- Breast implant
A breast implant is a
prosthesisused to enlarge the size of a woman's breasts (known as breast augmentation, breast enlargement, mammoplasty enlargement, augmentation mammoplasty or the common slang term boob job) for cosmetic reasons; to reconstruct the breast (e.g. after a mastectomy; or to correct genetic deformities), or as an aspect of male-to-female sex reassignment surgery. Pectoral implants are a related device used in cosmetic and reconstructive procedures of the male chest wall. According to the American Society of Plastic Surgeons, breast augmentation is the most commonly performed cosmetic surgical procedure in the United States. In 2006, 329,000 breast augmentation procedures were performed in the U.S.
There are two primary types of breast implants: saline-filled and silicone-gel-filled implants. "Saline implants" have a
siliconeelastomer shell filled with sterile saline liquid. "Silicone gel implants" have a silicone shell filled with a viscous siliconegel. There have been several alternative types of breast implants that were developed, such as polypropylene string or soy oil, but these are no longer manufactured.
Implants have been used since at least 1895 to augment the size or shape of women's
breasts. The earliest known implant was attempted by Vincenz Czerny, using a woman's own adipose tissue(from a lipoma, a benign growth, on her back). [cite journal | author = Czerny V | title = Plastischer Ersatz der Brusthus durch ein Lipoma | journal = Zentralbl Chir | year = 1895 | volume = 27 | pages = 72 | url= ] Gersuny tried paraffininjections in 1889, with disastrous results. Subsequently, in the early to mid-1900s, a number of other substances were tried, including ivory, glassballs, ground rubber, ox cartilage, Terylene wool, gutta-percha, Dicora, polyethylenechips, polyvinyl alcohol-formaldehyde polymer sponge(Ivalon), Ivalon in a polyethylene sac, polyether foam sponge (Etheron), polyethylene tape (Polystan) or strips wound into a ball, polyester(polyurethane foam sponge) Silastic rubber, and teflon-silicone prostheses. [cite book | author = Bondurant S, Ernster V, Herdman R (eds); Committee on the Safety of Silicone Breast Implants | title = Safety of Silicone Breast Implants | pages = 21 | publisher = Institute of Medicine | year = 1999 | url = http://www.nap.edu/books/0309065321/html/21.html | id = ISBN 0-309-06532-1] In recent history, various creams and medicaments have been used in attempts to increase bust size, and Berson in 1945 and Maliniac in 1950 performed a flap-based augmentation by rotating the patient's chest wall tissue into the breast to add volume. Various synthetics were used throughout the 1950s and 1960s, including silicone injections, which an estimated 50,000 women received. [cite journal | author = Anderson N| title = Lawsuit Science: Lessons from the Silicone Breast Implant Controversy | journal = New York Law School Law Review | year = 1997 | volume = 41 | issue = 2 | pages = 401–7 | url= ] Development of silicone granulomas and hardening of the breasts were in some cases so severe that women needed to have mastectomies for treatment. Women sometimes seek medical treatment for complications up to 30 years after receiving this type of injection.Fact|date=July 2008
Breast Implants and FDA Approval
The standard implant in the United States has been saline-filled, ever since the FDA moratorium on silicone gel filled breast implants in 1992. Yet, silicone breast implants have not ceased to exist due to the popularity of the more natural feel offered by this type of implant.
Silicone gel-filled breast implantswere first introduced in 1962. In 1976, the Medical Device Amendments were enacted, giving the FDA authority to regulate medical devices such as breast implants. In 1988, the FDA announced that all breast implants would be labeled as class III devices, meaning they are to be considered as medical breakthrough, new technology devices, and devices with poorly established or questionable safety and effectiveness. In addition, the FDA called for implant manufacturers to submit PMAs in which data showing the safety and effectiveness of these devices would have to be approved before the device could be placed on the market. Breast implants were now under careful scrutiny of the FDA. [http://www.fda.gov/cdrh/breastimplants/indexbip.html] In early 1992, the FDA placed a moratorium on silicone gel breast implants provided to the mainstream market for cosmetic purposes after many women who had received implants complained of pain and illness as a result of the implants leaking. The FDA concluded there was "inadequate information to demonstrate that breast implants were safe and effective." Access to silicone gel-filled breast implants continued to be allowed under controlled clinical studies for reconstruction after mastectomy, correction of congenital deformities, or replacement of ruptured silicone gel-filled implants due to medical or surgical reasons. Implant manufacturers were required to collect clinical trial data and were allowed distribution of the implants to a limited number of augmentation patients for these studies. [http://www.fda.gov/cdrh/breastimplants/indexbip.html]
In mid-1992, the FDA approved [http://www.loveyourlook.com Mentor Corporation's] adjunct study protocol for silicone gel-filled breast implants for reconstruction and revision patients. That same year, silicone and breast implant manufacturer, Dow Corning, announced that it would no longer make five implant grades of silicone, but that it would continue to manufacture 45 other medical grades of silicone materials. Just three years later, in 1995, Dow Corning Corp., once the major manufacturer of silicone breast and other implants, faced 19,000 lawsuits, pushing it into bankruptcy. [http://www.fda.gov/cdrh/breastimplants/indexbip.html]
In 1997, the Department of Health and Human Services began one of the most extensive research studies in medical history by appointing the Institute of Medicine of the National Academy of Science (IOM) to examine potential complications during or after surgery. After reviewing years of evidence and research concerning silicone gel-filled breast implants, the IOM found that "Evidence suggests diseases or conditions such as connective tissue diseases, cancer, neurological diseases or other systemic complaints or conditions are no more common in women with breast implants than in women without implants." Most studies have failed to find a link between silicone breast implants and disease. [http://www.fda.gov/cdrh/breastimplants/indexbip.html]
In 1998, the FDA approved Inamed Corporation's adjunct study protocol for silicone gel-filled breast implants for reconstruction and revision patients only and also approved, later that same year, the corporation's IDE study for silicone gel-filled breast implants for a limited number of augmentation, reconstruction, and revision patients. [http://www.fda.gov/cdrh/breastimplants/indexbip.html]
Also in 1998, Mentor Corporation and its subsidiary, Mentor Texas, signed a consent decree of permanent injunction, promising to manufacture its breast implants in compliance with the Quality System Regulation which helps to assure that medical devices are consistently high in quality and are safe and effective. The FDA permitted Mentor Corporation to continue marketing its breast implants because the deficiencies in Mentor Corporation's manufacturing process were not shown to result in a significantly increased risk to women who received this company's breast implants. [http://www.fda.gov/cdrh/breastimplants/indexbip.html]
In 1999, the IOM released a comprehensive report on both saline-filled and silicone gel-filled breast implants entitled Safety of Silicone Breast Implants. The determination was that there was insufficient evidence to establish that either or both types of breast implants cause systemic health effects and that there was no new health or safety issues associated with the use of both types of implants. The IOM concluded that local complications are "the primary safety issue with silicone breast implants", making a clear distinction between local complications and systemic health concerns. Bothersome results such as rupture, pain, capsular contracture, disfigurement, and infection, were stated to be possible local complications that could require medical intervention or repeat surgeries. [http://www.fda.gov/cdrh/breastimplants/indexbip.html] The IOM report can be read online at http://books.nap.edu/catalog/9602.html. A consumer booklet on the IOM study, Information for Women about the Safety of Silicone Breast Implants, can be read at http://books.nap.edu/catalog/9618.html.
