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15. BREAST CANCER DETECTION AND TREATMENT

 

Every time we see a patient about her breasts we should recommend they follow the guidelines of the American Cancer Society regarding mammograms and record on our record that we did. A copy of the American Cancer Society recommendations is as follows:

 

"The American Cancer Society suggests that women without symptoms have their first breast x-ray to compare with future breast x-rays between the ages of 35 and 40.

          Women aged 40 to 49 should have breast x-rays ever year or two depending on their risk factors.

          Women aged 50 and over should have breast x-rays every year.

          Women who have had breast cancer or whose family members have had breast cancer may need more frequent          breast x-rays and should consult their doctor for advice."

If in doubt, recommend a mammogram and another opinion .

We are aware of the many changes in breast cancer detection and treatment that have occurred in just the past few years. The  public is also being made aware by news articles and by the state  law in California that requires doctors to inform patients of the alternatives of treatment for breast cancer that are available.

Hopefully, women will become more attuned to awareness of  the advantages of early detection and will in the future require  less radical procedures, because they are detecting cancer earlier.

The interference of breast implants with mammography is very variable and somewhat unavoidable.  They definitely interfere to some extent. But there is some disagreement among  radiologists who read them. And the amount of interference is  partly dependent on the individual patient and the size of implant and proportionate amount of breast tissue.

The question of biopsy with breast implants is like mammography in that the indications are the same as without breast implants. Briefly stated, if there is a lump a biopsy is indicated. A negative mammogram does not mean there is no cancer and does not mean that a biopsy is not indicated.

Most mammogram reports state that, "A negative report should not delay a biopsy if a dominant or clinically suspicious mass is present. " In relation to breast implant surgery, if the same guidelines for mammography are to apply, we should only request a preoperative mammogram of asymptomatic patients beginning at 35 years of age.

After surgery, a baseline mammogram is indicated and can be recommended while giving the patient a copy of the guidelines of the American Cancer Society, which  include their standard protocol for mammograms and physical exams for all of the age groups as quoted above.  Handout copies of these guidelines may be obtained  with a phone call to your local American Cancer Society.

More biopsies are being done with needle biopsy rather than open biopsy.

 

16.  SAFETY  OF BREAST IMPLANTS

 

The workshop is not about the possibility of the relationship of silicone breast implants to scleroderma and autoimmune disease. The FDA under Kessler declared a moratorium on silicone breast implants in 1992. Then, the litigation exploded. Dow Corning is still in bankruptcy.

Almost all of the scientific studies done show that there is no relationship between these conditions and breast implants. This has been thoroughly discussed in the news and by several documentaries on the subject.

The United States is the only country to ban silicone gel. That the weight of scientific evidence  against causation has not eliminated multimillion verdicts by plaintiffs claiming ill health due to breast implants is an interesting fact. It shows how capricious and arbitrary and dangerous our tort system is. How unjust our system of justice is.

The evidence shows that there seems to be no higher incidence of breast cancer or other disease with implants.

The main considerations are the safety of the procedure, of the anesthesia and of the potential long-term unknown effects.

Obviously the surgery and implants could interfere with nursing. And one retrospective study recently indicated that the effect on limiting a woman's ability to nurse was greater with the areolar incision. One would expect this because it goes through breast tissue. But it has not been the experience of my patients, and I have done more than 500 areolar incision cases in the past 25 years.

Some long term effects might be atrophy of the underlying muscle and, just as with chin implants, the erosion of the underlying bone, i.e. the ribs. And this would be logical especially with the submuscular implantation and the pressure of the muscle on the implants. This will probably be reported in the future from patients who have had the implants for decades.

The FDA has an excellent booklet about breast implants that is free to anyone who requests. The FDA consumer information hotline as of 1998 is 800-532-4440. Be prepared to leave your name and address and request a copy of the booklet "Breast Implants", an information update published in July 1997.

The text of the booklet and any new information is available on the internet web site of the FDA: www.fda.gov/oca/hotopics.htm.

 

 

17. OTHER TOPICS

 

1. Rippling

The rippling problems that we are seeing with breast implants first began with the introduction of textured silicone gel implants in 1989.

The texturing was introduced to prevent capsule contracture. It was noted that the polyurethane implants would not allow capsule formation and they would not become very hard.

