Self-reported symptoms among women after cosmetic breast implant and breast reduction surgery.

A retrospective cohort study was performed in Sweden to evaluate the possibility that an individual symptom or constellation of illness symptoms related to silicone occurs in women after breast implant surgery. A random sample (n = 2500) of all women in the Swedish national implant registry who underwent breast augmentation surgery with alloplastic breast implants during the years 1965 through 1993 was compared with a sample (n = 3500) of women who underwent breast reduction surgery during the same period, frequency matched to the implant patients for age and calendar year at the time of surgery. In total, 65 percent of the breast implant patients (n = 1546) and 72 percent of the breast reduction patients (n = 2496) completed a self-administered questionnaire covering 28 rheumatologic and other symptoms and lifestyle and demographic factors. Practically all of the 28 symptoms inquired about were reported more often by women in the breast implant cohort, with 16 (57 percent) significantly more common in breast implant recipients. In contrast, few significant differences or consistent patterns were observed in the length of time since the implant and in the type (silicone or saline) or volume of the implant. Although women with breast implants report a multitude of symptoms more often than women who have breast reduction surgery, the lack of specificity and absence of dose-response relationships suggest that the excess of reported symptoms is not causally related to cosmetic implants.

Local complications and subsequent symptom reporting among women with cosmetic breast implants.

Epidemiologic studies have found no association between breast implants and cancer or well-defined connective tissue diseases. However, women with cosmetic breast implants continue to report specific as well as nonspecific physical and psychological symptoms after receiving their implants. In an attempt to determine whether local complications of implantation may contribute to this excess of symptom reporting, the authors studied a large cohort of women in Sweden with cosmetic breast implants (n = 1280) and a comparison cohort of women who had cosmetic breast reduction surgery (n = 2211). Both groups of women had operations between 1969 and 1996. Medical record reviews of local complications revealed that approximately 31 percent of the women with cosmetic breast implants had an implant change, implant leakage, or a capsulotomy. Capsulotomies occurred more often in women who were age 35 or older at the time of the operation, had ever smoked, and had implants with a smooth surface. On self-administered questionnaires, symptoms were reported more often by the women who had implants regardless of whether they had local complications. Twenty of the 28 symptoms occurred more frequently among women with local complications and breast implants, compared with the women in the breast reduction comparison group or the women with breast implants but no local complications. This study suggests that local complications, particularly capsular contractures as indicated by capsulotomy, may be an important factor to consider when studying symptom reporting among women with breast implants.

Characteristics of women with cosmetic breast augmentation surgery compared with breast reduction surgery patients and women in the general population of Sweden.

To determine whether women with cosmetic breast implants have distinct demographic, lifestyle, and reproductive characteristics that put them at increased risk for subsequent morbidity, the authors compared 1,369 such women to 2,211 women who had undergone breast reduction surgery, and to a random sample of 49,262 women from the general population of Sweden. Information was collected through self-administered questionnaires, and comparisons were made using the prevalence odds ratio. Women with cosmetic breast implants were significantly (p <0.05) more likely to be current smokers, have a lower body mass index, have had a prematurely terminated pregnancy (induced abortion or miscarriage), and have had fewer live births than either women who underwent breast reduction or women from the general population. Type of implant (silicone gel or saline) did not modify the associations. Regardless of the comparison group used, studies of the health effects of breast implants need to consider that women who undergo cosmetic breast implantation have certain distinct characteristics.

Breast implants and risk of neurologic disease: a population-based cohort study in Sweden.

