A meta-analysis of breast implants and connective tissue disease

Environmental Risks for Systemic Sclerosis

There is an increasing body of literature suggesting a relationship between environmental factors and the development of systemic sclerosis (SSc). These include occupational exposures, chemical materials, medications, alterations in the microbiome, and dysbiosis. Environmental exposures may impact epigenetic regulation thereby triggering an aberrant immune response resulting in the clinical and serologic phenotype that we diagnose as SSc. Screening and studying putative triggers will not only improve our understanding of the pathogenesis of SSc but also inform the institution for protective measures.

A Practical Guide to Managing Patients With Systemic Symptoms and Breast Implants

Numerous studies have explored the possibility of an association between breast implants and systemic symptoms potentially linked to exposure to silicone. Some studies show no direct association whereas others provide insufficient scientific evidence to prove or disprove an association. Nonetheless, some patients with breast implants remain concerned about the possible role of their implants in systemic symptoms they may be experiencing. This paper provides a practical approach for plastic surgeons in managing patients with breast implants who present with systemic symptoms, including recommendations for patient counseling, clinical and laboratory assessment of symptoms, and/or referral. Integral components of patient counseling include listening attentively, providing unbiased information, and discussing the risks and benefits of options for evaluation and treatment. A thorough history and assessment of symptoms, including appropriate laboratory tests, may identify underlying conditions to expeditiously address patients’ health issues through a specialist referral. Diagnosing and treating disorders that are causing a patient’s symptoms, if unrelated to their implant, would avoid a potentially unnecessary surgery. Ultimately, better information is needed to reliably guide patients in an evidence-based fashion. Long-term follow-up of patients who are explanted to see what symptoms may or may not improve could be useful in educating patients. Control groups in studies prospectively following women with implants for development of systemic symptoms would also be useful because the symptoms reported are common in women without implants. Cases are presented to illustrate the recommendations for a practical approach toward management of women reporting systemic symptoms with breast implants.

Association of Silicone Breast Implants, Breast Cancer and Anti-RNA Polymerase III Autoantibodies in Systemic Sclerosis: Case-Based Review

Some case reports and small case series of patients with silicone breast implant (SBI) have reported the development of systemic sclerosis (SSc) many years later, despite conflicting evidence of this association in the literature. Recently, patients with SSc and anti-RNA polymerase III antibodies positivity have been associated with previous silicone implants and/or breast cancer, showing clinical features that differ from the classic SSc, such as rapid and diffuse cutaneous involvement and scleroderma renal crisis (SRC). The specific autoimmune reaction is not yet fully understood, although knowledge in this regard is increasing. We describe a case that can support these previous observations, strengthening this association which must be taken into account. Clinicians should be aware of this new clinical entity, given the widespread use of silicone implants.

[ASIA syndrome associated with breast implants: Fortuitous link or association?]

OBJECTIVE

The "Autoimmune/Autoinflammatory Syndrome Induced by Adjuvants" (ASIA syndrome) described in 2011 by Shoenfeld and Agmon-Levin is believed to be the consequence of several immunological dysfunctions triggered by exposure to an adjuvant. Controversies regarding the existence of this syndrome and its possible link to silicone breast implants (SBI) have been growing via social networks and patient groups. The objective of our review was to identify all published cases of ASIA syndromes in SBI carriers to determine the circumstances of onset, key characteristics, and possible biases.

METHOD

A literature search of the Pubmed database selecting only original articles written in English between 2011 and 2019 found 126 cases of ASIA syndromes, defined according to the criteria of Shoenfeld and Agmon-Levin, associated with SBI.

RESULTS

This syndrome was diagnosed in nearly ¾ cases in a context of prosthetic complications (rupture, effusion, peri-prosthetic shell, infection) with a median time interval of 4 years between SBI implantation and the onset of symptoms. Explantation of the SBI led to an improvement in symptoms in about half of the cases. However, animal, biological and histological studies have provided conflicting results on the links between silicone and dysimmune syndromes.

