Buckled Upper Pole Breast Style 410 Implant Presenting as a Manifestation of Capsular Contraction

Recent experience with the cohesive gel implant has shown an interesting variation of capsular contracture. Instead of spherical contraction, the capsule formation around the 410 implant seems to cause a buckling of the superior pole of the implant. This buckling has been observed in four implants and presented clinically in 2 of 50 patients with a superior pole mass. The capsular contraction around the implant and the buckling are probably camouflaged by a subpectoral implantation and this presentation should be recognized by the surgeon, especially when considering placement of the cohesive gel implant in a subglandular position. Histological sections of a capsule around the implant show fragmented silicone, with a cellular reaction around the fragmented silicone.     

Partial Myotomy of the Pectoralis Major in Submuscular Breast Implants

Several authors report that retropectoral or submuscular placing for prostheses reduces the incidence of capsular contracture, preserves the sensitivity of the areola, and gives the breast a more natural look; however, displacement of the prosthesis when contracting the arm, shoulders, and thorax muscles is often observed. In order to prevent this deficiency, partial thickness myotomy was performed in the pectoralis major muscle. Since 1987, our team has carried out 120 subpectoral augmentation mammoplasties by submammary approaches using this procedure. The ages of the patients ranged from 19 to 44 years old. In all cases, physiological saline microtextured prostheses were used. Volumes were between 225 and 275 cc. The results were satisfactory in all cases, with no hematomas, infections or capsular contractures. The main advantage of this technique is that it prevents displacement of the prostheses after movements of the arms or shoulders.     

Analysis of silicon in human breast and capsular tissue surrounding prostheses and expanders.

Diffusion of polydimethylsiloxane from silicone breast prostheses and soft-tissue expanders has been associated with capsular contraction. We used electron dispersive x-ray analysis and scanning electron microscopy to assess the presence of silicon in capsular tissue surrounding three categories of breast prostheses and expanders. Breast and subcutaneous tissues external to the capsules were used as control specimens. Semiquantitative results allowed capsules to be ranked according to implant type. Silicon was localized within the inner 2.0 mm of capsular tissue. The analyses of tissues from 2 patients exhibiting unilateral, Baker grade IV contraction after bilateral placement of prostheses showed less silicon present in the severely contracted capsule than in the less-contracted capsule. Results from this study diminish the importance of silicon as the initiator of capsular contraction.     

Prospective Study of Clinical Findings and Changes in 56 Trilucent Implant Explantations

Between 1995 and 1998 we implanted 88 Trilucent? implants in 48 patients. The experience of 56 explantations in 30 patients are presented in this prospective study. Of 48 patients, 32 returned for review after we wrote to them. Twenty-seven elected to have their implants exchanged immediately for a fourth-generation cohesive silicon implant and three decided to have the implants removed and not replaced. In 14 patients it was clinically obvious that the volume of the implant had changed, although not all patients realized this. The absence of capsular contraction was notable (unanimously Baker II), so that most patients were asymptomatic and had to be convinced of the need for explantation. However, perioperatively, 55% of the implants had thickening or color change caused by the peroxidation of the triglyceride content. Typically the implant capsule was adherent to the surrounding tissues, especially pectoralis major. This prolonged operative time (184 min, on average) and hemostasis was a problem. During the study we developed a standardized operative technique, which enabled us to reduce operative times. Special attention had to be paid to the selection of the new implant volume, because many patients had become accustomed to the increase in the size of their breasts caused by the peroxidation of the implant content. Forty-three percent of patients preoperatively expressed the wish to have even bigger breasts than before. Nearly all of our patients at the three-month postoperative follow-up were happier with the new implants than before. It became apparent that after only two to three years there were obvious oxidative changes in the implants in asymptomatic patients. Based on our study result, the recommendations regarding explantation of Trilucent? implants seem justified.     

Aesthetic Breast Augmentation: The Double Implant

The objectives of the augmentation prostheses are to increase the volume, enhance the shape, and improve the projection of the breast. Since 1962, plastic surgeons have used the silicone gel-filled breast implant created by Cronin and Gerow [6]. The contents of the standard implant have been modified: silicone gel-filled, PVP, dextran, oil, saline hydrogel, etc. The shell of the prostheses had been made with a smooth surface, textured silicone, and polyurethane-covered silicone. The shape has been modified: In 1993, A. Miller patented the stacked breast implant used in breast reconstruction [7]. This contribution tends to improve the projection of the breast. In 1994, the authors [1,3,4] described a new surgical procedure for locating the standard implants named the double pocket technique. Simultaneously, the authors [2–5] modified the shape of the prosthesis creating the double implant prostheses.     