OBJECTIVE: To examine the risk of neurologic disorders among women with breast implants. BACKGROUND: Case reports in the literature have raised concern about a possible link between silicone breast implants and some types of neurologic disorders, but there is a dearth of epidemiologic studies in this area. METHODS: Through the nationwide Swedish hospital discharge register, we identified a population-based cohort of 7433 women with breast implants. A similarly identified cohort of 3351 women who underwent breast reduction surgery served as a comparison. The women were followed from 1972 (or date of breast surgery if it occurred later) through 1993 by means of record linkages and review of inpatient medical records. Ratios of observed to expected numbers, and relative risks (RR) with 95% confidence intervals (CI), were calculated as measures of the risk of neurologic diseases among women with implants. RESULTS: A direct comparison of the exposed (implant) versus comparison (breast reduction) groups, after exclusion of patients with pre-existing disease or incorrect neurologic diagnoses, showed no excess risk among implant patients (RR = 0.8; 95% CI = 0.5 to 1.4). When external rates derived from the background population were used as comparison, we found a small, statistically nonsignificant excess of neurologic disorders both in the breast implant (RR = 1.3; 95% CI = 0.9 to 1.9) and the breast reduction (RR = 1.5; 95% CI = 0.9 to 2.4) cohorts. CONCLUSION: Our results provide no support for the conjecture that breast implants cause neurologic disease.

Risk of connective tissue disease and related disorders among women with breast implants: a nation-wide retrospective cohort study in Sweden.

OBJECTIVE: To examine the relation between connective tissue disease and related conditions and breast implants. DESIGN: Retrospective cohort study of all women in the Swedish national inpatient registry who underwent breast augmentation surgery with artificial implants during 1964-93, compared with women who underwent breast reduction surgery during the same period. SETTING: Sweden. SUBJECTS: 7442 women with implants for cosmetic reasons or for reconstruction after breast cancer surgery and 3353 women with breast reduction surgery. MAIN OUTCOME MEASURES: Subsequent hospitalisation for definite connective tissue diseases (rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, dermatomyositis, and Sjögren's syndrome) or related disorders. RESULTS: 29 women with implants were hospitalised for definite connective tissue disease compared with 25.5 expected based on general population rates (standardised hospitalisation ratio 1.1 (95% confidence interval 0.8 to 1.6)). There were no diagnoses of systemic sclerosis, and no significant excess in risk for polymyalgia rheumatica, fibromyalgia, and several related disorders. Among women who underwent breast reduction surgery, 14 were hospitalised for definite connective tissue disease compared with 10.5 expected (standardised hospitalisation ratio 1.3 (0.7 to 2.2)). Compared with the breast reduction group, women with breast implants showed a slight reduction for all definite connective tissue disease (relative risk 0.8 (95% confidence interval 0.5 to 1.4)). CONCLUSIONS: This large nationwide cohort study shows no evidence of association between breast implants and connective tissue disease.

Tendency to capsular contracture around smooth and textured gel-filled silicone mammary implants: a five-year follow-up.

The aim of this prospective, controlled clinical investigation was to compare the capsular contracture rate between silicone implants with a smooth and those with a textured surface. The implants were otherwise identical. Twenty-five women with bilateral mammary hypoplasia underwent augmentation mammoplasty. All received a textured implant on one side and a smooth implant on the other. Before surgery the patients were told that they could have the implants changed if the study showed that one type was better than the other. The investigation was conducted with the double-blind technique, with the code broken 1 year after surgery. At 1-year follow-up (reported previously) three parameters were used to estimate the tendency to capsular contracture: (1) the patient's opinion on differences in hardness of the breasts, (2) the investigators' classification of capsular contracture, and (3) applanation tonometry. All parameters showed unequivocally that the breasts augmented with textured implants had a lower tendency to develop capsular contracture than those with smooth implants. Five years after surgery 17 patients had had their smooth implant changed to a textured one because of hardness. Only one of the textured implants had been removed. A comparison between the 1-year and 5-year tonometric results of the 24 breasts that still had the original textured implants showed that after 5 years, a small but statistically significant increase in hardness had occurred compared with that after 1 year.

Long-term results of anterior levatorplasty for fecal incontinence. A retrospective study.