CONCLUSION

Women should be clearly, fairly and appropriately informed of our uncertainties about ASIA syndrome. Mandatory reporting of dysimmune syndromes occurring in silicone MI carriers would increase our knowledge of this still poorly understood condition, for which a genetic predisposition is being investigated.

Scleroderma-like syndrome in a woman with silicone breast implants - case report and critical review of the literature

Various silicon compounds have been reported to stimulate autoimmune reactions in the human body. Based on case reports, a possible causal association between silicone breast implants and systemic sclerosis has been suggested since the end of the 1970s. Although the relationship between systemic sclerosis and silicone breast implants has been intensely investigated, no clear evidence of such an association has ever been found in epidemiological studies. Instead, it is now proposed that silicone breast implants can induce nonspecific symptoms of inflammatory diseases, despite not fulfilling the diagnostic criteria for a specific autoimmune disease. This phenomenon was named autoimmune syndrome induced by adjuvants (ASIA syndrome). ASIA syndrome is worth considering in the differential diagnosis in rheumatology patients. In this paper, we present a case of the scleroderma-like syndrome in a 48-year-old woman with a broken silicone breast implant and a review the current literature on this issue.

Breast implant-associated anaplastic large cell lymphoma: a review

Breast implant-associated anaplastic large cell lymphoma is a newly recognized provisional entity in the 2017 revision of the World Health Organization Classification of Tumors of Hematopoietic and Lymphoid Tissues. It is an uncommon, slow growing T-cell lymphoma with morphology and immunophenotype similar to anaplastic lymphoma kinase-negative anaplastic large cell lymphoma. However, the presentation and treatment are unique. Breast implant-associated anaplastic large cell lymphoma often presents as a unilateral effusion confined to the capsule of a textured-surface breast implant, a median time of 9 years after the initial implants have been placed. Although it follows an indolent clinical course, breast implant-associated anaplastic large cell lymphoma has the potential to form a mass, to invade locally through the capsule into breast parenchyma or soft tissue and/or to spread to regional lymph nodes. In most cases, an explantation with a complete capsulectomy removing all disease, without chemotherapy is considered to be curative and confers an excellent event free and overall survival. Here we provide a comprehensive review of breast implant-associated anaplastic large cell lymphoma, including history, epidemiology, clinical features, imaging and pathology findings, pathologic handling, pathogenic mechanisms, model for progression, therapy and outcomes as well as an analysis of causality between breast implants and anaplastic large cell lymphoma.

Post-reconstruction dermatitis of the breast

BACKGROUND

Approximately one-third of women diagnosed with breast cancer undergo mastectomy with subsequent implant-based or autogenous tissue-based reconstruction. Potential complications include infection, capsular contracture, and leak or rupture of implants with necessity for explantation. Skin rashes are infrequently described complications of patients who undergo mastectomy with or without reconstruction.

METHODS

A retrospective analysis of breast cancer patients referred to the Dermatology Service for diagnosis and management of a rash post-mastectomy and expander or implant placement or transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. Parameters studied included reconstruction types, time to onset, clinical presentation, associated symptoms, results of microbiologic studies, management, and outcome.

RESULTS

We describe 21 patients who developed a rash on the skin overlying a breast reconstruction. Average time to onset was 25.7 months after expander placement or TRAM flap reconstruction. Clinical presentations included macules and papules or scaly, erythematous patches and plaques. Five patients had cultures of the rash, which were all negative. Skin biopsy was relatively contraindicated in areas of skin tension, and was reserved for non-responding eruptions. Treatments included topical corticosteroids and topical antibiotics, which resulted in complete or partial responses in all patients with documented follow-ups.

CONCLUSION

Our findings suggest that tension and post-surgical factors play a causal role in this hitherto undescribed entity: "post-reconstruction dermatitis of the breast." This is a manageable condition that develops weeks to years following breast reconstruction. Topical corticosteroids and antibiotics result in restoration of skin barrier integrity and decreased secondary infection.