In 2000, the FDA granted approval of Mentor Corporation's and Inamed Corporation's saline-filled breast implant PMAs, showing data on the types and rates of local complications experienced by patients. [The 3-year complication rates are summarized in a FED press release available at http://www.fda.gov/bbs/topics/NEWS/NEW00727.html] “Despite complications experienced by some women, the majority of those women still in the Inamed Corporation and Mentor Corporation studies after three years reported being satisfied with their implants.” [http://www.fda.gov/cdrh/breastimplants/indexbip.html] Both PMAs were approved for breast augmentation to females of at least 18 years of age and for breast reconstruction.
[The approval letter, the labeling at the time of approval, and the Summary of Safety and Effectiveness (SSED) are available at http://www.fda.gov/cdrh/pdf/p990075.html for Mentor Corporation and at http://www.fda.gov/cdrh/pdf/p990074.html for Inamed Corporation. Updated clinical data from Mentor Corporation's (http://www.mentorcorp.com) and Inamed Corporation's (http://www.allergan.com) ongoing postapproval studies for these PMAs are available in the patient labeling on FDA's website at http://www.fda.gov/cdrh/breastimplants, as well as on the websites for both companies.]
The manufacturers continued to improve their gel-filled products, developing a more cohesive gel implant, and continued with their studies. In November of 2006, the FDA approved the new and improved
siliconegel-filled breast implants produced by the two manufacturers, Mentor Corporationand Allergan, both for breast reconstruction and for cosmetic breast augmentation. Cosmetic use of the implants was restricted to women aged 22 and older. The approval was given with a number of conditions including a requirement to complete 10-year studies on women who have already received the implants and a 10 year study on the safety of the devices in 40,000 women. The post-approval studies will be closely monitored by the FDA.] . [ cite web |url= http://www.fda.gov/bbs/topics/NEWS/2006/NEW01512.html |title=FDA Approves Silicone Gel-Filled Breast Implants |accessdate=2008-07-01 |publisher=FDA ] The FDA warned that the implants are not without risk and that women receiving implants should have regular MRI exams to watch for any signs of rupture or leakage. It was also mandated that patients be given brochures explaining the risks. [http://www.fda.gov/cdrh/breastimplants/indexbip.html]
Currently the FDA has approved silicone gel-filled breast implants and over a million women around the world have already received these implants.
Breast implants are used for:
* primary reconstruction (to replace breast tissue that has been removed due to cancer or trauma or that has failed to develop properly due to a severe breast abnormality)
* revision-reconstruction (revision surgery to correct or improve the result of an original breast reconstruction surgery)
* primary augmentation (to increase breast size for cosmetic reasons)
* revision-augmentation (revision surgery to correct or improve the result of an original breast augmentation surgery)
Patients seeking breast augmentation have been reported as being usually younger, healthier, from higher socio-economic status, and more often married with children than the population at large.cite journal | author = Brinton L, Brown S, Colton T, Burich M, Lubin J | title = Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery | journal = Plast Reconstr Surg | volume = 105 | issue = 3 | pages = 919–27; discussion 928–9 | year = 2000 | pmid = 10724251 | doi = 10.1097/00006534-200003000-00014] Many of these patients have reported greater distress about their appearance in a variety of situations, and have endured teasing about their appearance. Studies have identified a pattern (shared by many cosmetic surgery procedures) that suggest women who undergo breast implantation are slightly more likely to have undergone psychotherapy, have low levels of self-esteem, and have higher prevalences of depression,
suicideattempts, and mental illness (including body dysmorphiacite journal | author=Crerand CE,, "et al." | title=Body dysmorphic disorder and cosmetic surgery | journal=Plast Reconstr Surg.| year=2006 | issue=July| pages=1672–1802|pmid= 17102719 ] ) as compared to the general population.cite journal | author=Sarwer DB,, "et al." | title=Body image concerns of breast augmentation patients | journal=Plast Reconstr Surg.| year=2003 | issue=July| pages=83–90| pmid=12832880 | doi=10.1097/01.PRS.0000066005.07796.51 | volume=112 ]
Post-operative surveys on mental health and quality of life issues have reported improvement on a number of dimensions including: physical health, physical appearance, social life, self confidence, self esteem, and sexual function.cite journal | author=Young VL, "et al." | title=The efficacy of breast augmentation: breast size increase, patient satisfaction, and psychological effects | journal=Plast Reconstr Surg.| year=1994 | issue=Dec| pages=958–69| pmid=7972484 ] cite journal | author=Chahraoui K,, "et al." | title=Aesthetic surgery and quality of life before and four months postoperatively | journal=J Long-Term Effects Medical Implants | year=2006 | pages=207–210 | pmid=16181718 ] cite journal | author=Cash TF, "et al." | title=Women's psychosocial outcomes of breast augmentation with silicone gel-filled implants: a 2-year prospective study | journal=Plast Reconstr Surg.| year=2002 | issue=May| pages=2112–21| pmid=11994621 | doi=10.1097/00006534-200205000-00049 | volume=109 ] cite journal | author=Figueroa-Haas CL | title=Effect of breast augmentation mammoplasty on self-esteem and sexuality: a quantitative analysis| journal=Plast Surg Nurs.| year=2007 | issue=Mar| pages=16–36| pmid=17356451] Longer term follow-up suggests these improvements may be transitory, with the exception of body esteem related to sexual attractiveness.cite journal | title=Important Information for Women About Breast Augmentation with Inamed Silicone Gel-Filled Implants| year=2006 | url = http://www.fda.gov/cdrh/pdf2/P020056d.pdf ] Most patients report being satisfied long-term with their implants even when they have required re-operation for complications or aesthetic reasons.cite journal | author=HandelN, "et al." | title=A long-term study of outcomes, complications, and patient satisfaction with breast implants | journal=Plast Reconstr Surg.| year=2006 | issue=Mar| pages=757–67| pmid=16525261 | doi=10.1097/01.prs.0000201457.00772.1d | volume=117 ] cite journal | author=Young VL, "et al." | title=The efficacy of breast augmentation: breast size increase, patient satisfaction, and psychological effects | journal=Plast Reconstr Surg.| year=1994 | issue=Dec| pages=958–69| pmid=7972484 ]
The surgical procedure for breast augmentation takes approximately one to two hours. Variations in the procedure include the incision type, implant material, and implant pocket placement.
