Faculty Bibliography

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

Although the use of injected liquid silicone for breast augmentation has all but ceased since its widespread use in the 1960s, patients with injected silicone are still seen with a multitude of symptoms. Silicone mastitis is a well-documented phenomenon; however, there has been a paucity of information regarding cancer detection in this group of patients. We report 2 patients who presented with chronic mastitis but on further workup were found to have breast cancer. In both patients, early cancer detection was adversely affected by the presence of free liquid silicone. In view of this and other similar case reports, we advise that simple mastectomy be recommended to those patients with breasts inspissated with liquid silicone who not only have suspicious masses but present with recurrent mastitis or a family history of breast cancer

Recent controversy encountered with silicone breast implants has increased the use of autogenous tissue for breast reconstruction following mastectomy. Surveillance of patients who have undergone autogenous tissue reconstruction is important in the evaluation of recurrent or new cancer. Magnetic resonance imaging (MRI) has proven to be a useful technique in the delineation of soft tissues and provides excellent resolution. Recently, MRI has been reported to be a valuable diagnostic imaging modality for the evaluation of augmented breast implant patients with regard to implant rupture detection, silicone granuloma identification, and silicone gel migration delineation. In this study, various autologous tissue donor sites currently available for breast reconstruction were imaged by MRI. The following donor flaps were included: fleur-de-lis, TRAM, gluteal, and tensor fasciae latae. A total of 10 clinical cases were investigated. The anatomic basis of each flap type is illustrated, and various tissue components of flap tissue (skin, fat, and muscle) are demonstrated on MRI scan. Anatomic knowledge of autogenous tissue types and MRI appearance of the flap-breast-chest-wall interface are critical in the surveillance and follow-up of breast cancer patients

Silicone elastomer shell rupture is a complication of silicone implants. To date, the rate of implant rupture has not been well documented. Magnetic resonance imaging and sonography are noninvasive breast implant imaging modalities that have been shown to be useful in evaluating the integrity of implants. We present a case of rupture detection using a follow-up computed tomographic (CT) scan of a breast cancer patient, which prompted us to use CT scans to evaluate explants of patients undergoing implant removal surgery. The purpose of the investigation was to evaluate the effectiveness of CT scan in detecting rupture. CT scan was performed on 22 explants with intact capsules, for which 17 ruptures were confirmed: 16 true-positive ruptures, 5 true-negative ruptures, O false-positive ruptures, and 1 false-negative rupture were identified. CT scan was shown to be highly sensitive and specific in rupture detection, comparable to magnetic resonance imaging. Although CT scans are consistently reliable, patients are exposed to ionizing radiation; therefore, it is not recommended for patients with augmentation mammoplasty. This study characterizes the appearance of implant rupture on CT scan, which may be useful in evaluating breast cancer patients reconstructed with silicone implants

With the current controversy regarding the safety of silicone implants, the detection and evaluation of implant rupture are causing concern for both plastic surgeons and patients. Our study obtained comparative value analysis of mammography, sonography, and magnetic resonance imaging (MRI) in the detection of silicone implant rupture. Twenty-nine symptomatic patients (total of 59 silicone implants) were entered into the study. Intraoperative findings revealed 21 ruptured implants (36 percent). During physical examination, a positive 'squeeze test' was highly suggestive of implant rupture. Mammograms were obtained of 51 implants (sensitivity 11 percent, specificity 89 percent). Sonography was performed on 57 implants (sensitivity 70 percent, specificity 92 percent). MRI was performed on 55 implants (sensitivity 81 percent, specificity 92 percent). Sonographically, implant rupture is demonstrated by the 'stepladder sign.' Double-lumen implants may appear as false-positive results for rupture on sonography. On MRI, the 'linguine sign' represents disrupted fragments of a ruptured implant. The most reliable imaging modality for implant rupture detection is MRI, followed by sonogram. Mammogram is the least reliable. Our study supports the clinical indication and diagnostic value of sonogram and MRI in the evaluation of symptomatic breast implant patients

The current literature is reviewed, and four clinical cases of silicone-gel migration are reported. All 4 patients reported here had histories of closed capsulotomy, and all were symptomatic. Preoperative magnetic resonance imaging demonstrated the anatomical locations of silicone-gel migration into the chest wall muscles, axillae, and upper extremity. Intraoperative and pathological findings correlated with the presence of silicone-gel migration and granulomas in various anatomical regions. With the recent advances in diagnostic breast imaging of silicone-implant patients, intracapsular rupture can be identified. Implant removal may be indicated for intracapsular ruptures to prevent silicone-gel migration into parenchyma, chest wall muscles, axillae, and the upper extremity

The microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced. The 3M microvascular anastomotic coupling device, a polyethylene ring-pin device, was found to be highly successful in numerous animal studies. It has been available for use in human subjects for the last 4 years, but clinical experience remains sparse. Our clinical experience with the 3M coupler is reported in 100 free-tissue transfers. The average anastomotic time was 4 minutes. Mean follow-up was 8.6 months, and flap survival was 100 percent. The overall success rate for 3M (MACD) coupler use in microvascular anastomoses is 98.4 percent (121 of 123). Nine abandoned anastomoses were converted to sutured anastomoses intraoperatively. The over-all failure rate for 3M coupler anastomoses is 1.6 percent (2 of 123). We conclude that the 3M device is best suited for minimally discrepant, soft, pliable venous microvascular anastomoses and is unsuitable for end-to-side anastomoses in clinical situations. When carefully and selectively employed by a trained microvascular surgeon, the 3M coupler can be a safe, fast, and reliable adjunct for free-tissue transfers

Adequate knowledge of perforator location preoperatively will enable the surgeon to achieve optimal flap design and flap survival. Most previous attempts have relied on the use of Doppler ultrasound and earlier anatomic knowledge. With ultrasound, there may at times be signals from overlapping blood vessels. Magnetic resonance imaging (MRI) is sensitive to flowing blood and, on an MRI scan, dark-flow void characterization is used to identify perforators. This study was undertaken to evaluate the anatomic location and the number of perforators in the flap zone, based on inherent blood flow, and to determine information about the dominant perforators for free-flap design, using MRI. The CSMEMP technique allowed the characterization of flow void signals, which appeared in the image as dark spots. This technique also enabled differentiation of the surrounding tissue, with a high degree of accuracy. The relationship of the perforators aided in an 'ideal' flap design. No necrosis was noted in any of these cases. It appears from this study that MRI can be a useful imaging modality, to assess the location and number of perforators in musculocutaneous flaps