External Ultrasonic Treatment of Capsular Contractures in Breast Implants

The authors report their experience on the nonsurgical treatment of capsular contractures due to breast implant augmentation mammaplasty. External ultrasonic repeated applications have been applied to 24 patients after closed capsulotomy procedures in order to reduce the recurrency rate. The new ultrasonic device used was based on a 2-MHz generator with a timing adjustable power emission connected to eight transducers designed for breast anatomy. The authors report significant improvement of the closed capsulotomy technique demonstrating a persistent stability of the achieved results in 82% of the treated contractures, even in severe cases (Baker's IV), after a minimum follow-up period of 12 months. Methods of application, technical features of the ultrasonic device, experimental charts, and results obtained on 34 breast implant capsular contractures are reported and discussed.     

Late Spontaneous Extrusion of a Texturized Silicone Gel Mammary Implant

A case report of late spontaneous extrusion of a 250-cm³, round, texturized silicone gel mammary implant, 14 months after implantation, is presented. The irregular surface of the implant, the location of the implant pocket, and the absence of the fibrous capsule were responsible for alterations in the skin thickness. In addition, the pressure exerted by the implant against the skin provides for stasis with venous trombosis at the inferior portion of the breast. The continuous manipulation of the breast over a thin skin with vascular alterations led to the skin perforation with implant extrusion.     

Breast Augmentation: Teaching Our Patients How Compression Can Help Prevent Capsular Contracture

If we insert a foreign body into a human being, physiologically, we get a capsular contracture because a periprosthetic scar contracts to give the implant a spherical shape, the smallest surface area for a given volume. To antagonize this contracture, one must stretch the periprosthetic scar and this can be accomplished with compression.     

Five-Year Experience on Ultrasonic Treatment of Breast Contractures

The authors report their experience in five years of treating breast implant capsular contractures with an external ultrasonic device that facilitates the closed capsulotomy technique. A set of 52 patients have been treated with a 82.6% of improvement at a year follow up. Methods of application and results are discussed.     

Augmentation of Shoulder Contour Using a Calf Implant

Sprengel deformity is a rare orthopedic condition that is associated with functional and cosmetic impairment. Results of orthopedic procedures are usually inconsistent and cosmetic results are far from satisfactory in these patients. A silicone-gel-filled calf prosthesis was used to correct the shoulder contour in a patient with Sprengel deformity. Cosmetically the deformity can be restored by using a calf implant for patients in whom orthopedic procedures are not likely to yield a satisfactory outcome.     

Breast Implantation and the Incidence of Upper Extremity Somatic Complaints

Attention has been drawn to elevated laboratory tests of inflammation as indicators of a possible reaction to silicone breast implants. These patients have complaints of joint pain, pain, and myalgia that were possibly caused by a reaction to silicone. This study is a retrospective review of 100 consecutive patients (79 female, 21 male) who were evaluated because of a purported industrial injury to the upper extremity. Patients were examined by a single examiner and all had laboratory screening for indicators of inflammation (sedimentation rate, anti-nuclear antibody levels, C-reactive protein, anti-streptolysin, rheumatic factor), endocrine abnormalities (thyroid panel), and serum glucose. None of the patients had any history of breast augmentation with any implant. Of the 79 female patients, 50 had an identifiable clinical diagnosis and 18 of them had elevation of at least one of the indicators of inflammation. The remaining 29 did not have an identifiable diagnosis and 21 of them had elevation of at least one indicator of inflammation (P < 0.01). There were 74 out of 79 females with subjective complaints of upper extremity pain, joint pain, and aching. Forty-five of these patients had an identifiable diagnosis and 17 of them had elevation of at least one inflammatory indicator. Of the 74 female patients, 29 had no identifiable diagnosis and 21 of them had elevation of at least one inflammatory indicator (P < 0.01). In summary, there were a high number of female patients with complaints of upper extremity symptoms with no prior exposure to silicone from breast implantation. There was a statistically significant correlation in these patients who had no identifiable diagnosis and elevated indicators in inflammation. This study suggests these markers of inflammation should not be used as indicators of a reaction to silicone from breast implantation in patients with upper extremity subjective complaints.     