Complex Shape Changes in Isolated Rat Osteoclasts: Involvement of Protein Kinase C in the Response to Calcitonin

The cytoplasmic spreading of osteoclasts has been used to assess responsiveness to agents such as calcitonin and associated signal transduction mechanisms. Although cyclic AMP and intracellular calcium are known mediators of calcitonin effects in osteoclasts, the role of protein kinase C (PKC) is less clear. We have used time-lapse videomicroscopy of isolated rat osteoclasts to characterize shape changes induced by calcitonin, forskolin, and phorbol 12-myristate-13-acetate (PMA) in the absence and presence of PKC blockers. Treatment with calcitonin reduced cytoplasmic plan area but increased perimeter length, resulting in a characteristic ``stellate' appearance, whereas forskolin produced ``nonstellate' contraction. The response of osteoclasts to PMA was dose dependent. High concentrations (10⁻⁷–10⁻⁶ M) produced biphasic responses with transitory, calcitonin-like ``stellate' contraction followed by sustained expansion, whereas low concentrations (10⁻¹¹–10⁻⁹ M) produced expansion only. The effects of low-concentration PMA could be prevented by pretreatment with a PKC blocker, whereas the effects of high concentrations were only partially inhibited. The effects of forskolin were unchanged by pretreatment with the PKC blocker. Treatment with calcitonin in the presence of various PKC blockers resulted in paradoxical transient expansion followed by contraction. These results indicate that calcitonin-induced shape change in osteoclasts is a complex process involving protein kinase C in addition to cyclic AMP-dependent mechanisms and possibly other factors. Received: 31 October 1996 / Accepted: 26 April 1997     

Breast reconstruction with perforator-based inframammary de-epithelized flap: a case report

Patients with silicon gel-injected breasts sometimes appear even now, demanding removal of this foreign body. These requests are often challenging for us—the removal leaves distortion of the breast contour. Musclocutaneous flap transfer is a good method for reconstruction, but scar formation for flap harvest is a problem. Most patients are reluctant to accept these scars. Reconstruction with prostheses has been another method. But the absence of subcutaneous tissue and degenerated muscle make implantation difficult. For one of these patients, the authors applied a method for breast reconstruction with perforator-based inframammary flap. After the removal of the siliconoma with surrounding degenerated tissues, a crescent-shaped skin flap was designed on the inframammary area. Preserving perforators into the flap, it was elevated with adipose tissue. After the skin was de-epthelized, the adipose tissue and skin flap were turned over to make the breast protrusion. The donor site is closed primarily. Ten months after the operation, there was little atrophy of the reconstructed breast, and the patient is satisfied with the result, especially with the softness of the reconstructed breast. Although this method has limitation for volume, less morbidity for donor site and volume reduction in inframammary area are advantageous. In conclusion, this inframammary flap seems to be a good tool for breast surgery.     

Inflammatory Reaction and Capsular Contracture Around Smooth Silicone Implants

Histologic studies were performed on capsular tissue resected from 21 patients who were implanted with smooth silicone prostheses filled with gel. The results disclosed a non-uniform response to the implants. The granulomatous reaction to the silicone showed important variations along the same surface of the implants, between the plane and the concave surfaces, between equivalent points at the right and left sides, and among the patients. Also, a significant difference was observed between reactions and capsules in early and late stages. The author believes these variations of the capsular inflammatory reaction promote different sites of contraction between cell-to-cell, or cell-to-collagen-to-cell. These adding forces result in vectors of different intensities and directions around the implants which explains the various clinical grades of capsular contracture.     

Deepithelialized Vertical Rectus Abdominis Flap in Calf Augmentation

This is the first report of a case of aesthetic calf augmentation with microvascular transferred autologous material. The technique regarding to calf augmentation using silicon prostheses is described and the advantages and disadvantages of this method are discussed. This should incite discussion on the use of free-flap technique in aesthetic operations.     

