Perforator flap breast reconstruction after unsatisfactory implant reconstruction

In 2009, 86,424 breast reconstructions were performed in the United States, with 76% being implant-based procedures. Capsular contracture and infection are the 2 most cited indications for implant explantation, resulting in a reconstruction failure. However, several patients are dissatisfied with implant reconstruction even without the aforementioned complications. We hypothesize that microvascular autologous tissue transfer with perforator free-flap breast reconstruction provides an excellent salvage modality in the face of an unsatisfactory implant reconstruction, resulting in an improved cosmetic and functional outcome, with low risk of complications. We retrospectively reviewed the charts of patients in the senior author's practice who underwent perforator flap breast reconstruction between the years 1998 through 2008, and identified all patients who had prior implant reconstruction. Indications for implant explantation, medical history, operative procedure, and postoperative complications were reviewed. During the study period, 1846 perforator flaps were performed. We found 191 patients who underwent autologous breast reconstruction after implant reconstruction with a total of 284 flaps (15.4%). The most frequent patient complaint was unnatural appearance and feel of the implants (Baker I or Baker II), and the majority of patients had not undergone radiation. Most patients were reconstructed using abdominal flaps with 164 deep inferior epigastric perforators, 50 superior gluteal artery perforators, 30 superficial inferior epigastric arteries, 35 inferior gluteal artery perforators, and 5 transverse upper gracilis. The total complication rate was 7.4%, with most complications related to wound healing at the donor site. There were 3 flap losses (1%), all of which were later successfully reconstructed with another perforator flap. Implant failures are traditionally thought to be in patients with Baker grade III/IV capsular contractures and in patients status post radiation therapy. However, in our study, the majority of patients seeking perforator flap reconstruction after implant reconstruction complained of an unnatural feel and appearance of their breasts, and did not have a severe capsular contracture deformity (Baker III/IV), nor had they undergone radiation. This suggests that implant reconstruction can lead to patient dissatisfaction severe enough to warrant removal even with Baker I/II results, and not in the setting of postradiation changes.     

Mastectomy with breast reconstruction in previously augmented patients: indications for implant removal

Surgeons performing breast reconstruction in previously augmented patients can either leave the preexisting implant in place and incorporate the implant into the reconstruction, or remove the implant, usually performing an implant exchange. The focus of this study is to identify indications for implant removal in previously augmented patients undergoing mastectomy with breast reconstruction. We performed a retrospective chart review of patients who underwent breast reconstruction from 1997-2007 at University of Alabama, Birmingham Medical Center. Of these patients, 54 had previous augmentation with silicone or saline implants. Twenty-two of these underwent bilateral breast reconstruction, making a total of 76 reconstructed breasts. Patients were followed for a mean of 2.1 years (range 0.1-5.1 years). The mean body mass index was 23.0 (range 18-30). Implants were explanted in all but one patient. Reasons for implant removal or exchange included subglandular position (n = 39), aged silicone implant (n = 50), rupture or leak (n = 24), implant exposure (n = 1), and infection (n = 1). Some patients had more than one reason for explantation. We recommend removal of preexisting implants for patients who have implants in a subglandular position, ruptures or leaks, site infections, implant exposures, capsular contractures, pain, indolent seromas, aged silicone implants, poor cosmesis, plans for or history of radiotherapy, and close proximity of tumor to implant. We also remove implants to respect patient preferences and to achieve symmetry in our reconstruction. Consequently, we find in our practice that most of previously augmented patients who undergo breast reconstruction will also undergo implant removal.     

Silicone breast implants and immune disease.