Silicone Breast Implants, Breast Cancer and Specific Connective Tissue Diseases: A Systematic Review of the Data in the Epidemiological Literature

Unanswered concerns about the systemic safety of silicone breast implants (BI) underlay the Food and Drug Administration's moratorium pronouncement in 1992. Since then, many epidemiological studies have been reported that examined either the association between BI and cancer, particularly breast cancer, or the association between BI and connective tissue diseases (CTD), particularly scleroderma. These studies are reviewed, and their data are synthesized. Three breast cancer easel control studies that examine BI as a risk factor show no association between BI and breast cancer. Nor do four BI cohort studies. The data appear to show a reduced risk. No association has been seen between Bl and either breast sarcomas or total cancers. Case-control studies do not show an association between BI and scleroderma (four studies), rheumatoid arthritis (three studies), systemic lupus erythematosus (two studies), or other connective tissue diseases. Eight cohort studies of women with breast implants sought an association between BI and CTD. Seven had negative results. One found a statistically significant risk of self-reported CTD of 1.24 (upper confidence limit = 1.41), but medical record review for diagnostic confirmation has not yet been performed. In toto, the epidemiological studies do not indicate an association between breast implants and breast cancer, though they suggest possibly a negative association. In toto, the epidemiological studies do not indicate an association between breast implants and specific connective tissue diseases, though one study's current results present a small statistically significant association with self-reported CTD.

Systemic sclerosis and silicone breast implant: a case report and review of the literature

Environmentally induced systemic sclerosis is a well-recognized condition, which is correlated with exposure to various chemical compounds or drugs. However, development of scleroderma-like disease after exposure to silicone has always been a controversial issue and, over time, it has triggered spirited debate whether there is a certain association or not. Herein, we report the case of a 35-year-old female who developed Raynaud's phenomenon and, finally, systemic sclerosis shortly after silicone breast implantation surgery.

Prediction of future rheumatoid arthritis

Rheumatoid arthritis (RA) results from an interaction between genetic susceptibility and environmental factors. Several of these factors are known, such as family history of RA, high birth weight, smoking, silica exposure, alcohol nonuse, obesity, diabetes mellitus, rheumatoid factor, anti-citrullinated protein antibody, and genetic variants such as the shared epitope and protein tyrosine phosphatase nonreceptor type 22. The impact of these factors can be modeled in the 2 main groups at risk of RA: family members of patients with RA and seropositive persons with or without arthralgia. Current models have the potential to select individuals for preventive strategies.

Incidence of capsular contracture in silicone versus saline cosmetic augmentation mammoplasty: A meta-analysis

INTRODUCTION

Capsular contracture after augmentation mammoplasty occurs at a rate of 15% to 45%. The purpose of the present study was to determine the effect of implant core type (silicone versus saline) on the rate of capsular contracture in augmentation mammoplasty.

METHODS

A systematic review was conducted through a search of three electronic databases. Two reviewers independently scanned titles yielded by the search and identified potentially relevant papers. Inter-reviewer variability and the scientific quality of the articles were assessed. Meta-analysis was performed.

RESULTS

Eighty-eight titles of potential relevance were selected from the 393 articles yielded by the search. Inter-rater agreement for selection of potentially relevant articles was 84% (kappa=0.54). Four comparative studies were included in the analysis. Scientific quality scores of the included studies ranged from 5 of 14 to 9 of 14. Three of the four studies reported a higher rate of capsular contracture in patients with silicone implants. A combined odds ratio calculated on two of the studies found a 2.25-fold increased risk of capsular contracture in patients who received silicone implants. Eight series of patients who received cohesive gel silicone implants reported rates of capsular contracture from 0% to 13.6%.

CONCLUSIONS

Higher rates of capsular contracture were found in patients who received silicone implants when compared with those who received saline implants. However, the scientific quality of the comparative studies to date on this subject is poor. Recent series evaluating cohesive gel implants report relatively low rates of capsular contracture. A randomized controlled trial comparing rates of capsular contracture in cohesive gel and saline implants is recommended.