Breast implants for augmentation may be placed via various types of incisions:
* Inframammary - an incision is placed below the breast in the
infra-mammary fold(IMF). This incision is the most common approach and affords maximum access for precise dissection and placement of an implant. It is often the preferred technique for silicone gel implants due to the longer incisions required. This method can leave slightly more visible scars in smaller breasts which don't drape over the IMF. In addition, the scar may heal thicker.
* Periareolar - an incision is placed along the areolar border. This incision provides an optimal approach when adjustments to the IMF position or
mastopexy(breast lift) procedures are planned. The incision is generally placed around the inferior half, or the medial half of the areola's circumference. Silicone gel implants can be difficult to place via this incision due to the length of incision required (~ 5cm) for access. As the scars from this method occur on the edge of the areola, they are often less visible than scars from inframammary incisions in women with lighter areolar pigment. There is a higher incidence of capsular contracturewith this technique.
* Transaxillary - an incision is placed in the armpit and the dissection tunnels medially. This approach allows implants to be placed with no visible scars on the breast and is more likely to consistently achieve symmetry of the inferior implant position. Revisions of transaxillary-placed implants may require inframammary or periareolar incisions (but not always). Transaxillary procedures can be performed with or without an
* Transumbilical (TUBA) cite journal | author=Johnson GW, Christ JE.| title=The endoscopic breast augmentation: the transumbilical insertion of saline-filled breast implants| journal=Plast Reconstr Surg.| year=1993 | pages=801–8| volume=92 | issue=5 | pmid=8415961] - a less common technique where an incision is placed in the navel and dissection tunnels superiorly. This approach enables implants to be placed with no visible scars on the breast, but makes appropriate dissection and implant placement more difficult.Fact|date=February 2008 Transumbilical procedures may be performed bluntly or with an endoscope (tiny lighted camera) to assist dissection. This technique is not appropriate for placing silicone gel implants due to potential damage of the implant shell during blunt insertion.
* Transabdominoplasty (TABA) cite journal | author=Wallach SG.| title=Maximizing the use of the abdominoplasty incision| journal=Plast Reconstr Surg.| year=2004 | pages=411–7| volume=113 | issue=1 | pmid=14707667| doi=10.1097/01.PRS.0000091422.11191.1A] - procedure similar to TUBA, where the implants are tunneled up from the abdomen into bluntly dissected pockets while a patient is simultaneously undergoing an abdominoplasty procedure.
Types of implants
Saline-filled breast implants were first manufactured in France in 1964, introduced by Arioncite journal|author=Arion HG|title=Retromammary prosthesis|journal=C R Soc Fr Gynecol|year=1965|volume=5] with the goal of being surgically placed via smaller incisions. Current saline devices are manufactured with thicker, room temperature vulcanized (RTV) shells than earlier generations of devices. These shells are made of a silicone elastomer and the implants are filled with salt water (saline) after the implant is placed in the body. Since the implants are empty when they are surgically inserted, the scar is smaller than is necessary for silicone gel breast implants (which are filled with silicone before the surgery is performed). A single manufacturer (Poly Implant Prosthesis, France) produced a model of pre-filled saline implants which has been reported to have higher failure rates in vivo.cite journal|author=Stevens WG, Hirsch EM, Stoker DA, Cohen R.|title=In vitro deflation of prefilled saline breast implants|journal=Plast Reconstr Surg.|year=2006|pages=347–9|volume=118|issue=2|pmid=16874200|doi=10.1097/01.prs.0000227674.65284.80]
Saline-filled implants were most common implant used in the United States during the 1990s due to restrictions that existed on silicone implants, but were rarely used in other countries. Good to excellent results may be obtained, but as compared to silicone gel implants, saline implants are more likely to cause cosmetic problems such as rippling, wrinkling, and to be noticeable to the eye or the touch. Particularly for women with very little breast tissue, or for post-mastectomy breast reconstruction, silicone gel implants are considered as superior. In patients with more breast tissue in whom submuscular implant placement is used, saline implants can look very similar to silicone gel.
Silicone gel implants
Thomas Cronin and
Frank Gerow, two Houston, Texas, plastic surgeons, developed the first silicone breast prosthesis with the Dow Corning Corporationin 1961. The first woman was implanted in 1962. Silicone implants are generally described in terms of five generations which segregate common characteristics of manufacturing techniques.
* First generation
The Cronin-Gerow implants were made of a tear drop shaped silicone rubber envelope (or sac), filled with a thick, viscous silicone gel with a Dacron patch (to reduce rotation of the implant)on the posterior shell.cite journal | author = Cronin TD, Gerow FJ | title = Augmentation mammaplasty: a new "natural feel" prosthesis | journal = Excerpta Medica International Congress Series | year = 1963 | volume = 66 | pages = 41 | url= ]
* Second generation
In response to surgeons' requests for softer and more lifelike implants, breast implants were redesigned in the 1970s with thinner, less cohesive gel and thinner shells. These implants had a greater tendency to rupture or "gel bleed" silicone through an intact implant shell, and complications such as
capsular contracturewere quite common. It was predominantly implants of this generation that were involved in the American class action-lawsuits against Dow-Corning and other manufacturers in the early 1990s.
Another development in the 1970s was a "polyurethane foam coating" on the implant shell which was very effective in diminishing capsular contracture by causing an inflammatory reaction that discouraged formation of fibrous tissue around the capsule. These implants were later briefly discontinued due to concern of potential carcinogenic breakdown products from the polyurethane. cite journal | author=Luu HM, Hutter JC, Bushar HF | title=A physiologically based pharmacokinetic model for 2,4-toluenediamine leached from polyurethane foam-covered breast implants | journal=Environ Health Perspect | year=1998 | pages=393–400 | volume=106 | issue=7 | pmid=9637796 [http://www.ehponline.org/members/1998/106p393-400luu/luu-full.html Full text] | doi=10.2307/3434066] A review of the risk for cancer from TDA by the FDA later concluded that the risk was so small so as not to justify recommending explantation of the devices from individual patients. Polyurethane implants are still used in Europe and South America, but no manufacturer has sought FDA approval for sale in the United States. [cite journal | author=Hester TR Jr, Tebbetts JB, Maxwell GP | title=The polyurethane-covered mammary prosthesis: facts and fiction (II): a look back and a "peek" ahead | journal=Clin Plast Surg | year=2001 | pages=579–86 | volume=28 | issue=3 | pmid=11471963] Second-generation implants also saw the introduction of various "double lumen" designs. These implants were essentially a silicone implant inside a saline implant. The double lumen was an attempt to provide the cosmetic benefits of gel in the inside lumen, while the outside lumen contained saline and its volume could be adjusted after placement. The failure rate of these implants is higher than for single lumen implants due to their more complex design. The contemporary versions of these devices ("Becker Implants") are used primarily for breast reconstruction.