Silicone was originally regarded as inert in the human body. Silicone medical devices have been associated with various complications that may involve an immune reaction to silicone or a silicone organic complex. There have been more than 80 cases reported in the medical literature of a varied systemic autoimmune illness in patients who have had various foreign materials placed in the breast. Controversy exists as to which complications have a cause and effect relationship, and which represent coincidental findings. It is difficult to distinguish between nonspecific local reactions and reactions that have an immunological basis. Approximately 1,000,000 to 2,000,000 women in the United States have had silicone breast implants inserted for reconstruction or augmentation mammaplasty; 28 of those patients have been reported to have developed a systemic autoimmune disease. Data on the 28 reported cases do not in any way prove a causal relationship between breast implants and immune disease. Given the natural incidence of autoimmune diseases, we would expect a coincidental occurrence in the United States of more than 1,000 cases of autoimmune disease in women who had undergone breast implant surgery. Additional information must be obtained to resolve the question. The true incidence of autoimmune disease in patients with implants needs to be determined. A prospective registry of implant patients should be established and comprehensive retrospective information obtained on the implant patient population. Further experimental work is necessary on the bioreactivity of silicone. Patients with implants and autoimmune disease, once identified, must be carefully evaluated by physicians who are experienced in the treatment of autoimmune disease.     

Anatomic breast implants in aesthetic and reconstructive surgery: report of 135 cases

The aim of this work is to precise the indications to respect and the pitfalls to avoid in prosthesis setting using anatomical cohesive silicone gel implants.135 patients that undergone a reconstructive or cosmetic prosthesis setting were reviewed. Patients satisfaction has been assessed basing on the breast shape, consistency and symmetry. Complications (both usual and specific) were assessed and analysed. The results for mammary reconstruction after expansion or autologous flap and for cosmetic submuscular breast augmentation were good. Complications were unusual as far as the appropriate surgical procedure had been performed rigorously. These implants are an interesting alternative solution to round shape prosthesis in reconstruction indication. In breast augmentation border line indications, a beautiful result may be expected using these implants.     

Immediate breast reconstruction: A retrospective study with emphasis on complications and risk factors

Abstract

The use of skin-sparing mastectomy (SSM) with immediate reconstruction is preferred, as it has cosmetic and psychological advantages, and comprises one operation. We retrospectively reviewed the complication rate after SSM and immediate reconstruction with implants in 141 consecutive patients with 208 reconstructions. Risk factors were related to both patients and the procedure. The overall morbidity was 42/208 (20%) with one or more minor or major complications including epidermolysis, skin necrosis, or infection. The overall explantation rate was 26/208 (13%). Smoking was a significant risk factor for infection and explantation, and tended to increase risk of necrosis (p = 0.05). Preoperative radiation did not increase the risk of explantation. Age above the median of 44 (range 25–67) years implied a significantly increased risk of epidermolysis, infection, and explantation. Women who had a one-stage procedure with implantation of fixed-sized implant experienced explantation four times more often than women who had a two-stage procedure with tissue expander (p = 0.001). In conclusion, SSM with immediate reconstruction yields a low complication rate when patients are carefully selected. SSM with immediate reconstruction should be done for younger women who have had no previous radiation. Patients should stop smoking to ensure optimal outcome.     

Silicone gel implants in breast augmentation and reconstruction

Silicone gel implants have been widely used for breast augmentation and reconstruction since the 1960s. Several alterations to both elastomer shell and filler gel have been made over the years to improve their ability to replicate the natural breast and to decrease the incidence of capsular contracture. The latter is a pathologic process involving the periprosthetic tissues formed in response to the presence of the implant. When severe, capsular contracture may cause firmness, distortion, and pain. In response to many claims of implant-related connective tissue disease, the US Food and Drug Administration placed a moratorium in 1992 on silicone gel breast implants for cosmetic purposes. Despite a preponderance of scientific data to their safety, silicone gel implants are presently available in the United States only as part of limited clinical trials. They continue to be used in Europe and other parts of the world.     