PURPOSE: To review the long-term results of anterior levatorplasty for fecal incontinence. METHODS: Fifty-four women with obstetric trauma and 31 with idiopathic incontinence responded to a questionnaire 1.5 to 18.5 (median, 8.5) years after anterior levatorplasty. Results were classified as excellent, good, fair, or poor. RESULTS: An excellent or good result was reported in 40 of 54 (74 percent) patients with an obstetric injury and in 14 of 31 (45 percent) patients in the idiopathic group (P < 0.01). The presence of a cloaca (P < 0.05) and a young age (P < 0.05) were associated with a favorable outcome in the obstetric and idiopathic group, respectively. Length of follow-up and preoperative severity of incontinence were not significantly related to outcome. CONCLUSIONS: This study suggests that every second patient undergoing anterior levatorplasty for fecal incontinence has a successful result that is sustained in the long term. Obstetric trauma, presence of a cloaca, and young age are associated with a successful outcome.

A clinical comparison of the tendency to capsular contracture between smooth and textured gel-filled silicone mammary implants.

The aim of this prospective, controlled clinical investigation was to find out if there is a difference in the capsular contracture rate between silicone implants with a smooth or textured surface as the only difference. Twenty-five women with bilateral mammary hypoplasia underwent mammary augmentation. All got a textured implant on one side and a smooth implant on the other. The implants were placed subglandularly. Follow-up examinations were done on six occasions. Three parameters were used for estimation of the tendency to capsular contracture: (1) the patient's opinion on differences in hardness of the breasts, (2) the investigator's classification of capsular contracture, and (3) applanation tonometry. At the end of the follow-up period, after 1 year, all parameters showed with no doubt that the breasts augmented with textured implants had a lower tendency to develop contracting capsules than the breasts augmented with smooth implants.

Free autogenous muscle transplantation in children. Long-term results.

For more than 15 years we have been using free muscle transplantation in the treatment of anal incontinence in children. This method implies transposition of a striated muscle, usually the palmaris longus, two weeks after denervation, to the perirectal area as a U-sling around the rectum corresponding to the location of the so-called puborectalis muscle. We have now evaluated the long-term results in all 26 children operated on by this method. Before the operation all children were totally incontinent after a primary repair. At follow-up after an average of 11 years and 4 months, 60% of the cases were regarded as good, 16% as fair, 8% as improved and 16% as failures. In our opinion, free muscle transplantation offers a good chance of achieving acceptable continence in a majority of incontinent children.

Origin and relationship between different cell types in malignant fibrous histiocytoma.

The derivation of histiocyte-like cells in malignant fibrous histiocytoma (MFH) has been a matter of debate. To shed light on this problem two cell lines from two subsequent recurrencies of MFH were established. The existence of two different cell populations, mainly fibroblast-like in the first cell line and mainly histiocyte-like in the second, was shown by light and electron microscopy, DNA measurements, and karyotype analysis. By detailed banding analysis and identification of several identical chromosomal marker types in the two cell lines, it was proven that they originally derived from the same single cell or single clone. Because the first cell line, with mainly fibroblast-like cells, was in the hypotriploid region and the second, with mainly histiocyte-like cells, was in the penta-hexaploid region, the data explained the appearance of histiocyte-like cells in MFH as a consequence of chromosomal progression.

Malignant, locally recurring cystosarcoma phyllodes in an adolescent female. A case report.

A 16-year-old girl presented with a large and rapidly growing cystosarcoma phyllodes in her right breast. The excised tumour showed unequivocal malignant characteristics at light and electron microscopy and was oestrogen-receptor negative. After repeated early local recurrences, a subcutaneous mastectomy ultimately led to local tumour control and the patient is now disease free 5.5 years after diagnosis.

Urinary incontinence in children: treatment with free autogenous muscle transplantation.