Histomorphologic and Volumetric Analysis of Implanted Autologous Preadipocyte Cultures Suspended in Fibrin Glue: A Potential New Source for Tissue Augmentation

Previous efforts to use adipocyte transplants for tissue augmentation have been limited by high and unpredictable resorption rates. Preadipocytes are precursor cells that are capable of replication and differentiation into mature adipocytes. Furthermore, they are more resilient to ischemia, making them a desirable transplant media. Utilizing fibrin glue as a transport vehicle and a prefabricated intramuscular capsule pouch as the recipient site, we have demonstrated the successful transplantation of cultured preadipocytes without the previously presented resorption sequelae. Histological analysis at 2 weeks has demonstrated establishment of vascular supply and the complete resorption of fibrin glue. Most importantly, using planimetric analysis, volume retention has been demonstrated in implanted areas up to 1 year following implantation. Finally, BrdU labeling has been utilized to demonstrate the lack of increased and uncontrolled replication rate, an index of potentially tumorigenic tissue. In conclusion, we have demonstrated a potentially new and safe source of tissue augmentation in the rat model.     

Immediate Reaugmentation of the Breasts Using Bilaterally Divided TRAM Flaps After Removing Injected Silicone Gel and Granulomas

The authors present eight cases of reconstruction of the breasts using bilaterally divided TRAM flaps after removing the injected silicone gel and granulomas. In Japan, we have the opportunity to examine many patients who have had foreign substance injections to the breasts for purposes of augmentation, however, most of them are now suffering from delayed complications. Until now we have reconstructed breasts such cases by use of silicone bag prostheses after removal of granulomas; however, now it is difficult to obtain silicone prostheses. Thus, we have decided to reconstruct by the use of autogenous cutaneous and adipose tissue flaps as presented by us in this article.     

Reconstruction of Extensive Long-Bone Defects in Sheep Using Porous Hydroxyapatite Sponges

The capacity of hydroxyapatite (HA) implants to support large defect repair in weight-bearing long bones of large size animals was investigated. Diaphyseal resections 3.5 cm of the tibia were performed in five adult sheep. They were substituted with HA macroporous ceramic cylinders anatomically shaped, and an external fixator was assembled. The sheep were sacrificed at 20, 40, 60, 120, and 270 days after surgery, respectively. Histology and micro X-ray study of resected implants and adjacent tissues showed proper integration of ceramic with newly formed periosteal bone as early as 20 days after surgery. In one sheep, the external fixator was removed 5 months after surgery. The animal gained the ability to walk with no functional impairment until it was sacrificed 4 months later. At this time, extensive integration of ceramic with bone was detected radiographically and confirmed by a morphological study of the resected sample. Our data indicate that large defects in a weight-bearing long bone can be repaired to the extent necessary for full functional recovery in large animals. These data set the stage for further intervention on material properties as well as for preliminary attempts to use ceramic prostheses for reconstruction of large bone defects in humans. Received: 15 July 1997 / Accepted: 9 July 1998     

A Different Strategy in the Surgical Treatment of Capsular Contracture: Leave Capsule Intact

The authors present their experience with the surgical treatment of capsular contracture to achieve better results in a safe, predictable, and practical way, and discuss the possible treatment modalities. They simply advise leaving the capsule intact, even if it is calcified, and create another pocket, rarely in the front or, more typically, at the back of the capsule. If the breast tissue is also ptotic, a mastopexy procedure may be added to the procedure, in addition to augmentation, with a rather small prosthesis placed in the new pocket or, occasionally, in the old one. External, forceable massage is not advisable to treat the capsule. Open capsulotomy and/or partial capsulectomy can be applied to release the capsule. However, it is not advisable since recurrence is usually inevitable. The purpose of this paper is to present a series of surgical procedures to avoid the problems created by the capsule and present different cases with good results.     