Epidemiological investigation of local complications after cosmetic breast implant surgery in Denmark

Concern has been raised recently regarding the absence of information on the occurrence and severity of local complications after cosmetic breast implantation. The authors evaluated the occurrence of local complications in a large epidemiological retrospective cohort study of women with cosmetic breast implants in Denmark. All women with breast implants were identified from the files of two private clinics of plastic surgery in Denmark. Information on implant characteristics, surgical procedure, as well as short- and long-term complications was obtained through medical record review. Patient characteristics were obtained through a self-administered questionnaire. A total of 754 women (1,572 implants) had at least one cosmetic implantation performed at the study clinics. Average age at implantation was 32 years. Implant types included silicone double lumen with textured surface, 31.2%; silicone single lumen with textured surface, 27.8%; silicone single lumen with smooth surface, 24.5%; silicone double lumen with smooth surface, 0.8%; and other or missing information, 15.7%. Average implant size was 247 ml (range, 110-630 ml). Placement was submuscular for 91.3% of implants, subglandular for 2.6%, and 6.1% had no available information. Overall, 77.8% of implantations were not followed by complications, 17.8% were followed by one complication, 3.6% were followed by two complications, and 0.8% were followed by three or more complications. In 94.6% of implantations, no additional hospitalizations were recorded as a result of complications. Forty-seven of 57 explantations/reimplantations were secondary to postoperative complications. General complications such as hematoma and infection were rare, occurring in 2.3% and 2.0% of implantations respectively. Capsular contracture remains the most common complication, occurring in 11.4% of implantations. In this investigation, among the first epidemiological studies of local complications, the authors found cosmetic breast implant surgery to be associated with a low frequency of normal surgical complications such as infection, hematoma, and wound dehiscence. Most complications were mild and did not lead to additional hospitalization. The complication that led most frequently to the need for additional surgery/hospitalization was capsular contracture. Kj?ller K, H?lmich LR, Jacobsen PH, Friis S, Fryzek J, McLaughlin JK, Lipworth L, Henriksen TF, J?rgensen S, Bittmann S, Olsen JH. Epidemiological investigation of local complications after cosmetic breast implant surgery in Denmark.     

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.

Silicone augmentation rhinoplasty in an Oriental population

Aesthetic augmentation rhinoplasty is gaining in popularity among Oriental populations. Despite being widely criticized in the literature, silicone implants remain the most commonly used as a result of their ease of application and lack of donor site morbidity. The authors present 355 consecutive Chinese patients who underwent silicone augmentation rhinoplasty from January 1999 to April 2003. During a mean follow-up period of 160 days, 28 patients (7.9%) developed major complications that required either removal or revision of the implant. The patients who had received the largest volume implants had the highest extrusion and infection rates, indicating that overaugmentation is the main cause. The authors hypothesize that the lower complication rates in Oriental compared with white populations is primarily the result of structural differences in the soft tissue envelope of the nose. In our series of patients, nasal augmentation with silicone implants proved to be effective and safe.     

Breast-Related CSF Shunt Complications: Literature Review with Illustrative Case

In this article, we discuss and classify breast-related ventriculoperitoneal (VP) cerebrospinal fluid (CSF) shunt complications, and provide a literature review. Shunt complications related to pre-existing breast implants comprise nearly half of the breast-related shunt complications reported thus far. We present a complication of shunt failure in a 61-year-old woman who had previously undergone mastectomies for breast cancer with implant reconstruction. Following shunting, she developed headaches, fever, and right-sided breast swelling and erythma consequent to breast implant rupture, distal shunt migration, and CSF pseudocyst. This case is unique in that it involved rupture of a breast implant from VP shunt insertion. For complication avoidance, neurosurgeons should be aware of the potential pitfalls in shunting patients with breast implants.     

治疗小颏畸形的三种术式对比分析

目的 对比分析硅胶假体置入隆颏术、自体骨移植隆颏术和颏部水平截骨颏成形术的临床效果和常见并发症。方法 通过三维CT、头颅正侧位X线检查和第2次手术观察，分析三种治疗小颏畸形手术各自的优缺点并明确其适应证。结果 硅胶假体置入隆颏术后存在假体位置异常、颏部骨质吸收、假体周围骨膜反应、颏部矫正不足等缺点；自体骨移植隆颏术后存在较严重的远期移植骨质吸收和颏部形态改善不足问题；颏部水平截骨颏成形术矫正小颏畸形效果良好。结论 硅胶假体置入隆颏术适用于轻度的下面部矢状方向发育不良、不伴有前下面高不足、无面部不对称且颏唇沟较浅的患者。颏部水平截骨颏成形术适用于各种程度及类型的小颏畸形的矫治，尤其适用于颏部偏斜和面部不对称的调整。自体骨移植隆颏术长期效果不佳，应谨慎使用。     

Experience of explantation of Trilucent breast implants.