A Review of the Literature on the Etiology of Capsular Contracture and a Pilot Study to Determine the Outcome of Capsular Contracture Interventions

The etiology of capsular contracture is unclear and probably multifactorial. This review covers the literature on several proposed contracture factors, including filler material, implant placement, surface texture, and bacterial infection. The pilot study's goal was to test the feasibility of a data collection form, which could be used in a scaled-up study analyzing multiple surgeon's records. The goal of the expanded version of this study will be to determine the efficacy of available interventions for capsular contracture, including surveillance. The Breast Implant Public Health Project, LLC (BIPHP), piloted a retrospective review of outcomes in women who had interventions to relieve capsular contracture or had chosen a wait-and-watch approach. An evaluation of the efficacy of various treatments can help women decide if they want to pursue treatment at all and, if so, which treatment might offer them the best solution. BIPHP researchers (E.E.A., M.E.) developed a data collection form after reviewing records of three surgeons (B.C., W.P., V.L.Y.). During the data collection using the same records, we tested a randomization process to identify women with capsular contracture who underwent various interventions, including a wait-and-watch strategy, and those who had no mention of any intervention or waiting approach. Data were gathered on a total of 90 breasts with capsular contracture (scored Baker I–IV or qualitatively), of which 45 underwent a total of 102 interventions for capsular contracture. Interventions were classified as ``closed capsulotomy,' ``surgical,' or ``watchful waiting.' Closed capsulotomy was performed most often (47%), followed by surgery (29%) and watchful waiting (21%). Presurgical Baker scores averaged higher in breasts that underwent surgery (3.1) than for watchful waiting (2.5) or closed capsulotomy (2.3). Though closed capsulotomies had 100% of outcomes scoring ``improved' or ``same,' 58% of the breasts underwent the procedure more than once, suggesting that the favorable outcome was short-lived. The wait-and-watch approach resulted in scores of either ``same' or ``worse'; surgery (open capsulotomy, repsoitioning, or capsulectomy) resulted in 79% improved, 16% same, and 5% worse outcomes in breasts with outcomes listed. In all intervention procedure categories, outcomes were frequently unavailable; they were noted only 60% of the time (52/87). The missing 40% may have resulted from the doctor's failure to note it in the chart, satisfied patients not returning for additional treatment, or dissatisfied patients seeking treatment elsewhere. Generally, the data collection forms and procedures were workable; however, we uncovered issues to address in the scale-up of this pilot study: (1) the outcome report rate was 60%; (2) though Baker scores are commonly used to evaluate the degree of capsulaar contracture, it seems that grade I may have different meanings for different surgeons, which would need to be clarified; (3) participating surgeons will need to divulge standard-of-care items that they may not have included in medical records, but routinely performed (e.g., patient massage, use of prophylactic antibiotics); and (4) records were initially separated by ``implant,' then researchers realized that a more useful collection would be by ``breast.' The latter approach captures the history of the breast in one record, which may be more important to contracture than the differences in implants. With the modifications discussed, the study can be scaled up to encompass as many records as necessary to achieve robust statistical power. These data will add to the existing literature regarding factors associated with capsular contracture and identify factors that affect the successful outcome of capsular contracture interventions.     

PVP breast implants after two years: initial results of a prospective study

A prospective study of a new mammary prothesis with PVP-based gel as filling material was carried out. Scheduled follow-ups were planned at 3, 6, 12, and 24 months post-implantation to assess all complications, Baker scores, and the patient's, and the physician's global assessment of each implant. PVP-filled implants were used in 95 breasts for augmentation (60%) or reconstruction (40%). Sixty-nine percent of all patients underwent a primary procedure, 19% had a history of severe capsular fibrosis. During follow-up, a hematoma was observed in 2% and a seroma in 5%. Leakage occurred in 3% (one iatrogenic and two cases of unknown reason), a Baker 3 in 6% (12 months). No volume increase of the implants occurred. The probability that a patient would be complication-free at 24 months was 0.86. Physician's and patient's satisfaction rating after 12 months remained high without any time effect (physician very good/good 63%, patient 75%). According to our current experiences, the PVP-filled implants are a remarkable alternative with an improved viscosity and enhanced x-ray transmission, compared to saline filled implants.     