Meta-analysis of rare and adverse event data

Potentially beneficial drugs may have side effects. Such adverse events may be serious but rare, making their effect difficult to quantify, or even their identification problematic within randomized controlled trials. Meta-analysis provides a means of combining such outcome data across a series of studies and provides a more powerful analysis than is possible from a single study. However, meta-analysis of adverse event data presents some unique methodological challenges. Procedural issues pertaining to study selection and the inclusion of both randomized and observational data are discussed. The statistical problem of combining rare outcomes is also considered at length. Model choice, continuity corrections, exact statistics, Bayesian methods and sensitivity analysis are all covered. The application of results from adverse event meta-analyses to clinical and economic decision models is also considered. A number of examples are presented to illustrate the key points.

Serum proteins and paraproteins in women with silicone implants and connective tissue disease: a case-control study

Prior studies have suggested abnormalities of serum proteins, including paraproteins, in women with silicone implants but did not control for the presence of connective-tissue disease (CTD). This retrospective case–control study, performed in tertiary-care academic centers, assessed possible alterations of serum proteins, including paraproteins, in such a population. Seventy-four women with silicone implants who subsequently developed CTD, and 74 age-matched and CTD-matched women without silicone implants, were assessed in the primary study; other groups were used for additional comparisons. Routine serum protein determinations and high-sensitivity protein electrophoresis and immunofixation electrophoresis were performed for detection of paraproteins. Women with silicone implants, either with or without CTD, had significantly lower serum total protein and α₁-globulin, α₂-globulin, β-globulin, γ-globulin, and IgG levels compared with those without silicone implants. There was no significant difference, however, in the frequency of paraproteinemia between women with silicone implants and CTD (9.5%) and age-matched and CTD-matched women without silicone implants (5.4%) (odds ratio, 1.82; 95% confidence interval, 0.51–6.45). Paraprotein isotypes were similar in the two groups, and the clinical characteristics of the 13 women with paraproteinemia were comparable with an independent population of 10 women with silicone breast implants, CTD, and previously diagnosed monoclonal gammopathies. In summary, this first comprehensive study of serum proteins in women with silicone implants and CTD found no substantially increased risk of monoclonal gammopathy. Women with silicone implants, however, had unexpectedly low serum globulin and immunoglobulin levels, with or without the subsequent development of CTD. The causes and clinical implications of these findings require further investigation.

Antipolymer antibody is not associated with fibromyalgia in Korean female patients

To examine the levels of antipolymer antibody (APA) in Korean female patients with fibromyalgia (FM) and to determine whether the levels of APA correlate with FM severity. Serum samples from patients with FM (n = 69), patients with rheumatoid arthritis (RA) (n = 71), and controls (n = 75) were assayed for APA. All of the subjects were female, and the controls were age-matched healthy volunteers. FM tender point counts and scores were examined, and FM patients were asked to complete a Korean version of the Fibromyalgia Impact Questionnaire (FIQ), the State-Trait Anxiety Inventory (STAI), and the Beck Depression Inventory (BDI). APA-positive samples were detected in five (7.2%) of the 69 FM patients, seven (9.9%) of the 71 RA patients, and four (5.3%) of the 75 controls. The prevalence of seropositivity and the level of APA in FM patients did not differ from those in RA patients and controls. The proportion positive for APA was not higher for FM patients with severe symptoms than for FM patients with mild symptoms. There was a negative association between the APA level and age. The APA level in FM patients was not correlated with age at diagnosis, age at symptom onset, disease duration, education, tender point counts and scores, FIQ, STAI, or BDI. The prevalence of APA in Korean FM patients was quite low. Owing to the low prevalence of APA in this study, the APA assay did not distinguish FM patients with severe symptoms from those with mild symptoms.

Successful Treatment of Granulomatous Reactions Secondary to Injection of Esthetic Implants

BACKGROUND

In recent years, various injectable materials have come into use to improve esthetic appearance.

OBJECTIVE

We describe the clinical and histopathologic aspects of two patients who received intradermal injections of an unknown dermal filler and the different diagnostic tools used to identify the unknown injected material (reflexion electron microscopy, electron dispersing x-ray) and discuss the possibility of a metastatic granulomatous reaction in one patient. We also describe two treatments for this complication and evaluate the legal considerations of the use of materials that have been adulterated and/or whose composition is unknown to the patient.