* Third & Fourth generation
Third & fourth generation implants, from the mid 1980s, represented sequential advances in manufacturing principles with elastomer-coated shells to decrease gel bleed, and are filled with thicker, more cohesive gel. The increased cohesion of the gel filler reduced potential leakage of the gel compared to earlier devices and the more substantial shell improved durability as compared to 2nd generation implants. A variety of both round and tapered anatomic shapes are available from different implants in this group. The anatomic or shaped implants are uniformly impregnated with a textured surface to reduce rotation, while round devices are available in both smooth or textured surfaces.
* Fifth generation
Evaluation of "
gummy bear" or solid, high-cohesive, form-stable implants is in preliminary stages in the United States but these implants have been widely used since the mid 1990s in other countries. The semi-solid gel in these type of implants largely eliminates the possibility of silicone migration. Studies of these devices have shown significant potential improvements in safety and efficacy over the older implants with low rates of capsular contracture and rupture. cite journal | author=Brown MH, Shenker R, Silver SA | title=Cohesive silicone gel breast implants in aesthetic and reconstructive breast surgery | journal=Plast Reconstr Surg | year=2005 | pages=768–79; discussion 780–1 | volume=116 | issue=3 | pmid=16141814 | doi=10.1097/01.prs.0000176259.66948.e7] cite journal | author=Fruhstorfer BH, Hodgson EL, Malata CM | title=Early experience with an anatomical soft cohesive silicone gel prosthesis in cosmetic and reconstructive breast implant surgery | journal=Ann Plast Surg | year=2004 | pages=536–42 | volume=53 | issue=6 | pmid=15602249 | doi=10.1097/01.sap.0000134508.43550.6f] cite journal | author=Heden P, Jernbeck J, Hober M | title=Breast augmentation with anatomical cohesive gel implants: the world's largest current experience | journal=Clin Plast Surg | year=2001 | pages=531–52 | volume=28 | issue=3 | pmid=11471959]
Polypropylene breast implants
Polypropylene breast implants, also known as string breast implants, are a form of breast implant using polypropylene developed by Dr. Gerald W. Johnson. Due to a number of medical complications, the device has been banned in the European Union and United States. They work by absorbing fluid and expanding inside the body, resulting in extreme breast sizes. They are rarely seen outside of the adult entertainment industry.
Implant pocket placement
The placement of implants is described in relation to the
pectoralis major muscle.
* Subglandular- implant between the breast tissue and the pectoralis muscle. This position closely resembles the plane of normal breast tissue and is felt by many to achieve the most aesthetic results. The subglandular position in patients with thin soft-tissue coverage is most likely to show ripples or wrinkles of the underlying implant. Capsular contracture rates are also slightly higher with this approach, and placement of implants in this pocket might be inappropriate in women who are at risk for capsule formation (smokers, multiple breast surgeries).
* Subfascial cite journal | author=Graf RM, et al | title=Subfascial breast implant: a new procedure| journal= Plast Recon Surg | year=2003 | pages=904–8 | volume=111 | issue=2 | pmid=12560720 | doi=10.1097/01.PRS.0000041601.59651.15] - the implant is placed in the subglandular position, but underneath the fascia of the pectoralis muscle. The benefits of this technique are debated, cite journal | author=Tebbetts JB| title=Does fascia provide additional, meaningful coverage over a breast implant?| journal= Plast Recon Surg | year=2004 | pages=777–9 | volume=113 | issue=2 | pmid=14758271| doi=10.1097/01.PRS.0000104516.13465.96] but proponents believe the (sometimes thick) fascial sheet of tissue may help with coverage and sustaining positioning of the implant. Implants that undergo capsular contraction are unlikely to displace upward or toward the underarm.
* Subpectoral ("dual plane") cite journal | author=Tebbetts T | title=A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics| journal= Plast Recon Surg | year=2002 | pages=1396–409 | volume=109 | issue=4 | pmid=11964998 | doi=10.1097/00006534-200204010-00030] - the implant is placed underneath the pectoralis major muscle after releasing the inferior muscular attachments. As a result, the implant is partially beneath the pectoralis in the upper pole, while the lower half of the implant is in the subglandular plane. This is the most common technique in North America and achieves maximal upper implant coverage while allowing expansion of the lower pole. Animation or movement of the implants in the subpectoral plane can be excessive to some patients.
* Submuscular - the implant is placed below the pectoralis without release of the inferior origin of the muscle. Total muscular coverage may be achieved by releasing the lateral chest wall muscles (serratus and/or pectoralis minor) and sewn to the pectoralis major. This technique is most commonly used for maximal coverage of implants used in breast reconstruction.
Depending on the level of activity required, patients are generally able to resume normal activity in approximately one week's time. Women who have their implants placed underneath the muscle (submuscular placement) will generally have a longer recovery time and experience slightly more pain due to the muscle being cut during surgery.During initial recovery it is important not to use the arms or strain the body in any way, and to avoid cigarettes.Scars from a breast augmentation surgery will last six weeks or longer and usually begin to fade several months after surgery.