On 6 June 2000, the Medical Devices Agency (MDA) recommended that all Trilucent (soya-bean-oil filled) breast implants should be removed. This accelerated a trend that had already begun in our unit. This study follows our previous report on a 3 year series of women with Trilucent breast implants. The aim was to present our operative findings at explantation, and to correlate them with the preoperative signs and symptoms, the postoperative complications and the details of the hospital stay. In total, 44 patients (82 implants) underwent explantation, of whom 34 were cosmetic cases and 10 were reconstructive. Five patients had their implants removed before the MDA announcement. Implant rippling was the most common problem reported (25%), followed by pain (18%), implant deflation (9.1%) and capsular contracture (4.5%). Free oil was seen around the implant in 15 cases; four of these presented with clinical deflation, and three with rippling. The remaining eight patients were asymptomatic. We conclude that these implants tend to bleed, as evidenced by the presence of free oil around the implant in 34% of patients. The absence of free oil in 73% of the patients who presented with rippling suggests that the leaking oil is often metabolised and absorbed. The findings of this study are significant for women in whom free oil was found around the implant during explantation, and for those who still have Trilucent implants in place, for whatever reason, in spite of the MDA recommendation.     

Squamous cell carcinoma following breast augmentation.

Controversy over the safety of breast implants has increased significantly over the past several years. Several companies have discontinued their manufacture of silicone implants. Although there have been reports of breast cancer developing in a patient who previously had undergone breast augmentation, a review of the literature has failed to reveal a patient with cancer arising from the breast implant capsule. We present a woman with squamous cell carcinoma apparently arising from an implant capsule 15 years after breast augmentation.     

Residual silicone detection using mri following previous breast implant removal: Case reports

The current controversy surrounding the safety of silicone gel breast implants has resulted in an increasing number being removed. Although previous reports have suggested that remnants of the implant capsule are reabsorbed after explantation surgery, the persistence of the capsule in fact may be associated with implant fragments and silicone gel leakage. In this study we have used magnetic resonance imaging (MRI) to identify residual silicone gel and silicone granulomas following the removal of silicone gel breast implants. Four representative clinical case reports are presented. These patients, who had residual silicone present in their bodies, presented to us with breast pain, palpable masses, or abnormal calcific mass densities apparent on a mammogram. High-resolution MRI images were found to be helpful in identifying local and remote collections of silicone gel, silicone granulomas, and residual capsules that were incompletely removed from previous explantation surgery. MRI breast images demonstrated high resolution and provided the accurate anatomical locations of residual silicone gel and silicone granulomas in all the regions of breast parenchyma, chest wall muscles, and axillae. Patients with persistent local symptoms following explantation surgery may benefit from an evaluation of the breast using MRI.     

Breast reconstruction: late cosmetic results of implant reconstruction

The long cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate breast reconstruction with various types of implant has been prospectively analysed over a 10-year period. 334 patients who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (<2 months) was 9.1%, with an explantation rate of 1.6%. The late complication rate (>2 months) was 23%, with a pathological capsular contracture rate of 11% at two years and 15% at five years, and an implant removal rate of 7%. The revisional surgery rate was 30.2%. The cosmetic results were prospectively assessed using an objective five point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorates in a linear fashion from an initial acceptable result in 86% of patients two years after completion of their reconstruction to only 54% at five years. This fall off in the cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient or the type of mastectomy incision employed. Radiotherapy was not a significant factor as only 28 patients were irradiated. However, on Cox model analysis pathological capsular contracture was the only factor which significantly contributed to a poor cosmetic outcome(P<0.0001 (relative risk 6.3). In spite of a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of those patients without a capsular contracture who demonstrated a deterioration in their cosmetic scores, it became clear that a possible reason for their poor result was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis as the patients aged.     

Immediate bilateral autologous breast reconstruction for silicone intolerance.