METHODS

We present two patients who developed a granulomatous foreign-body reaction after the subcutaneous injection of an esthetic implant. We treated patient 1 with isotretinoin and 2 months later with doxycycline. We administered isotretinoin to patient 2.

RESULTS

We observed a partial improvement in patient 1 after isotretinoin treatment and a remarkable improvement after administration of doxycycline. In patient 2, we observed an excellent response to isotretinoin.

CONCLUSION

Isotretinoin and doxycycline, when administered separately, seem to offer effective treatment for reactions resulting from silicone implants. However, further studies that include a larger number of patients and those with reactions secondary to other fillers are clearly needed before the effectiveness of this treatment can be confirmed.

Augmentation mammoplasty and 'silicone-osis'

BACKGROUND

Claims have been made that breast augmentation induces a previously unrecognized disease ("silicone-osis").

AIMS

To confirm the existence of "silicone-osis", qualify and quantify its characteristics.

METHODS

In this population-based retrospective cohort study, the health status of 458 female Sydney residents who had augmentation mammoplasty for cosmetic reasons ("augmentation mammoplasty-exposed" or "exposed" cohort) between 1979 and 1983 was compared with the health status of 687 female Sydney residents who had non-silicone-associated plastic surgery ("augmentation mammoplasty-nonexposed" or "non-exposed" cohort). Both groups were matched for age (+/- 5 years), year of plastic surgery (+/- 2 years), plastic surgeon, anaesthetist and mode of anaesthesia. Outcome measures comprised dummy symptoms to assess reporting bias, as well as symptoms and symptom clusters from a comprehensive 78-symptom list.

RESULTS

Dummy variables were not over-reported by the exposed cohort. The following individual symptoms developed more commonly in the exposed cohort after index plastic surgery: "memory loss/confusion", "altered bowel habit", "chest pain made worse by deep breathing", "shortness of breath after walking up 10 steps", "breast pain", "sweating mainly at night" and "tunnel vision". Of eight identified symptom clusters, three were rejected as biologically unimportant: "joint swelling of the bunion joint", "haemorrhoids" and "breast lumps" (the latter two occurring more commonly in the non-exposed cohort). In contrast, five symptom clusters were thought to have potential biological importance and occurred more commonly in the exposed cohort. The symptom "night sweats" was common to all five clusters, and comprised the sole symptom in one instance. The other four multisymptom clusters were also characterized by "low energy" (lethargy) and "pins and needles", whereas "breast pain", "impaired memory", "muscle pain" and "reflux", occurred in three of the four clusters.

CONCLUSION

Cluster analysis suggested the existence of a multisystem disorder occurring more commonly in the exposed cohort and characterized by night sweats, lethargy, breast pain, impaired mentation, reflux, paraesthesiae, hand muscle weakness and myalgia. The argument against this being a new disease entity --"silicone-osis"-- however, was its presence, albeit at lower frequency, in the silicone-unexposed cohort. Thus this study did not confirm the existence of a new disease entity "silicone-osis" uniquely and causally associated with silicone exposure. The possible interpretations of these findings are discussed.

Comparative examination of complaints of patients with breast-cancer with and without silicone implants

OBJECTIVE

To measure the relationship between silicone breast implants and various symptoms using a control group.

STUDY DESIGN

A matched-pair-analysis of 96 women with breast-cancer (32 with silicone implants (K I); 64 without implants (K II)) was performed with help of a standardized questionnaire in respect to 50 single criteria. The condition of implants was monitored by MR-imaging.

RESULTS

Athralgias and myalgias were not significantly more frequent in K I. Only six symptoms were reported significantly more often in patients with implants. Positive correlation with implant rupture was given only for the numb feeling/tingling sensation in extremities (P=0.02). There was no correlation between silicone implants and the symptoms of the "chronic-fatigue syndrome" nor any other described silicone-induced disease.