Claims of systemic illness and disease
Since the early 1990s, a number of independent systemic comprehensive reviews have examined studies concerning links between silicone gel breast implants and
systemic diseases. The consensus of these reviews is that there is no clear evidence of a causal link between the implantation of silicone breast implants and systemic disease.cite book|author=Therapeutic Goods Administration|title=Breast Implant Information Booklet|edition=4th ed.|publisher=Australian Government|year=2001|url=http://www.tga.gov.au/docs/pdf/breasti4.pdf|id=ISBN 0-642-73579-4 ] cite web|author=European Committee on Quality Assurance and Medical Devices in Plastic Surgery|title=Consensus Declaration on Breast Implants|work=|url=http://www.secpre.org/pdf/equam.pdf|date=2000-06-23|accessdate=2007-05-04] cite web|title=Silicone Gel Breast Implant Report Launched - No Epidemiological Evidence For Link With Connective Tissue Disease - Independent Review Group|url=http://www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4024791|date=1998-07-13|accessdate=2007-05-04] cite web|title=Expert Advisory Panel on Breast Implants: Record of Proceedings|publisher=HealthCanada|url=http://www.hc-sc.gc.ca/dhp-mps/md-im/activit/sci-consult/implant-breast-mammaire/eapbi_rop_gceim_crd_2005-09-29_e.html|date=2005-09-29|accessdate=2007-05-04]
Thousands of women claim that they have become ill from their implants; complaints include neurological and rheumatological problems. Some studies have suggested that subjective and objective symptoms of women with implants may improve when their implants are removed.cite journal|author=Vasey FB, Zarabadi SA, Seleznick M, Ricca L|title=Where there's smoke there's fire: the silicone breast implant controversy continues to flicker: a new disease that needs to be defined|journal=J Rheumatol|year=2003|pages=2092–4|volume=30|issue=10|pmid=14528500]
As studies have followed women with implants for a longer period of time, more data have become available on systemic diseases as well as autoimmune symptoms. Several large studies from the national health registry in Denmark found implant recipients no more likely to be diagnosed with an increased incidence of classic auto-immune symptoms as compared to women of the same age in the general population,cite journal|author=Breiting VB, Holmich LR, Brandt B, Fryzek JP, Wolthers MS, Kjoller K, McLaughlin JK, Wiik A, Friis S|title=Long-term health status of Danish women with silicone breast implants|journal=Plastic and Reconstructive Surgery|year=2004|pages=217–226|volume=114|pmid=15220596|doi=10.1097/01.PRS.0000128823.77637.8A] and that musculoskeletal symptoms were generally lower among women with implants compared with women with other cosmetic surgery and women in the general population.cite journal | author=Kjoller K, Holmich LR, Fryzek JP, Jacobsen PH, Friis S, McLaughlin JK, Lipworth L, Henriksen TF, Hoier-Madsen M, Wiik A, Olsen JH|title=Self-reported musculoskeletal symptoms among Danish women with cosmetic breast implants|journal= Plastic Ann Plast Surg.|year=2004|pages=1–7|volume=52 | pmid= 14676691|doi=10.1097/01.sap.0000101930.75241.55] Recent longitudinal follow-up of these patients has confirmed previously reported findings.cite journal|author=Fryzek JP, Holmich L, McLaughlin JK, Lipworth L, Tarone RE, Henriksen T, Kjoller K, Friis S|title=A Nationwide Study of Connective Tissue Disease and Other Rheumatic Conditions Among Danish Women With Long-Term Cosmetic Breast Implantation|journal=Ann Epidemiol|year=2007|pmid=17321754|doi=10.1016/j.annepidem.2006.11.001|volume=17|pages=374]
Several studies have established that women who elect to undergo breast augmentation or other plastic surgery tend to be healthier and more affluent than the general population, prior to surgery and afterwards. For example, two large studies of plastic surgery patients found a decreased
standardized mortality ratioin both breast implant and other plastic surgery patients, but an increased risk of respiratory cancer deaths in breast implant recipients compared to other forms of plastic surgery. Smoking was statistically controlled in one study and not in the other, but the authors speculated that there could potentially be differences in smoking that might contribute to the higher lung cancer deaths among women with implants. [cite journal|author=Brinton LA, Lubin JH, Murray MC, Colton T, Hoover RN|title=Mortality rates among augmentation mammoplasty patients: an update|journal=Epidemiology|year=2006|pages=162–9|volume=17|issue=2|pmid=16477256|doi=10.1097/01.ede.0000197056.84629.19] [cite journal|author=McLaughlin JK, Lipworth L, Fryzek JP, Ye W, Tarone RE, Nyren O|title=Long-term cancer risk among Swedish women with cosmetic breast implants: an update of a nationwide study| journal=J Natl Cancer Inst.|year=2006|pages=557–60|volume=98|issue=8|pmid=16622125] Another large study with long-term follow-up of nearly 25,000 Canadian women with implants reported: "Findings suggest that breast implants do not directly increase mortality in women."cite journal|author=Villenueve PJ, et. al|title=Mortality among Canadian Women with Cosmetic Breast Implants|journal=Am J Epidemiol|year=2006|month=June|pmid=16777929|doi=10.1093/aje/kwj214|volume=164|pages=334 ]
In 2001 a study suggested an increase in
fibromyalgiaamong women with extracapsular silicone gel leakage, compared to women whose implants were not broken or leaking outside the capsule.cite journal|author=Brown SL, Pennello G, Berg WA, Soo MS, Middleton MS|title=Silicone gel breast implant rupture, extracapsular silicone, and health status in a population of women|journal=J Rheumatol|year=2001|pages=996–1003|volume=28|issue=5|pmid=11361228 [http://www.fda.gov/cdrh/breastimplants/extracapstudy.html FDA Summary] ] This association has not been repeated in a number of related studies, [cite journal|author=Lipworth L, Tarone RE, McLaughlin JK.|title=Breast implants and fibromyalgia: a review of the epidemiologic evidence|journal=Ann Plast Surg.|year=2004|pages=284–7|volume=52|issue=3|pmid=15156983|doi=10.1097/01.sap.0000116024.18713.28] and the US-FDA concluded "the weight of the epidemiological evidence published in the literature does not support an association between fibromyalgia and breast implants."cite web|title=Diseases|work=FDA Breast Implant Consumer Handbook - 2004|url=http://www.fda.gov/cdrh/breastimplants/handbook2004/diseases.html|date=2004-06-08|accessdate=2007-05-04]
While there is a general international consensus that silicone implants have not been shown to cause systemic illness, excluding the possibility that a small group of patients may become ill through (as of yet) unknown mechanisms may prove difficult. The US-FDA notes that "researchers must study a large group of women without breast implants who are of similar age, health, and social status and who are followed for a long time (such as 10-20 years) before a relationship between breast implants and these diseases can conclusively be made."
Surgeries involving breast implants, whether for cosmetic or reconstructive surgery, carry risk common to many types of surgery. These include adverse reactions to anesthesia, post-operative bleeding (
hematoma)or fluid collection ( seroma), surgical site infection or breakdown, breast pain or alterations in sensation cite web | title = Saline-Filled Breast Implant Surgery: Making An Informed Decision (Mentor Corporation) | work = FDA Breast Implant Consumer Handbook - 2004 | url = http://www.fda.gov/cdrh/breastimplants/labeling/mentor_patient_labeling_5900.html | date = 2004-01-13 | accessdate = 2007-05-04] , unfavorable scarring (6-7%) cite web | title = Important Information for Augmentation Patients About Mentor MemoryGel Silicone Gel-Filled Breast Implants | url = http://www.fda.gov/cdrh/pdf3/p030053d.pdf | date = 2006-11-03 | accessdate = 2007-05-04] , interference with breast feeding, visible wrinkling, asymmetry, thinning of the breast tissue, and synmastia (disruption of the natural plane between breasts which is sometimes referred to as 'bread loafing'). Complications and reoperations related to surgeries with breast implants or tissue expanderscan add signifigant long term costs to patients and health care systems.