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.     

Augmentation Mammaplasty with a New Cohesive Gel Prosthesis

We present our experience with augmentation mammaplasty on 14 patients with a thin chest wall and poor subcutaneous tissue. Thanks to Polytech Silimed code 20675, a new anatomical prosthesis filled with ``soft' cohesive gel, the lodging in a subglandular position was possible without anomalous salience in the upper pole, and a more natural mammary profile was achieved without capsular contracture, dislocation, or misplacement of the mammary implants.     

Factors Associated with Breast Implant Rupture: Pilot of a Retrospective Analysis

This pilot study's goal was to test the feasibility of a data collection form which will be used in a scale-up study analyzing multiple surgeons' records. The goal of this expanded study will be to develop identifying factors for women who are at greater risk for having ruptured implants and, if necessary, target them for screening, surveillance, or intervention. In the pilot study, we compared factors associated with implant rupture in women with and without rupture. Similar studies have considered one or a few factors at a time and, generally, have given little attention to implant generation. We developed a data collection form after reviewing records of three surgeons. A total of 92 records was collected and analyzed. An important feature in the pilot was to compare the results of patients whose implants the surgeons had both implanted and explanted (n= 34) with those of patients whose implants the surgeons had only explanted (n= 55) (unknown = 3). This comparison could show if including all explantation patients in a surgeon's practice would bias the sample; however, based on this pilot data, concerns regarding this type of bias seem to be minimal. Similar amounts of data (e.g., implant information, history of capsular contracture, etc.) were collectible on patients whose surgeons both implanted and explanted them (87%) and who had different surgeons for implantation and explantation (84%). Though the data from this limited sample cannot offer firm conclusions on rupture associations, a few factors stood out: size of implants (38.3% of ruptured versus 15.9% of intact implants were 100–200 cm³), history of mammography (46.8% of ruptured versus 24.4% of intact had mammograms, which is likely due to older women with older implants having more mammograms), and history of closed capsulotomy (85.1% of ruptured versus 68.9% of intact). Interestingly, additional procedures performed on the breast (e.g., scar revision, wound repair, etc.) did not affect rupture: both the ruptured and the intact groups had an average of 1.7 procedures performed. The data collection form tested very well in this pilot study. Also, including all patients in the study sample, instead of excluding those who received their implants elsewhere, did not change the results. Though there are not enough data to draw any firm conclusions regarding rupture factors, the collection instrument was rigorously tested and should perform well in an expanded study.     

Breast Reconstruction by Expansion and Advancement of the Upper Abdominal Flap

Inspired by successful reconstruction obtained using the Lewis–Ryan lower thoracic advancement flap to rebuild missing breast, we have adapted that extremely simple technique to prior serial expansions, in order to create more natural mounds, better defined submammary folds, and when possible, some grade of ptosis, without additional, new scarring. The procedure is introduced and compared to other such flaps as the TRAM and the latissimus dorsii. In our series, 30 patients were evaluated according to the quality of the final results, and the most frequent complications are pointed out and discussed.     

Breast Autoinflation with Sterile Pus as a Marker of Implant Rupture: Single-Stage Treatment and Outcome for Five Consecutive Cases

Augmentation mammaplasty is one of the most common aesthetic procedures performed. Early complications of the procedure are hematoma and infection, and late complications include capsular contracture and device failure or its displacement. Failure of saline implants is readily identifiable, whereas rupture of silicon gel implants can occur without symptoms due to lack of volume loss. Autoinflation of the breast caused by intracapsular and intraprosthetic collection of sterile pus has been reported. A series of five consecutive breast autoinflations with sterile pus is presented. All the patients presented with acute swelling of the breast 2–10 years after prostheses implantation. Intracapsular sterile pus with macroscopic shell tear was seen in four cases. In the remaining case, an intracapsular and intraprosthetic collection of sterile pus with a tear in an otherwise intact implant was seen under the microscope. All five cases showed no microbial growth on culture or sensitivity, and all were treated using a single-stage procedure. The follow-up periods ranged from 8 weeks to 1 year without recurrence of symptoms.     

