A case of malignant hypertension and scleroderma after cosmetic surgery

Gluteal Black Market Silicone-induced Renal Failure: A Case Report and Literature Review

Very few cases of successful surgical treatment for renal failure due to gluteal silicone injections have been reported in the literature. The silicone toxicity and subsequent renal failure seem to follow repetitive silicone injections and silicone injections in large quantities. This is a case of a 31-year-old woman who developed renal failure after 6 years of gluteal silicone injections who underwent radical resection of bilateral gluteal regions in an attempt to mitigate her impending complete renal failure. A systematic review of the literature was conducted using PubMed database and with assistance from medical library staff to conduct keyword searches for “Silicone,” “Renal failure,” “Silicone emboli syndrome,” “Silicone granuloma,” and “Silicone end organ toxicity.” The search results were reviewed by the authors and selected based on the relevance to the case report presented. Extensive literature relating to silicone granulomas and their systemic effects supports the use of steroids for immediate treatment and eventual surgical resection for cure of the various silicone-related end-organ toxicities including renal failure.

The immunopathology of siliconosis. History, clinical presentation, and relation to silicosis and the chemistry of silicon and silicone

Recent evidence confirms the fundamental involvement of the human immune system in the reaction to implantation of silicone-based medical devices. An as yet-to-be particularized epitope of many complex substances sharing siloxane structures is presented through the MHC-II apparatus with development and retention of T cell memory. This memory can be tested for in practical terms using one or more forms of silica, which links the immuno-histopathology and autoimmune attributes of "silicosis" with those of "siliconosis." The lesions of siliconosis are typical of those for persistent antigens and delayed, cell mediated hypersensitivity. The basic descriptive pathology of the reaction to silicone has been known since soon after introduction of silicones in medical procedures, with the exception of some details related to the more recent discoveries on the role of cytokines in the immunopathic process. The clinical consequences of siliconosis are common and can be severe in some individuals implanted with silicone devices.

Assessment of viability and proliferation of in vivo silicone-primed lymphocytes after in vitro re-exposure to silicone

The functional response of peripheral blood lymphocytes isolated from 22 patients with silicone gel-filled breast implants was assessed after in vitro re-exposure to silicone. Using cell culture test methods to quantify proliferation and viability and/or activation of lymphocyte microcultures, i.e., the uptake of tritiated thymidine (3H-TdR uptake test) and the reduction of formazan salts (MTT assay), interesting data were obtained. Peripheral blood lymphocytes purified from patients wearing silicone gel-filled breast implants react in vitro to silicone showing a statistically significant increase of both proliferation and viability, while healthy subjects do not respond on in vitro exposure to silicone. Differences resulted even more statistically significant when patients were divided into two groups depending on the type of surgery they underwent: patients with breast augmentation for aesthetic reasons seem to have an increased responsiveness in vitro to silicone compared to patients who experienced a reconstructive surgery of the breast. Although they are still preliminary, being referred to a limited population, these results suggest that the lymphocytes of patients with silicone gel-filled breast implants could be sensitized in vivo toward silicone; the re-exposure of these cells to silicone leads to a higher functional response which could be looked for by using quantitative in vitro test methods.

Trends in the utilization of silicone breast implants, 1964-1991, and methodology for a population-based study of outcomes

Using the unique data resources of the Rochester Epidemiology Project, we have designed a population-based retrospective cohort study to examine the risks and complications of silicone breast implants among 749 Olmsted County, Minnesota, women who received these devices between 1964 and 1991, and 1498 control women who did not receive such devices. In this paper, we present data describing the population-based trends in the utilization of these devices from 1964 to 1991. In addition, we discuss the case ascertainment, outcome assessment, and reliability of the data collection for the outcomes study. The utilization of breast implants increased markedly over the past 30 yr with the rate of new implants per 100,000 women (> or = 15 years of age) rising from 3.5 in 1964 to 95 in 1979, remaining stable thereafter. The prevalence of breast implants among Olmsted County women > or = 15 years of age on 1 January 1992 was approx. 1%. An examination of the characteristics of these women reveals that recent utilization of breast implants has increased more rapidly among rural than among urban women, that the proportion of women receiving implants for breast cancer mastectomy reconstruction has increased in recent years, and that the great majority of women receiving implants are married at the time of implant. These trends also revealed that the average age of women who receive implants is rising and that in more recent years both much younger and much older women are receiving implants.