Specific complications to indwelling breast implants that have received notable attention involve surveillence and treatment for implant rupture and the phenomena of capsular contracture.
Breast implants can potentially remain intact for decades in the body, but all such devices will fail at some point.Fact|date=October 2008 When saline breast implants break, they often deflate quickly and can be easily removed. Prospective studies of saline-filled breast implants showed rupture/deflation rates of 3-5% at 3 years and 7-10% at 5 years for augmentation patients.
Among the suspected mechanisms for rupture are damage during implantation or other procedures, degradation of the implant shell, blunt or penetrating chest trauma, and in rare instances from the pressure of traditional mammograms.cite web | title = Local Complications | work = FDA Breast Implant Consumer Handbook - 2004 | url = http://www.fda.gov/cdrh/breastimplants/handbook2004/localcomplications.html | date = 2004-06-08 | accessdate = 2007-05-04]
The age and design of the implant are the most important factors in rupture, but estimating ruptures rates of contemporary devices has been difficult, as most previous reports cite journal | author=Brown SL, Middleton MS, Berg WA, Soo MS, Pennello G | title=Prevalence of rupture of silicone gel breast implants revealed on MR imaging in a population of women in Birmingham, Alabama | journal=AJR Am J Roentgenol | year=2000 | pages=1057–64 | volume=175 | issue=4 | pmid=11000165] mixed heterogeneous groups of devices in non-randomized populations. The only available literature with longer term available MRI data on single lumen 3rd/4th generation silicone implants comes from Europe and has reported silent rupture rates of an implant at between 8% to 15% at or around a decade (or 15-30% of patients). cite journal | author=Holmich LR, et al | title=Incidence of silicone breast implant rupture| journal=Arch Surg. | year=2003 | pages=801–6| volume=138 | issue=7 | pmid=12860765 | doi=10.1001/archsurg.138.7.801] cite journal | author=Heden P, et al | title=Prevalence of rupture in inamed silicone breast implants| journal=Plast Reconstr Surg. | year=2006 | pages=303–8| volume=118 | issue=2 | pmid=16874191 | doi=10.1097/01.prs.0000233471.58039.30] cite web | url=http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4101b1_Mentor-Briefing%20doc-supplement.DOC | title=FDA summary of clinical issues (MS Word document)] The first series of MRI evaluation of the highly-cohesive (5th generation) gel implants suggests improved durability, with a rupture rate reported at 1% or less at a median age of six years. cite journal | author=Heden P, et al | title=Style 410 cohesive silicone breast implants: safety and effectiveness at 5 to 9 years after implantation| journal=Plast Reconstr Surg. | year=2006 | pages=1281–7| volume=118 | issue=6 | pmid=17051096 | doi=10.1097/01.prs.0000239457.17721.5d]
Its been suggested that clinical exams alone are inadequate to evaluate suspected rupture after a study reported that only 30% of ruptures in asymptomatic patients are accurately detected by experienced plastic surgeons, compared to 86% detected by MRIs cite journal | author=Holmich LR, Fryzek JP, Kjoller K, Breiting VB, Jorgensen A, Krag C, McLaughlin JK | title= The diagnosis of silicone breast-implant rupture: clinical findings compared with findings at magnetic resonance imaging | journal=Ann Plast Surg | year=2005 | pages=583–9 | volume=54 | issue=6 | pmid=15900139 | doi=10.1097/01.sap.0000164470.76432.4f] The US-FDA has recommended that MRIs be considered to screen for silent rupture starting at three years after implantation and then every two years thereafter.cite web | title = Important Information for Women About Breast Augmentation with INAMED Silicone-Filled Breast Implants | url = http://www.fda.gov/cdrh/pdf2/P020056d.pdf | date = 2006-11-03 | accessdate = 2007-05-04] Other countries have not endorsed routine MRI screening, and have taken the position that MRI should be reserved only for cases involving suspected clinical rupture or to confirm mammographic or ultrasound studies suggesting rupture.
When silicone implants break they rarely deflate, and the silicone from the implant can leak out into the space around the implant. An intracapsular rupture can progress to outside of the capsule (extracapsular rupture), and both conditions are generally agreed to indicate the need for removal of the implant. Extracapsular silicone has the potential to migrate, but most clinical complications have appeared to be limited to the breast and axillae cite journal| author=Holmich LR , et. al |title= Untreated silicone breast implant rupture | journal=Plast Reconstr Surg.| year=2004|pages=204–14|volume=114 | issue=1 |pmid= 15220594 |doi= 10.1097/01.PRS.0000128821.87939.B5 ] in the form of
granulomas(inflammatory nodules) and axillary lymphadenopathycite journal | author=Katzin, William E, Ceneno, Jose A, Feng, Lu-Jean et al | title=Pathology of Lymph Nodes From Patients With Breast Implants: A Histologic and Spectroscopic Evaluation | journal=American Journal of Surgical Pathology | year=2001 | pages=506–511 | volume=29 | issue=4 | url = http://www.ajsp.com/pt/re/ajsp/abstract.00000478-200504000-00013.htm;jsessionid=G3QMCQKJ6hM5VsXLk60GQByjJfkSq7rzMMVZwKbyvpwxmmZXrQpK!-1734750035!-949856144!8091!-1] (enlarged lymph glands in the armpit area).cite web | title = Study of Rupture of Silicone Gel-filled Breast Implants (MRI Component) | work = FDA Breast Implant Consumer Handbook - 2004 | url = http://www.fda.gov/cdrh/breastimplants/handbook2004/diseases.html | date = 2000-05-22 | accessdate = 2007-05-04] The specific risk and treatment of extracapsular silicone gel is still controversial.
:"See main article,"
Capsules of tightly-woven collagen fibers form as an
immune responsearound a foreign body (eg. breast implants, pacemakers, orthopedic joint prosthetics), tending to wall it off. Capsular contractureoccurs when the capsule tightens and squeezes the implant. This contracture is a complication that can be very painful and distort the appearance of the implanted breast. The exact cause of contracture is not known. However, some factors include bacterial contamination, silicone rupture or leakage, and hematoma. Capsular contracture may happen again after this additional surgery.