CONCLUSIONS

According to our analysis many of the symptoms examined here are present in middle-aged women regardless of silicone implants and underlying disease.

Toxicology of polymers for implant contraceptives for women

This article reviews the toxicology of polymers that are used in contraceptive implants. The two main classes of synthetic, nondegradable polymers used in the delivery of female contraceptives are silicone elastomers (e.g., Silastic) and ethylene co-vinyl acetate (EVA; ELVAX). The controversies surrounding the silicone breast implants have prompted several studies to evaluate the toxicity of silicones. The epidemiologic data obtained thus far have overwhelmingly concluded that no correlation exists between certain chronic symptoms, such as arthritis, in patients and silicone prosthesis. This conclusion has been echoed by the expert panel report by the Institutes of Medicine. Although the IOM report focused on the safety of silicone breast prosthesis, data emerging from the joint reconstruction area also suggests that Silastic is safe for in vivo use. The toxicological studies on EVA are few, and the conclusion thus far is that they elicit no adverse local or systemic response over extended periods in vivo. In conclusion, the prognosis for Silastic and ELVAX as of now is excellent. However, any future implant development using these polymers should place an emphasis on processing parameters to minimize potential small molecule leachants and establish safety as a function of both site and duration of implantation.

Breast implants and illness: a model of psychological factors

Studies of disease outcomes have not produced an explanation or an intervention for the symptoms and complaints that some women have attributed to breast implants. Reviews of the literature have found no increased risk of specific systemic disease, and no treatment recommendations have emerged. However, similar symptoms in fibromyalgia, chronic fatigue, and other contexts have been considered to be stress or behaviourally mediated, and a number of promising behavioural interventions have been developed. Aetiological, research, and treatment implications may follow from the consideration of such symptoms within a behavioural medicine model that allows for the interaction of physical and psychological influences. In the case of implants, a mass somatisation model may also help to discern the potential effects of litigation and other social influences.

Dermatologic diseases of the breast and nipple

Breast and nipple skin is commonly affected by various inflammatory and neoplastic processes. Despite this fact, many physicians are unaware of the spectrum of diseases that can involve this area. Because breast and nipple skin represents a cosmetically, sexually, and functionally important entity to most patients, awareness of these disease entities is invaluable. This article reviews the normal anatomy of the breast, cutaneous manifestations of neoplastic processes that can present in these areas, and common inflammatory diseases of the breast and nipple skin.

An exact method for meta-analysis of case-control and follow-up studies

In this paper, we describe an exact method for estimating a common relative risk across different epidemiologic study designs. The types of studies allowed by the method include case-control studies, follow-up studies with an internal comparison group, and follow-up studies with an external comparison group. Because the method is exact, sparseness of individual studies is not an issue. Those wishing to perform a meta-analysis of case-control studies and follow-up studies in which both the exposure and outcome are rare will find the method particularly useful. To allow one to perform the computations efficiently, we present a partial polynomial multiplication algorithm. We also describe a public-domain computer program that performs the necessary calculations.

Current Status of Breast Implant Survival Properties and the Management of the Woman with Silicone Gel Breast Implants