If the standard silicone implants of the 1980s were used without some sort of special technique to prevent hardness, such as submuscular placement or use of steroids, the incidence of grade III and grade IV moderately severe and severe capsule contracture was more than fifty percent.

Some surgeons such as Richard Dolsky and Gary Fenno from the early 1980's exclusively used polyurethane implants be  cause of this capsule contracture problem. During the latter of the 1980s more and more surgeons were moving toward the polyurethane implants. The plastic surgeons who wrote most articles on breast implant surgery, such as Bostwick and Tebbets, started using the polyurethane in primary augmentations routinely to prevent capsules.

It was discovered that the texturing of the polyurethane as compared to the slick surface of the gel had a lot to do with preventing capsules. Therefore, the textured silicone implants were made available by Mentor and McGhan in the last two years of the 1980s.

Though the texturing does seem to prevent capsule formation, the additional thickness of the silicone bag causes waves or ripples of the bag that show through the breasts, especially in a slender woman.

With round implants over filling can show less rippling, but when they are over filled they become a ball or a sphere like an orange and become firm and unnatural in appearance.

Rippling from breast implants is the appearance of the implant through the patient's tissue, and is proportional to the thickness of the implant wall and the thinness of the tissues covering the implant.

When a saline or gel filled silicone textured implant is held up, you can see vertical folds. If the patient has thin tissues above the nipple overlying the implant, these folds will show through. To prevent this rippled appearance above the nipple, the implant can be placed below the muscle.

Ripples occur with silicone textured implants as well as with saline. The saline textured implants ripple the most. However, saline without texturing can also ripple.

Even if the implants are below the muscle, the rippling can still show in the lower part of the breast especially laterally in the area of the anterior axillary line. And this shows most when the patient leans forward.

The McGhan 468 implant is teardrop in shape and is filled more tightly without spherical distortion. It is more firm than the more loosely filled implants. But as a Biocell it is a very deeply textured implant. It is probably the least likely to have a capsule of any on the market today.

Certainly if I were revising a patient for a capsule problem, I would consider the 468 implant to prevent recurrence. Capsules frequently recur. The 468 also because of its tight fill will not show rippling very much at all. The trade off is the firmness and immobility that is present with the 468.

The PIP pre-filled, soft, smooth implant seems to have the least thickness of the implant wall. Therefore, it has the least amount of rippling and the most desirable softness together. Surely with this implant being very much like the natural feel and softness of the silicone implants we were using in the 1980's, the capsule rate is going to be fairly high.

At the present time of this writing,  March 11, 1998, the PIP smooth implants are not available because of FDA questions about the methods of manufacturing of these implants.

In summary:  Rippling is due to the thickness of the implant. Texturing doubles the thickness and increases the chance of rippling. Even the smooth inflatable saline implants are thick enough and stiff enough to ripple if the tissues covering are thin. The textured implant that does not ripple is the tightly filled 468. The soft, smooth pre-filled implant that does not ripple is the PIP smooth, which right now is not available.

 

2. Seroma

Seroma is the accumulation of serum-like fluid around an implant. It frequently occurs years after surgery.

The incidence is in about one or two percent of patients. In over one thousand patients, I have seen seroma in about six.

The usual patient with a seroma is one who previously had a very good result and four to twelve years later develops a swelling of one side. On examination the one side with a seroma is larger, but usually not very tight or very tender. Most often there are no signs of redness or inflammation such as fever.

A swollen breast after surgery is usually a hematoma. The hematoma will not transilluminate. The normal breast with a clear saline or gel implant transilluminates very well. Even if the implant is under the muscle, a hematoma will transilluminate a lot less than the opposite side. Since the lower half of the breast is not covered by muscle, the transillumination can be detected with the light going transversely through the breast rather than from the bottom up.

With seroma the transillumination is preserved. A seroma transilluminates just as well as the other breast with an implant and no seroma. The fluid around the implant with seroma is serum or straw-colored and usually cloudy. Those I have cultured have shown no growth.

Very often all that is needed is a course of antibiotics and of steroids to eliminate the seroma. If it comes back, the steroids and antibiotics can be repeated. If the seroma persists and will not diminish with steroids and antibiotics, then it may be necessary to remove the implant and leave it out for several months as we would do with infection. A new implant can then be replaced at a later date.

Two other steps can be taken before this drastic event of implant removal. One is to use a blunt, small needle like instrument, such as a liposuction canula or microlipo canula. This can be inserted through a tiny incision just posterior to the anterior axillary line where it will not leave much of a mark. And through a tract down to the breast implant so that leakage will not occur, the capsule can be perforated and the seroma aspirated and drained.