Ultrasonography of the ureter after surgical trauma

Background: The purpose of the study was to discover whether ultrasonography can be used in diagnosing ureteral complications during surgery. Methods: The study consisted of an animal experiment with five pigs, that underwent laparotomy. The right ureter was electrocauterized and transsected, and the left ureter was ligated. The type and frequency of peristaltic waves and the diameter of the ureter were recorded by perioperative ultrasonography. Four patients with ureteral trauma during gynecologic surgery were also examined. Results: In the animal study six out of nine ureters dilated after the procedure. In seven ureters the contraction segment became smaller, and the lumen did not close properly during the peristaltic wave. The frequency of peristalsis diminished in all cases after ligation. Human ureters showed similar changes when examined 1.5–48 h after surgical trauma. Conclusions: Perioperative ultrasonography has great diagnostic potential as a method for noninvasive evaluation of ureteral conditions during both laparoscopy and laparotomy. Received: 16 June 1997/Accepted: 4 December 1997     

Gasless videoendoscopic implantation of aortobifemoral vascular prostheses via transperitoneal versus extraperitoneal approach in an animal model

Background: The goal of this acute experimental study was to demonstrate the practicability and reproducibility of aortobifemoral bifurcational prosthesis implantations via either a transperitoneal or extraperitoneal approach using gasless videoendoscopic instrumentation. The endoscopically sutured end-to-side aortic anastomoses were also examined for fluid tightness. Methods: Eighteen of the 20 domestic pigs in this experimental study received aortobifemoral vascular prostheses in a gasless videoendoscopic procedure. Bursting pressures and leakage (ml/min) were compared for the endoscopically sutured aortic end-to-side anastomoses versus those sutured in conventional techniques using 6-h-old porcine aortas and 6-mm prostheses. Results: The surgical procedures averaged 4 h for the transperitoneal approach (n= 9) and 4.5 h for the extraperitoneal approach (n= 9). However, these times were significantly reduced with increasing routine. Average aortic occlusion times were 1 h for the transperitoneal approach and 1 h 15 min for the extraperitoneal approach; the average iliacofemoral occlusion time ranged from 1 h 45 min with the transperitoneal approach to 1 h 15 min with the extraperitoneal approach, depending on which side was involved. There were no significant differences in in vitro bursting pressure or leakage amounts between endoscopic and conventionally sutured aortic end-to-side anastomoses. Conclusions: Gasless videoendoscopic implantation of aortobifemoral vascular prostheses in animal subjects is both practicable and reproducible using either a transperitoneal or extraperitoneal approach. The extraperitoneal approach has proven advantages over the transperitoneal approach. The in vitro fluid tightness achieved with endoscopically sutured aortic end-to-side anastomoses is comparable to conventionally sutured anastomoses.     

Calfplasty

The author describes a method of calf augmentation by a silicone prosthesis implant for correction of asymmetrical legs or aesthetic problems. Preference is given to the placement of soft silicone implants (Glitzentein implants); they are more natural looking than hard implants. The implants are placed over both heads of the gastrocnemius muscle or beneath the fascia cruris superficialis. Operations were performed from November 1985 to August 1999. One hundred patients were studied: 95 female and 5 male. Two hundred calf implants were performed: 188 soft implants (Glitzenstein), 6 hard implants (Aiache), and 6 together on the same leg (Glitzenstein and Aiache implants). No infection problems, prosthesis rupture, or hematomas occurred. There were four seromas, but they disappeared in 15 days. Four prostheses were removed in two patients who did not like the final result. One prosthesis changed place, to the upper part of the calf. The operation is performed under sedative and local anesthesia, with an incision of approximately 4 to 5 cm in the popliteal pleat, at the same height as the fascia cruris. To date, no functional problem or muscular dysfunction has been provoked by silicone prosthesis implants. The patient walks 8 h after the surgery. We selected 500 patients who received implants in the legs with calf prostheses, fat implants, and prosthesis and fat implant together, during 14 years of follow-up, but the focus of this paper is a calf implant with prosthesis in 100 patients with 200 calf prosthesis implants.     

How Reliable Are Textured Implants Used in Breast Surgery? A Review of 510 Implants

Five hundred ten implants were used in 273 patients. The follow-up was between 3 months and 8 years. Four hundred nineteen prostheses were used for subglandular breast augmentation, 91 for subpectoral breast reconstruction. All the breasts were checked personally: 397 augmented breasts and 86 reconstructed breasts—94.7%. The objective criterion was the Baker classification: grades I and II, good result; and grades III and IV, poor result. Results were as follows: Baker I, 397 breasts; Baker II, 78 breasts (I + II, 98.3%); Baker III, 5 breasts; Baker IV, 3 breasts (III + IV, 1.7%). Three prostheses were removed after 3, 4, and 6 years because the textured surface was totally damaged. Two bilumen prostheses lost the saline fluid. The complication rate due to the implants was very low.     

