to determine the prevalence of borderline lesions and of in situ and invasive carcinoma in specimens of the contralateral breast in a mammoplasty for symmetry in patients with breast cancer.

Methods

We conducted a retrospective study of 145 breast reconstructions with mammoplasty for symmetry conducted at the Tours Regional Teaching Hospital in France.

Results

The glandular histologic result after mammoplasty was normal in 45.5% of patients, with benign pathologies in 38.9% and borderline lesions in 15.6% of patients. No invasive or in situ carcinoma was detected.

Conclusion

Systematic histologic analysis of glandular mammary tissue sampled after reduction mammoplasty in the particular context of breast reconstruction after breast cancer makes it possible to discover lesions that were not seen in presurgical evaluation. The early management of these borderline occult lesions could reduce the incidence of breast cancer in these at-risk patients.     

Intraoperative pulmonary function dynamics in adolescents undergoing reduction mammoplasty: A prospective case series

BACKGROUND:

Improvement of lung function following reduction mammoplasty has been previously reported among adult populations in the medical literature.

OBJECTIVES:

To evaluate the intraoperative dynamics of pulmonary function in adolescents undergoing reduction mammoplasty.

METHODS:

The present study is a prospective case series of female patients 13 to 18 years of age who underwent inferior pedicle reduction mammoplasty between November 20, 2006 and April 4, 2011. Documented variables included patient baseline characteristics, operation duration, muscle relaxant use and total breast tissue removed. Intraoperative pulmonary function data documented included: tidal volume, respiratory rate, peak inspiratory pressure, positive end-expiratory pressure, oxygen saturation percentage and pulmonary compliance. Differences in pulmonary function data were calculated as ratio between final and initial intraoperative values.

RESULTS:

Twenty-six patients were included in the analysis. Mean (± SD) age was 16.9±1.1 years and mean body mass index was 28.9±6.1 kg/m². Mean operation time was 218±52 min, with average total bilateral breast tissue removal of 1810±1065 g. Improvement in lung compliance was observed in 24 patients (92.3%; P<0.0001). Mean intraoperative lung compliance improvement was 23.92% (95% CI 8.3% to 37%; P=0.001).

CONCLUSION:

Intraoperative improvement in lung compliance was observed in adolescent patients undergoing reduction mammoplasty.     

Early experience with an anatomical soft cohesive silicone gel prosthesis in cosmetic and reconstructive breast implant surgery

Recently, an anatomic breast implant filled with soft cohesive silicone gel was introduced by Mentor Medical Systems onto the European market. This study reports the early experience of a single surgeon with this implant. All patients who received a Contour Profile Gel (CPG) implant from March 2001 to October 2002 were studied. Patient satisfaction with breast shape and consistency was assessed using linear analogue scales with a maximum score of 10. Thirty-five patients received CPG implants for cosmetic (10 patients, 20 breasts) and reconstructive (25 patients, 31 breasts) surgery purposes. Patients were satisfied with their breast shape (mean score: 8.3). Eighty-five percent of the breasts were rated as soft (score >/=6). No serious esthetic complications such as implant malposition or significant capsular contracture were observed. Anatomic soft cohesive gel implants provide excellent results in selected cases. They are well accepted by patients and not associated with an increased rate of complications.     

硅凝胶假体隆乳术后的随访观察

目的：随访硅凝胶假体隆乳术后病例,观察和总结术后效果及并发症发生情况,以指导临床工作的正确开展。方法：对228例硅凝胶假体隆乳者进行随访,通过术后留观、来院拆线、定期检查、电话随访、发生不适时前来就诊、再次接受其它美容治疗时的咨询和观察,判断隆乳术后效果,统计并发症情况,探讨并发症的正确处理。结果：228例中发生术后并发症的25例,其中术后血肿3例,感染3例,假体移位5例,假体破裂1例,纤维包膜挛缩10例,感觉异常1例,心理障碍2例。并发症经及时、正确处理后,效果满意。结论：硅凝胶假体隆乳整体而言效果良好,有一定并发症发生,经及时正确处理,可获得满意效果。     

Using therapeutic mammoplasty to extend the role of breast-conserving surgery in women with larger or ptotic breasts

Introduction

The equivalence of breast-conserving surgery followed by postoperative radiotherapy against mastectomy is now firmly established in patients with early breast cancer. The results of surgery in large-breasted women can be poor, with radiation-induced fibrosis, chronic pain and poor cosmesis contributing to long-term psychological and physical morbidity. Therapeutic mammoplasty offers an alternative management strategy to both enhance the role of breast-conserving surgery and provide better outcomes.

Methods

A retrospective note review was undertaken of all patients undergoing therapeutic mammoplasty for breast malignancy between 2007 and 2011. All cases were performed using a Wise pattern-reduction technique. Histology and pathological outcomes were assessed. Postoperative outcomes reviewed included wound infection, seroma and need for further intervention.

Results

During the study period, 20 patients underwent therapeutic mammoplasty with a mean follow-up duration of 36 months. The mean weight of the lumpectomy specimen was 330g. The average cancer size was 34mm, with a mean margin clearance of 7mm. There was one episode of wound infection and three of delayed wound healing at the T-junction. One patient required a mastectomy for involved margins. There were no recurrences at the most recent follow-up visit.

Conclusions

Therapeutic mammoplasty offers a tailored approach to women with larger breasts and early breast cancers with good cosmetic results and oncological outcomes.     

Needle aponeurotomy for Dupuytren contracture: Effectiveness of postoperative night extension splinting

BACKGROUND:

Night extension splinting has been used to treat patients with Dupuytren contracture to improve active range of motion (AROM) of the hand. A published case study demonstrated the benefit of splinting following needle aponeurotomy; however, no larger studies have evaluated the impact of postoperative splinting.

OBJECTIVES:

To compare the impact of night extension splinting on AROM, specifically extension, following needle aponeurotomy for Dupuytren contracture.

METHODS:

A retrospective chart review was conducted in which the charts of 53 patients who underwent needle aponeurotomy for Dupuytren contracture between 2009 and 2013 were reviewed. The control group consisted of patients who underwent needle aponeurotomy only, whereas the treatment group was also referred for fabrication of custom night extension splints after surgery. Comparisons in pre- and postoperative AROM measurements for the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were made between both groups of patients. The degrees of change in AROM for each joint were categorized in terms of levels of change: mild (0° to 29°); moderate (30° to 60°); and significant (≥61°).

RESULTS:

All patients exhibited increased AROM after surgery for both MCP and PIP joints. Both groups had a greater increase in AROM in the MCP joint. Twelve joints from the control group had moderate changes and two from the treatment group had significant changes. When both groups were compared, the levels of change of AROM between both groups did not vary significantly.

CONCLUSION:

Night extension splinting following needle aponeurotomy may not improve AROM of the MCP or PIP joints.