While this small canula is present in the capsule, the pocket can be irrigated with saline thoroughly. And we can also instill a small amount of our favorite antibiotic, such as Rocephin, and of our favorite steroid, such as 20 mg of Solumedrol or 5 mg of Kenalog. This can solve the problem.

Another slightly more conservative option to total removal of the implant for several months would be to remove the implant, thoroughly irrigate the implant and replace the implant.

The cause of seroma is probably different from one case to another. But it might be from hematogenous bacterial invasion of the foreign body area. Or it could be from some very late reaction to some very tiny particles of foreign bodies that are left at the time of surgery.

 

3. Blue Window

A blue window is a simple thinning of the tissues so that the implant can be seen as a bluish color. The skin over the implant can be so thin that it would seem that the slightest scratch or puncture of the skin would perforate the skin if not the implant as well.

Blue windows can be divided into those that are soft and those that are firm.

Soft blue windows occur especially frequently when steroids have been used in the implant. And a blue window may also occur from steroids that are long acting such as triamcinalone. This crystalline steroid will settle down to the bottom of the pocket and cause thinning.

The firm blue window occurs when there is some reaction to the implant causing a capsule and is a sign of impending extrusion.

Both types of blue windows usually occur in the lower thin portion of the breast near the inframammary fold. This is where the tissues are most thin.

Whenever the blue window is due to steroids, it can be eliminated quickly and easily by removing the implant and by washing out any steroids that are in the implant or in the surrounding pocket. Within a week of replacing the implant the blue window will be gone.

The blue window that is associated with a firm capsule can be followed and will probably result in breaking open at the site of thinning. And when the implant is exposed, it will extrude.

From my own experience I have seen only one implant from another surgeon extrude. And have had one patient of my own have extrusion of one side following pregnancy.

Of soft blue windows I have seen several dozen. This is because from about 1975 through 1986 I used double lumen implants made of gel in the center and covered by saline in almost all of my patients. To prevent a capsule, I put steroids into the outer saline compartment routinely. The steroids would prevent capsules from forming in the first two or three years in nearly all of the patients. The breasts would remain soft and natural and there were very few problems. In the early 1980s because a couple of patients developed capsules several years after surgery, I decided to increase the dose of steroids to prevent this problem. That is when I started seeing blue windows.

Because we wanted a long term anti-capsule or anti-scar tissue effect to the steroids, I chose to use long acting steroids in the implants. Kenalog 10 mg was used in each implant in most cases. This would produce a blue window in less than ten percent. A mild faint small blueness and thinning of the tissues would be followed and would usually go away within a year.

As I lowered the dose to 5 mg, the capsule prevention was almost as good and there were no blue windows.

At one time I increased the dose to 20 mg of Kenalog in each implant. And all of these patients developed blue windows and steroid atrophy. They were all corrected by washing out the steroids and replacing the same implant with fresh saline in the outer compartment. And in every case the blue window and steroid atrophy was almost completely gone in one or two weeks. None to my knowledge had persistent problems or ptosis.

In the case where there is a blue window and no steroid inside the implant, I think that if it is mild and not progressing, it can just be watched and it will by itself go away over a period of months without surgery.

Many surgeons have advocated the use of  steroids in and around implants. If using non-textured implants, I will put triamcinalone injection into the tissues behind the implant where steroid atrophy would not show to keep a capsule from forming in most cases still today.

With smooth implants, capsules are going to form even around smooth saline in a high percentage of cases. Long acting steroids injected behind the implants in a dose of 10 mg of kenalog for each side will prevent many capsules. Sometimes solumedrol 10 or 20 mg will be put in each implant instead of the kenalog injections.

 

4. References

In June 1997 Vice President Al Gore attended the ceremony of the opening of the National Institutes of Health Library on the internet in June 1997.

That means that we can all access the Medline of the NIH at www.nih.gov.  at   http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

If you type in breast implants for a search as there will be over a thousand references and most will be about things other than breast implant surgery.

Augmentation mammaplasty reveals hundreds articles that are more in line with our needs. And the additional spelling of augmentation mammoplasty reveals an additional several hundred other articles.

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The American Society of Cosmetic Breast Surgery 2017    Last modified: June 23, 2017