The Effect of Local Application of Mitomycin-C on the Development of Capsule Around Silicone Implants in the Breast: An Experimental Study in Mice

In this experimental study on mice we try to prove that capsule formation around breast implants is considerably diminished after topical application of Mitomycin-C (MMC). MMC solution is applied under the breast tissue or pectoralis major muscle, in the pocket of the silicone implant and just before placing it. This is a morphological study of the connective tissue formed around the implant, under light and electron microscope. Our results suggest that it is worthwhile working on a clinical study trying to prevent the most common complication of breast implants, contracture of a capsule.     

The use of suction-assisted surgical extraction of moderate and large lipomas: long-term follow-up

Solitary lipomas and familial multiple lipomatosis are the most common benign tumors and are very well encapsulated. They are very slow growing and have the potential for recurrence if incompletely excised and a very remote chance for malignant changes. These can be freed from surrounding tissue without difficulty, but because of the fibrous nature of the capsule, its violation is more likely with suction technique and may result in an inadequate resection, possibly leading to recurrence. Furthermore, liposuction alone will not allow histopathological study of the swellings. Therefore, we report here the treatment of moderate (>4–10 cm) and large (>10 cm) lipomas with liposuction-assisted surgical extraction of the capsule via the same wound (1 cm in length). This capsule extraction is aimed at avoiding recurrence and evaluating the histopathological nature of these swellings. 16 patients (nine men and seven women) presented with solitary lipomas (in 11 patients) and multiple lipomas (in five patients) have been successfully treated. Methods involved 1-cm incision for both liposuction and surgical removal of the capsule. Another 1-cm counter-incision may be needed in case of large size lipomas. High patient satisfaction was achieved because of the good cosmetic results due to the small postoperative residual scar and the smooth postoperative course. There has been no recorded recurrence in six years postoperative followup.     

Relationships Among Carbonated Apatite Solubility, Crystallite Size, and Microstrain Parameters

The use of the metastable equilibrium solubility (MES) concept to describe the solubility properties of carbonated apatites (CAPs) and human dental enamel (HE) has been well established in previous studies using a range of CAPs with varying carbonate contents and crystallinities. It was shown in these studies that the mean value of the CAP MES is directly related to the broadening parameter full width at half maximum (FWHM) of the 002 reflection of the X-ray diffraction profile. The apparent solubility of the CAPs increased monotonically with an increase in the broadening of the diffraction peaks, and when this peak broadening was taken into account, carbonate had no additional effect upon the MES. The broadening of the diffraction peaks has been used as an indicator of crystallinity, and is generally influenced by both crystallite size and microstrain. The purpose of the present study was to extract the crystallite size and microstrain parameters separately from the X-ray diffraction peaks and then to determine their relationships to the corresponding MES values. The samples studied were CAPs synthesized by precipitation from Ca(NO₃)₂ and NaH₂PO₄ solutions in carbonate containing media at temperatures of 95, 80, and 70°C, and powdered HE. The crystallite size and microstrain parameters were determined simultaneously with the refinement of the structural parameters with the Rietveld method of whole-pattern-fitting structure-refinement. A modified pseudo-Voigt function was used to model the observed peak profiles. The MES distributions for the CAPs and HE were determined by a previously described method. The results of this study showed that the CAPs possessed an MES distribution and therefore provided further support that MES distribution is a common phenomenon, regardless of the method of CAP synthesis. The crystallite size decreased and the microstrain increased with increasing carbonate content and decreasing temperature of synthesis of the CAPs. A plot of the mean of the MES distribution versus the microstrain parameter showed that the apparent solubility of the CAPs and HE correlated very well with the microstrain parameter. On the other hand, a plot of the mean of the MES distribution versus the crystallite size parameter showed a poor correlation between MES and crystallite size. These findings support a view that microstrain, rather than crystallite size, is the dominant factor governing the effective solubility of the CAPs and dental enamel. Received: 24 March 1998 / Accepted: 1 October 1998