A one step autologous approach to bilaterally correct recurrent complications of breast reconstruction or augmentation with silicone implants is presented together with five cases. This approach resulted in relief of symptoms with good cosmetic outcome avoiding multiple procedures.     

Evaluation of the tolerability of Hydrogel breast implants: a pilot study

BACKGROUND: During the 90s the widely publicised controversy regarding the use of silicone gel breast implants stimulated research into alternative alloplastic filling materials. In this context, a new type of breast implant, containing Carboxymethylcellulose at 3.7% in the form of Hydrogel, was introduced into the European market. METHODS: A preliminary pilot study was carried out to evaluate the tolerability and reliability of breast implants pre-filled with Hydrogel. A group of 12 consecutive patients was recruited for this purpose and underwent plastic surgery for breast augmentation or reconstruction (20 implants) at the Department of Plastic and Reconstructive Surgery at the University of Genoa between December 1996 and October 1997. All patients were then followed up for a minimum of 3.5 years. The mean age of patients was 50 years and ranged from 28 to 67 years old. After surgery the patients were examined at 4 weeks (evaluation of any immediate complications), 3 months, 6 months and 1 year (evaluation of any delayed complications). RESULTS: No immediate complications were reported in any patient. After 3.5 years of follow-up, the degree of capsular contraction according to Baker in these patients varies between 1 and 2. In general, the implants were very soft to touch even some time after surgery, above all in patients undergoing breast augmentation. Four implants (20%) were removed from 3 patients for reasons unconnected to the implants themselves (because of neoplasm in one case and due to inadequate volume in the other two patients). No case of rupture has been reported. CONCLUSIONS: This pilot study appears to confirm the validity of implants prefilled with Hydrogel in reconstructive or cosmetic breast surgery. A larger population and longer periods of minimum follow-up are obviously required to confirm these results over the long term.     

Characteristics of women with cosmetic breast augmentation surgery compared with breast reduction surgery patients and women in the general population of Sweden

To determine whether women with cosmetic breast implants have distinct demographic, lifestyle, and reproductive characteristics that put them at increased risk for subsequent morbidity, the authors compared 1,369 such women to 2,211 women who had undergone breast reduction surgery, and to a random sample of 49,262 women from the general population of Sweden. Information was collected through self-administered questionnaires, and comparisons were made using the prevalence odds ratio. Women with cosmetic breast implants were significantly (p <0.05) more likely to be current smokers, have a lower body mass index, have had a prematurely terminated pregnancy (induced abortion or miscarriage), and have had fewer live births than either women who underwent breast reduction or women from the general population. Type of implant (silicone gel or saline) did not modify the associations. Regardless of the comparison group used, studies of the health effects of breast implants need to consider that women who undergo cosmetic breast implantation have certain distinct characteristics.     

Histological examination of the capsules surrounding Trilucent breast implants.

Following a statement by the UK Medical Devices Agency (MDA), soya-oil-filled Trilucent implants for breast augmentation were withdrawn from sale in March 1999. The most recent report on the toxicity of the Trilucent implant suggests that one of the breakdown products of the filler is an aldehyde with an explicit risk of genotoxic and teratogenic effects. Explantation of all these prostheses was advised by the MDA in June 2000. No guidance regarding capsulectomy was put forward by any publication. The operation of capsulectomy confers an increased morbidity compared with simple prosthetic replacement. This study looks at the capsules of 18 consecutive patients who had received Trilucent implants for cosmetic breast augmentation, and who had undergone explantation and capsulectomy. The mean duration of implantation was 3 years (range: 2 years to 4 years 9 months). The capsules were examined histologically. The significant features of all the capsules included a florid foreign-body type reaction, synovial metaplasia, a villous hyperplasia and the presence of refractile material within the substance of the capsule. It is postulated that the refractile material is filler material that has bled through the wall of the intact Trilucent implant, and as such would represent a potential genotoxic hazard. Until such time as this potential hazard has been investigated fully and a conclusion reached, we recommend acceptance of the increased morbidity, and the performance of capsulectomies when explanting Trilucent implants.     

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。