The survival properties of silicone gel breast implants are dependent on their vintage (year of manufacture), duration in situ and manufacturer. A total of 527 gel implants have been explanted and analyzed in the author's laboratories. Of the 28 first-generation implants (1963 to 1972), 27 (96.4%) remained intact after 14 to 28 years in situ (mean 20.8 years). Of the 216 second-generation implants (1973 to mid-1980s) that were explanted from 1992 to 1998, 158 (73%) had disrupted. Kaplan-Meier survival curves demonstrated significantly different survival properties among second-generation manufacturers. Surgitek implants were by far the least durable. After 14 years, all second-generation Surgitek implants had disrupted. By contrast, after 20 years, about half of the Dow Corning and Heyer-Schulte implants remained intact. Among third-generation implants (mid-1980s to 1992), 43 of 46 (93.4%) remained intact after a mean of 6.3 years (range three to 12 years). The three disruptions were Surgitek implants. Implants from other manufacturers remained intact. However, the disruption frequencies of third-generation implants have yet to be measured over the relevant periods of time. Survival patterns appeared to be related to the thickness of the elastomeric shell of the three generations of implants. Mechanical strength analyses of the elastomeric shells of explants have exhibited little or no large scale material degradation, even after as long as 28 years in situ. The mechanism of implant disruption likely involves the ‘fold flaw’ theory, whereby an internal abrasion can develop over time at the site of a fold in the implant wall. Diagnosis of disruption is difficult. Mammography is helpful only if there has been extravasation of silicone gel into breast tissue. Extravasation was observed in only 4.2% of second-generation implants removed from 1992 to 1998. It was not seen with first- or third-generation implants. Ultrasound analyses are not generally helpful to predict disruption because they are very operator dependent and because capsular contracture causes folds in the implant wall, which result in false positives. Magnetic resonance imaging is the most accurate imaging modality to detect implant disruption. However, this technology is not indicated for monitoring implant status because it is too costly and time consuming, and because it has significant limitations, particularly with first-generation and textured implants. Careful explantation and direct visual examination are the standards for diagnosing gel implant disruption. Many implant disruptions are likely ‘silent’, with no specific symptoms or clinical findings. After disruption, none of the following are elevated above the levels seen in control women without implant exposure: serum autoantibodies, blood and serum silicon, and the incidence of breast cancer, autoimmune disease or any other medical disease. There is no evidence to support the existence of any ‘novel’ or ‘atypical’ syndrome associated with gel implants. Women over 30 years of age with breast implants require regular monitoring for breast cancer detection. This should include monthly breast self examination and annual clinical breast examination. In addition, women over 50 years old require annual eight-view mammographic assessment using the implant displacement technique. Even then, breast implants have been shown to interfere with complete imaging, particularly if the implants are subglandular, large or associated with significant capsular contracture. A logical approach to explantation should involve consideration of a patient's personal concerns and anxiety, her implant vintage, the plane of insertion of her implants, her current clinical status and whether she chooses to replace her gel implants. Women requesting explantation require extensive information before deciding on surgery. At explantation, capsulectomy seems to be indicated if there is capsular calcification or major capsular thickening. (Pour le résumé, voir page suivante)

Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases

BACKGROUND

The postulated relation between silicone breast implants and the risk of connective-tissue and autoimmune diseases has generated intense medical and legal interest during the past decade. The salience of the issue persists, despite the fact that a great deal of research has been conducted on this subject. To provide a stronger quantitative basis for addressing the postulated relation, we applied several techniques of meta-analysis that combine, compare, and summarize the results of existing relevant studies.

METHODS

We searched data bases and reviewed citations in relevant articles to identify studies that met prestated inclusion criteria. Nine cohort studies, nine case-control studies, and two cross-sectional studies were included in our meta-analyses. We conducted meta-analyses of the results of these studies, both with and without adjustment for confounding factors, and a separate analysis restricted to studies of silicone-gel-filled breast implants. Finally, we estimated the annual number of new cases of connective-tissue disease that could be attributed to breast implants.

RESULTS

There was no evidence that breast implants were associated with a significant increase in the summary adjusted relative risk of individual connective-tissue diseases (rheumatoid arthritis, 1.04 [95 percent confidence interval, 0.72 to 1.51]; systemic lupus erythematosus, 0.65 [95 percent confidence interval, 0.35 to 1.23]; scleroderma or systemic sclerosis, 1.01 [95 percent confidence interval, 0.59 to 1.73]; and Sjögren's syndrome, 1.42 [95 percent confidence interval, 0.65 to 3.11]); all definite connective-tissue diseases combined (0.80; 95 percent confidence interval, 0.62 to 1.04); or other autoimmune or rheumatic conditions (0.96; 95 percent confidence interval, 0.74 to 1.25). Nor was there evidence of significantly increased risk in the unadjusted analyses or in the analysis restricted to silicone-gel-filled implants.