Methods which have reduced capsular contracture include submuscular implant placement, using texturedcite journal | author=Barnsley GP| title= Textured surface breast implants in the prevention of capsular contracture among breast augmentation patients: a meta-analysis of randomized controlled trials | journal=Plast Reconstr Surg. | year=2006 | pages=2182–90| volume=117 | issue=7 | pmid=16772915| doi= 10.1097/01.prs.0000218184.47372.d5] cite journal | author=Wong CH, Samuel M, Tan BK, Song C.| title= Capsular contracture in subglandular breast augmentation with textured versus smooth breast implants: a systematic review| journal=Plast Reconstr Surg. | year=2006 | pages=1224–36| volume=118 | issue=5 | pmid=17016195| doi= 10.1097/01.prs.0000237013.50283.d2] or polyurethane-coated implants,cite journal | author=Handel N, et al| title= Long-term safety and efficacy of polyurethane foam-covered breast implants | journal=Aesth. Surg Journal | year=2006 | month=may | pages=265–74| volume=26 | issue=3| doi= 10.1016/j.asj.2006.04.001] limiting handling of the implants and skin contact prior to insertioncite journal | author=Mladick RA| title= "No-touch" submuscular saline breast augmentation technique | journal=Aesth. Surg Journal | year=1993 | pages=183–92| volume=17 | issue=3 | pmid= 8213311| doi= 10.1007/BF00636260 ] and irrigation with triple-antibiotic solutions.cite journal | author=Adams WP jr., et al| title= Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study | journal=Plast Reconstr Surg. | year=2006 | pages=30–36 | volume=117 | issue=1 | pmid=16404244 | doi=10.1097/01.prs.0000208306.79104.18]
Correction of capsular contracture may require surgical removal or release of the capsule, or removal and possible replacement of the implant itself. Closed capsulotomy (disrupting the capsule via external manipulation), a once common maneuver for treating hard capsules, has been discouraged as it can cause implant rupture. Nonsurgical methods of treating capsules include massage, external ultrasound,cite journal | author=Planas J| title= Five-year experience on ultrasonic treatment of breast contractures | journal=Aesthetic Plast Surg. | year=2001| pages=89–93 | volume=25 | issue=2 | pmid=11349308| doi= 10.1007/s002660010102] treatment with
leukotrienepathway inhibitors (Accolate, Singulair),cite journal | author=Schlesinger SL, wt al| title= Zafirlukast (Accolate): A new treatment for capsular contracture | journal=Aesthetic Plast Surg. | year=2002| pages=329–336| volume=22 | issue=4] cite journal | author=Scuderi N, et al.| title= The effects of zafirlukast on capsular contracture: preliminary report| journal=Aesthetic Plast Surg. | year=2006| pages=513–20 | volume=30 | issue=5 | pmid=16977359| doi= 10.1007/s00266-006-0038-3] and pulsed electromagnetic field therapy.cite journal | author=Silver H| title= Reduction of capsular contracture with two-stage augmentation mammaplasty and pulsed electromagnetic energy (Diapulse therapy) | journal=Plast Reconstr Surg. | year=1982| pages=802–8 | volume=69 | issue=5 | pmid=7071225| doi= 10.1097/00006534-198205000-00013]
Platinumis a catalystused in the making of silicone implant polymer shells and other silicone devices used in medicine. The literature indicates that small amounts of platinum leaches (leaks) from these implants and is present in the surrounding tissue. The FDA reviewed the available studies from the medical literature on platinum and breast implants in 2002 and concluded there was little evidence suggesting toxicity from platinum in implant patients.cite journal | author=Arepelli S, "et al." | title=Allergic reactions to platinum in silicone breast implants | journal=J Long-Term Effects Medical Implants | year=2002 | pages=299–306 | pmid=12627791 ]
In 2006, researchers published a controversial study that claimed to identify the previously undocumented presence of toxic platinum oxidative states "in vivo".cite journal | author = Lykissa E.D. and Maharaj S.V.M. | year = 2006 | month = April | title = Total Platinum Concentration and Platinum Oxidation States in Body Fluids, Tissue, and Explants from Women Exposed to Silicone and Saline Breast Implants by IC-ICPMS | journal = Anal. Chem. | volume = 78| issue = | pages = 2925| id =(due publication May 2006) | url =http://pubs.acs.org/cgi-bin/abstract.cgi/ancham/asap/abs/ac0514016.html | accessdate =2006-04-06 | doi = 10.1021/ac0514016] A letter from the editors of the publishing journal, "Analytical Chemistry", subsequently expressed concern over the research's experimental design and urged the journal's readers to "use caution in evaluating the conclusions drawn in the paper." [cite web| url=http://pubs.acs.org/cen/news/84/i31/8431notw5.html |title=Dubious Breast Implant Study: Doubts now surround study claiming to have found high levels of platinum in women with silicone breast|date=
July 31 2006] The FDA reviewed this study and the existing literature, concluding that the body of existing research did not support their findings, and that the platinum in new implants is likely not ionized and therefore would not represent a significant risk to women. [cite web| url=http://www.fda.gov/cdrh/breastimplants/platinum.html| title=FDA Backgrounder on Platinum in Silicone Breast Implants| publisher= Food and Drug Administration]
The presence of radio-opaque breast implants may interfere with the sensitivity of screening mammography. Specialized radiographic techniques where the implant is manually displaced (Eklund views) may improve this somewhat, but approximately 1/3 of the breast is still not adequately visualized with a resultant increase in false-negative mammograms.cite journal | author=Handel, N., Silverstein, M. J., Gamagami, P., Jensen, J. A., and Collins, A. | title=actors affecting mammographic visualization of the breast after augmentation mammaplasty| journal=JAMA| year=1992| pages=1913–17 | pmid=1404718 | doi=10.1001/jama.268.14.1913 | volume=268] A number of studies looking at breast cancers in women with implants have found no significant difference in stage of disease at time of diagnosis, and prognosis appears to be similar in both groups with augmented patients not a higher risk for subsequent cancer recurrence or death.cite journal | author=Clark CP 3rd, Peters GN, O'Brien KM. | title=Cancer in the augmented breast. Diagnosis and prognosis| journal=Cancer | year=1993| pages=2170–4 | pmid=8374874 | doi=10.1002/1097-0142(19931001)72:7<2170::AID-CNCR2820720717>3.0.CO;2-1 | volume=72 ] cite journal | author=Skinner KA, Silberman H, Dougherty W, Gamagami P, Waisman J, Sposto R, Silverstein MJ. | title=Breast cancer after augmentation mammoplasty| journal=Ann Surg Oncol. | year=2001| pages=138–44 | pmid=11258778 | doi=10.1007/s10434-001-0138-x | volume=8 ] Conversely, the use of implants for reconstruction "after" mastectomy for breast cancer also appears not to have a negative effect on cancer-related mortality.cite journal | author=Le GM, O'Malley CD, Glaser SL, Lynch CF, Stanford JL, Keegan TH, West DW. | title=Breast implants following mastectomy in women with early-stage breast cancer: prevalence and impact on survival| journal=Breast Cancer Res.| year=2005| pages=R184–93 | pmid=15743498 | doi=10.1186/bcr974 | volume=7]
An observation that patients with implants are more often diagnosed with palpable tumors (but not larger ones) suggest that tumors of equal size may be more easily palpated in augmented patients, and this may compensate somewhat for the potential impairment of mammography.cite journal | author=Handel N, Silverstein MJ | title=Breast cancer diagnosis and prognosis in augmented women| journal=Plast Reconstr Surg. | year=2006 | pages=587–93 | pmid=16932162 | doi=10.1097/01.prs.0000233038.47009.04 | volume=118 ] This palpability is due to thinning of the breast by compression, innately smaller breasts a priori, and that the implant serves as a base against which the mass may be differentiated.cite journal | author=Cunningham B | title=Breast cancer diagnosis and prognosis in augmented women- Discussion| journal=Plast Reconstr Surg. | year=2006 | pages=594–5 | pmid=16932163 | doi=10.1097/01.prs.0000233047.87102.8e | volume=118 ]
The presence of a breast implant does not influence the ability for breast conservation (lumpectomy) surgery for women who subsequently develop breast cancer, and does not interfere with delivery of external beam radiation (XRT) treatments that may be required.cite journal | author=SChwartz GF, "et al." | title=Consensus Conference on Breast Conservation| journal=JACAS | year=2006 | pages=198–207 | pmid=16864033 ] Fibrosis of breast tissue after XRT is common and an increase in capsular contracture rates would be expected.