Diaphragmatic hernia seen as a late complication of laparoscopic cholecystectomy

Laparoscopic surgery has emerged as the standard of care for the elective operative management of symptomatic gallbladder disease. The surgical literature is now beginning to accumulate sufficient case numbers that more clearly define the associated morbidity of this type of surgery. This article reports an instance of iatrogenic injury to the right muscular hemidiaphragm and subsequent hernia after laparoscopic cholecystectomy. Received: 22 July 1998/Accepted: 13 October 1998     

Semi-Quantitative Fluorescence Analysis of Calcein Binding as a Measurement of In Vitro Mineralization

We describe a new, highly sensitive semiquantitative method for rapid measurement of in vitro mineralization using calcein. Fluorescence analysis of the calcein bound to the calcium phosphate (hydroxyapatite) allows direct quantitation of extracellular matrix mineral content in monolayer cultures of bone-forming cells such as primary osteoblasts or osteosarcoma cells. Osteosarcoma cell lines UMR 106 and SaOS-2 were used to demonstrate that qualitatively, calcein was bound to the same regions of the mineralized cell monolayer as seen by conventional histological staining with von Kossa or Alizarin Red S. Moreover, total bound calcein could be quantitated by direct fluorescence analysis using a Cytofluor II plate reader. Changes in cell monolayer calcein fluorescence were shown to correlate well with direct colorimetric measurement of acid-solubilized Ca⁺² from parallel cultures. Relative mineral quantitation by calcein fluorescence is rapid and more sensitive than colorimetric Ca⁺² assays, can be performed directly on unfixed or fixed cell monolayers, and does not require the use of radioisotopes. The cell monolayer remains intact and potentially available for further analysis. Received: 7 June 1999 / Accepted: 24 January 2000     

Laminin, a Major Basement Membrane Component of the Blood Vessel, as a Negative Regulator of Osteoclastogenesis

Laminin, the major basement membrane glycoprotein of the blood vessel, inducing many cellular responses, inhibited the differentiation of osteoclasts in a rat bone marrow culture system when immobilized on the surface of the culture wells, showing that laminin acts as a negative regulator of osteoclast differentiation in a nonsolubilized form. Laminin inhibited the process of preosteoclast formation from early progenitor cells in bone marrow. This laminin-mediated inhibition of osteoclastogenesis was blocked by the addition of laminin fragment YIGSR, indicating that the inhibitory effect of laminin was mediated via laminin receptors. This finding suggests a significant role of basement membrane laminin of the blood vessels as a negative regulator of osteoclastogenesis. Received: 30 September 1996 / Accepted: 20 February 1998     

Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux

Background: This prospective study assesses the outcome results in 100 consecutive patients with gastroesophageal reflux disease (GERD) treated with a laparoscopic Toupet fundoplication. Methods: GERD was confirmed by 24-h pH study and/or esophagogastroduodenoscopy (EGD). Pre- and postoperative symptoms, operative times, and perioperative complications were recorded on standardized data forms. Early follow-up was at 3 months and late follow-up, including 24-h pH, manometry, and EGD was at 22 months. Results: Preoperative symptoms included heartburn (92%), regurgitation (58%), water brash (39%), and dysphagia (39%). Mean operative time was 3.2 hours. There were no conversions to celiotomy and there were no mortalities. The perioperative complication rate was 14%; 6% (5/83) of patients reported heartburn at 3 months and 20% (15/74) at 22 months. Early and late dysphagia was 20% (17/83) and 9% (7/74), respectively; 24-h pH testing was abnormal in 90% of symptomatic patients (9/10), 39% of asymptomatic patients (12/31), and 51% overall. Conclusions: Despite early improvement in reflux symptoms following laparoscopic Toupet fundoplications, there is a high incidence of recurrent GERD. Symptomatic follow-up underestimates the true incidence of 24-h pH-documented reflux. Based on these results we cannot recommend the laparoscopic Toupet repair for GERD patients with normal esophageal motility. Received: 24 March 1997/Accepted: 28 May 1997     