Silicone breast implants: the role of immune system on capsular contracture formation

We evaluated the role of the immune system in the pathogenesis of the periprosthetic capsular contracture, the most frequently occurring complication following the implant of silicone prostheses. Peripheral blood samples from 22 patients with silicone-gel-filled implants were examined. In all cases a capsule was felt by palpation, and it was classified according to the Baker scale. Ten patients (group 1) had a Baker 2 contracture, and 12 (group 2) had severe contracture rated 3 and 4. The cells positive to antigens CD3, CD4, CD8, HLA-DR, CD19, CD25, CD57, CD16, and CD14, and the cytotoxic activity of the lymphocytes on target cells K562 were assessed by cytofluorimetric analysis. At time 0 there were no statistically significant differences between patients and normal subjects, nor between the two groups. At 48 h, the group 2 patients had a number/mm3 of cells CD57 + significantly higher than both group 1 and control group (P < .05). In group 1 patients, the cytotoxic activity was similar to that of normal subjects, whereas in group 2 it was significantly increased, in respect to both the controls (P < .05) and group 1 (P < .001). In all groups, the contact of the lymphocytes with the silicone extract did not modify either the antigen expression or the lymphocyte functional activity. On the basis of these results we hypothesize the involvement of the immune system in the formation of the capsular contracture around the prosthesis.

Risk of connective-tissue diseases and other disorders after breast implantation

BACKGROUND

We conducted a population-based, retrospective study to examine the risk of a variety of connective-tissue diseases and other disorders after breast implantation.

METHODS

All women in Olmsted County, Minnesota, who received a breast implant between January 1, 1964, and December 31, 1991 (the case subjects), were studied. For each case subject, two women of the same age (within three years) from the same population who had not received a breast implant and who underwent a medical evaluation within two years of the date of the implantation in the case subject were selected as control subjects. Each woman's inpatient and outpatient medical record was reviewed for the occurrence of various connective-tissue diseases, certain other disorders thought to have an autoimmune pathogenesis (e.g., Hashimoto's thyroiditis), and cancer other than breast cancer, as well as related symptoms and abnormal results of laboratory tests. The case subjects were categorized according to whether they received implants for cosmetic reasons, for reconstruction after mastectomy for breast cancer, or for reconstruction after subcutaneous mastectomy for cancer prophylaxis. Additional control subjects (women treated for breast cancer who did not have breast reconstruction) were studied for comparison with the case subjects.

RESULTS

A total of 749 women who had received a breast implant were followed for a mean of 7.8 years, and 1498 community controls were followed for a mean of 8.3 years. In 5 case subjects, as compared with 10 subjects in the control group, one of the specified connective-tissue diseases was diagnosed (relative risk, 1.06; 95 percent confidence interval, 0.34 to 2.97). Twenty-five case subjects had signs or symptoms of arthritis, as compared with 39 control subjects (relative risk, 1.35; 95 percent confidence interval, 0.81 to 2.23). Among the various signs or symptoms examined, only morning stiffness was significantly increased among the women who had received a breast implant (relative risk, 1.81; 95 percent confidence interval, 1.11 to 2.95).

CONCLUSIONS

We found no association between breast implants and the connective-tissue diseases and other disorders that were studied.

Southwestern Internal Medicine Conference: The Many Faces of Scleroderma

This review integrates the clinical aspects of systemic sclerosis (SSc; scleroderma) and scleroderma-like conditions with new knowledge of the control of blood vessel tone and the role of anoxia in the activation of connective tissues leading to fibrosis. Serologic tests, high resolution computed tomographic scanning, bronchoalveolar lavage, and physiologic assessment of pulmonary gas diffusion are compared as diagnostic tools and as means of quantitating internal organ involvement. Treatment of Raynaud's disease and phenomenon, management of scleroderma renal crisis, and new means for improving gastrointestinal function with octreotide, the somatostatin analogue, also are discussed. The relationship between idiopathic forms of SSc and eosinophilic fasciitis/eosinophilia-myalgia syndrome caused by L-tryptophan ingestion and the scleroderma-like disease associated with silicone breast implants also is discussed.