Repair or revision surgery
Regardless of the type of implant, it is likely that women with implants will need to have one or more additional surgeries (re-operations) over the course of their lives. Breast implants do not last forever. According to studies conducted by implant companies for the U.S. FDA, they sometimes only last a few years. Most common indications for re-operations have included major or minor complications, capsular contracture treatment, and replacement of ruptured/deflated implants. Re-operation rates are predictably more frequent in breast reconstruction cases due to the dramatic changes in the soft-tissue envelope and anatomical breast borders after mastectomy, particularly when patients have received adjuvant XRT. Breast cancer patients also frequently undergo staged procedures for reconstruction of the nipple-areola complex (NAC) and symmetry procedures on the opposite breast.
It appears that re-operation rates in cosmetic cases can be improved by more carefully matching individual patients' soft-tissue characteristics to the type and size of implants used. Using appropriate device selection and proper technique, re-operation rates at up to seven years followup have been reported as low as 3%,cite journal | author= Tebbets JB | title=Out points" criteria for breast implant removal without replacement and criteria to minimize reoperations following breast augmentation | year=2006 | journal=Plast Reconstr Surg. | month= Oct | volume=114 | issue=5 | pages=1258–62 |pmid= 15457046] cite journal | author= Tebbets JB | title=Achieving a zero percent reoperation rate at 3 years in a 50-consecutive-case augmentation mammaplasty premarket approval study. | year=2006 | journal=Plast Reconstr Surg. | month= Dec | volume=118 | issue=6 | pages=1453–7 |pmid= 17051118 | doi=10.1097/01.prs.0000239602.99867.07 ] as compared with the 20 percent re-operation rate at 3 years in the most recent Food and Drug Administration study.
Since the early 1990s, nearly a dozen comprehensive systemic reviews have been commissioned by various governments' health ministries to examine the alleged links between silicone gel breast implants and systemic diseases. A clear consensus has emerged from these independent scientific reviews that there is no clear evidence of a causal link between the implantation of silicones and connective tissue disease. The conclusions of these reviews are summarized:
As studies have followed women with implants for a longer period of time, more information has been made available to assess these issues. A 2004 Danish study, reported that women who had breast implants for an average of 19 years were no more likely to report an excess number of rheumatic symptoms than control groups.cite journal | author=Breiting VB, Holmich LR, Brandt B, Fryzek JP, Wolthers MS, Kjoller K, McLaughlin JK, Wiik A, Friis S | title=Long-term health status of Danish women with silicone breast implants | journal= Plastic and Reconstructive Surgery| year=2004 | pages=217–226 | volume=114 | pmid= 15220596 | doi=10.1097/01.PRS.0000128823.77637.8A] A large study of plastic surgery patients found a decreased
standardized mortality ratioin both breast implant and other plastic surgery patients, but a relatively increased risk of lung cancerdeaths in breast implant recipients compared to other forms of plastic surgery. The authors attributed this to differences in smoking rates.cite journal | author=Brinton LA, Lubin JH, Murray MC, Colton T, Hoover RN | title=Mortality rates among augmentation mammoplasty patients: an update | journal=Epidemiology | year=2006 | pages=162–9 | volume=17 | issue=2 | pmid=16477256 | doi=10.1097/01.ede.0000197056.84629.19] Another large study of nearly 25,000 Canadian women with implants recently reported a 43 percent lower rate of breast cancer compared with the general population and a lower-than-average risk of developing cancer of any kind.cite journal | author=Villenueve PJ, et. al | title=Mortality among Canadian Women with Cosmetic Breast Implants | journal=Am J Epidemiol| year=2006 | month=June| pmid=16777929 | doi=10.1093/aje/kwj214 | volume=164 | pages=334 ]
International Health Ministry Links
* [http://www.fda.gov/cdrh/breastimplants/ U.S. Food and Drug Administration (FDA) - breast implant page]
* [http://www.hc-sc.gc.ca/dhp-mps/md-im/activit/sci-consult/implant-breast-mammaire/index_e.html Health Canada breast implant homepage]
* [http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&nodeId=225 U.K. Medicines & Health Care Products Regulatory Agency (MHRA) - breast implant page]
* [http://www.tga.gov.au/docs/html/breasti.htm Australia's Department of Health & Aging Therapeutic Goods Administration breast implant page]
General Breast Implant Links
* [http://www.emedicine.com/plastic/topic134.htm Basics of implant based breast reconstruction (E-medicine)]
* [http://www.nap.edu/catalog/9602.html Institute of Medicine (IOM) Report on Silicone Implants]
* [http://www.fjc.gov/BREIMLIT/SCIENCE/summary.htm National Science Panel report "Silicone Breast Implants in Relation to Connective Tissue Diseases and Immunologic Dysfunction"]
* [http://www.emedicine.com/plastic/topic500.htm Summary of Silicone Implant Safety (E-medicine)]
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