Majority of Hip Fractures Occur as a Result of a Fall and Impact on the Greater Trochanter of the Femur: A Prospective Controlled Hip Fracture Study with 206 Consecutive Patients

The objectives of this study were to learn how hip fracture patients fall, and to compare the mechanics of their falls with those falls that did not result in hip fracture. In this way we sought to obtain reliable insight into the etiology and pathogenesis of hip fracture and fracture prevention. A total of 206 consecutive patients with fresh hip fracture and 100 controls were interviewed and examined between October 1994 and May 1996. The only inclusion criterion was that the fracture had occurred within 24 hours of hospital admittance. The control subjects were admitted from the same community after an accidental fall that did not result in hip fracture. The characteristics of the accident were determined by personal interview and examination of the patients within 24 hours of the event. In 98% of the hip fracture patients, the fracture was a result of a fall. The majority of the patients (76%) reported that they had fallen directly to the side. Forty-eight fracture cases had one or more eyewitnesses and their reports supported this observation. In 56% of the hip fracture patients, a fresh subcutaneous hematoma was seen on the greater trochanter of the proximal femur; such a hematoma was rare in the controls (6%) (P < 0.001), and this gave evidence for the direct impact of the greater trochanter during the fall of the hip fracture subjects. Most of the elderly fallers who fractured a hip did not manage to break the fall, e.g., with an outstretched arm. In conclusion, our results suggest that a typical hip fracture is the result of a fall and a subsequent impact on the greater trochanter of the proximal femur. The clinical implication of this finding is that effective prevention of hip fractures could be achieved by the diminution of the number and severity of falls of the elderly. We suggest that the severity of the falls (impacts on the greater trochanter) could be decreased by an external hip protector. Received: 15 October 1997 / Accepted: 1 November 1998     

Effect of Aging on the Amide Group of Bone Matrix,Measured by FTIR Spectrophotometry,in Adult Subjects Deceased as a Result of Violent Death

In order to determine the effects of age on bone quality, human bone tissue taken from adult subjects deceased from violent death was analyzed by means of fast Fourier transform infrared spectrophotometry (FTIR) in the Diffuse Reflectance mode (DR). This technique allows the characterization of both the mineral and organic parts of bone in a nondestructive manner. Only the organic part is discussed in this report. A quantitative change in the entire organic part of bone tissue is observed with the aging of subjects. The effects of these changes on bone strength were not measured. Received: 4 December 1995 / Accepted: 9 August 1996     

Involvement of Phosphodiesterase I in Mineralization: Histochemical Studies Using Antler from Red Deer (Cervus elaphus) as a Model

The growing antler of 1-year-old red deer is an excellent system in which to study processes involved in ``cartilage model' endochondral-type bone growth. Antlers grow from the tip, permitting the developmental sequences of bone formation to be studied as distance-dependent phenomena, in which early processes can be observed at the distal end, and later events are sequentially more proximal. Quantitative light microscope histochemical assays for alkaline phosphatase (ALP) and phosphodiesterase I (PDE I) were used to determine the activities of these two phosphohydrolases in relation to antler mineralization and remodeling. Both enzymes were absent in proliferating young cartilage near the end, but progressively increased in activity in a proximal direction. ALP levels were maximal when mineralization was just beginning, whereas PDE I activity was greatest more proximally, where mineralization was more complete. This study provides strong indirect evidence that each of these enzymes has a function in mineralization, but that their roles are not identical. Received: 5 January 1998 / Accepted: 12 April 1999