CONCLUSIONS

On the basis of our meta-analyses, there was no evidence of an association between breast implants in general, or silicone-gel-filled breast implants specifically, and any of the individual connective-tissue diseases, all definite connective-tissue diseases combined, or other autoimmune or rheumatic conditions. From a public health perspective, breast implants appear to have a minimal effect on the number of women in whom connective-tissue diseases develop, and the elimination of implants would not be likely to reduce the incidence of connective-tissue diseases.

Silicone Breast Implants and Human Rheumatic Disease is there a Connection?

Silicone has been used with apparent safety in implanted medical devices since 1952. Despite the long history of clinical use of this material, concern has been expressed in some quarters about systemic disease etiologically related to silicone implantation. The first report concerning this phenomenon was in 1964 when Miyoshi et al. published 2 cases in the Japanese literature of patients with vague clinical syndromes occurring after the injection of probably adulterated silicone material into breasts for purposes of augmentation. Since that time there have been numerous case reports and series (<400 patients) reporting a variety of rheumatic diseases occurring after the implantation of silicone gel prosthesis. Approximately 20 epidemiological studies have been published investigating the possible relationship between silicone breast implants and rheumatic disease. Several studies have found very weak, but statistically significant, effects showing either a negative or positive association with connective disease syndrome. However, in the aggregate the existing epidemiology strongly supports the lack of association between the presence of silicone gel breast implants and any detectable risk of or protection from systemic disease. This presentation will review the existing clinical and epidemiologic data relating to the use of silicone breast implants.

A review of the possible health implications of silicone breast implants

BACKGROUND

The silicone gel breast implant has long been an important method of reconstruction for the mastectomy patient. Because of concerns about possible health implications of the implant, the Food and Drug Administration banned its use for augmentation mammaplasty and limited its use in the mastectomy patient to a research protocol study. This article reviews the recent literature about the possible health hazards of the silicone implant.

METHODS

In this review of the literature, specific attention was directed toward structural failure of the device as well as the diagnosis of rupture, tissue response to silicone, systemic immunologic response to silicone, the relationship of silicone to connective tissue diseases, and the association of the silicone implant with breast carcinoma in both the augmentation mammaplasty patient and the patient undergoing postmastectomy reconstruction. A total of 88 works were reviewed.

RESULTS

The literature fails to support an association between silicone gel breast implants and systemic diseases. Although implants may cause local symptoms, rupture over time, or be associated with an immunologic reaction, comprehensive epidemiologic studies have concluded that there is no connection between breast implants and the known connective tissue diseases or between the implants and breast carcinoma. There is no increase in the risk of recurrence in mastectomy patients reconstructed with implants and no delay in the detection of recurrences. Recent laboratory studies in animals suggest that silicone may have anticarcinogenic effects.

CONCLUSIONS

Silicone gel breast implants may rupture and cause local symptoms, but they have not been demonstrated to be a systemic health hazard for patients who have undergone augmentation mammaplasty or postmastectomy reconstruction.

Patient satisfaction following insertion of silicone breast implants

Because of allegations linking silicone implants with cancer and connective tissue diseases and mounting media coverage, women with silicone breast implants are extremely concerned, despite the lack of evidence showing a link between silicone gel-filled breast implants and connective tissue diseases or cancer. To assess whether or not this group of women were satisfied with their operations, we sent all women who had silicone breast implants inserted in the south-east of Scotland between 1982 and 1991 a quality of life questionnaire. One hundred and two breast augmentation and 212 breast reconstruction patients replied. Not everyone answered every question. The majority of women in our study, 84% (79/94) and 91.8% (192/209) of augmented and reconstructed patients, respectively, stated that they were satisfied with their operations, although only about half were very satisfied. Although 91.2% (270/296) of all the women were aware of the allegations with 29.7% (88/296) concerned, only 3% (9/296) of all the women felt that there was cause for concern. It would appear that, although most women with silicone breast implants are aware of the accusations regarding silicone and systemic illnesses, the adverse publicity has only given a small number of them a cause for concern and the majority are satisfied with the outcome of their operation and perceive the benefits to outweigh the risks.