Free autogenous muscle transplantation has now been carried out in 13 patients with anal incontinence and 16 patients with urinary incontinence. In anal incontinence the results have been excellent; all patients were improved and 12 out of 13 reached an acceptable level of continence. In 10 patients with urinary incontinence the results were good, with increase of functional bladder capacity and abandonment of nappies during the day. Two patients were improved and 4 were failures. Cinematographic studies in both anal and urinary incontinence clearly demonstrated the muscular activity of the transplants and confirmed the existence of a reinnervation process. The longest postoperative observation time is now 7-years in the anal patients and 6 years in the urinary patients.

Cross-face nerve grafting followed by free muscle transplantation in young patients with long-standing facial paralysis. Reanimation of the cheek and the angle of the mouth.

For reanimation of the cheek in 8 young patients with long-standing facial palsy a method with cross-face nerve grafting followed by free muscle transplantation has been used. The sural nerve was used as nerve graft and placed in a subcutaneous tunnel across the face. In the normal cheek 3-4 fascicles of the nerve were anastomosed to facial nerve branches innervating muscles elevating the angle of the mouth. Four to 13 months later the extensor digitorum brevis muscle to the second toe or the palmaris longus was transplanted to the paralysed cheek. It was attached between the zygomatic arch and the angle of the mouth. The end of the nerve was sutured to the muscle after taking a biopsy. The follow-up period has been 7-30 months. At 7 months 6 patients had positive EMG, either on voluntary movement or on stimulation of the contralateral facial nerve. Three of them had also a slight movement in the cheek. Two patients are as yet only 7 months postoperative. In the remaining two cases, No. 2 and 4, there were no signs of reinnervation. At 18 months 4 out of 6 patients had a synchronous natural contraction in the cheek giving increased balance to the mouth. These patients had a positive EMG. In patients No. 2 and 4 there was neither innervation nor improvement. At 30 months there was additional improvement in two cases but as previously in patients No. 2 and 4 there was neither improvement nor signs of innervation of the muscle on the EMG. The other 4 patients have not reached this postoperative stage.(ABSTRACT TRUNCATED AT 250 WORDS)

Further experience of free muscle transplantation in children with urinary incontinence.

Sixteen patients, 10 boys and 6 girls with severe urinary incontinence due to congenital malformations, were treated by free autogenous muscle transplantation. The mean follow-up period was 2.3 years. In 10 patients the results were good, implying increase in functional bladder capacity and abandoning of napkins during the day. Two patients were improved and 4 were failures. The earliest signs of improvement appeared 2 to 6 months after surgery. Most patients showed further improvement for at least 2 years post-operatively. Cine studies of micturition clearly showed activity of the transplant, most patients with good results being able to interrupt completely the urinary stream at will. Seven patients exhibited normal urinary flow post-operatively. In 5 patients the maximal urinary flow was around the lower normal limit, in two because of detrusor-sphincter dyssynergia. In boys, erection was unimpaired post-operatively. The prognosis seems to be better in girls than in boys, especially when comparing cases of epispadias. Patients with no sign of improvement during the first 6 months post-operatively had a poor prognosis. A relatively large bladder capacity before operation is advantageous, but not a prerequisite for continence, as bladder capacity can develop after transplantation. The ideal age for transplantation is 5 to 6 years.

Freely transplanted peroneus longus muscle in the cat reinnervated by a single nerve: physiological properties.

Physiological properties (tetanic tension, single twitch, fatigability) of free autologous muscle transplants in cats were examined in vivo five months after transplantation. After 2 weeks denervation the peroneus longus muscle was placed isometrically in the abdomen with the omentum around the muscle and with the proximal end of a cut branch of the femoral nerve attached to the muscle. (In one case a sensory nerve was used.) Five months after transplantation the function of the muscle was controlled in vivo by nerve stimulation. In the case when a sensory nerve was connected to the muscle no contraction was obtained upon indirect or direct stimulation. All the other muscles contracted when the nerve was stimulated. The mean maximum tetanic tension was 16% of the mean for the control. The twitch-time was about the same as in the control muscle but the contraction time was longer and the half relaxation time shorter compared with the control. The transplanted muscles fatigued more slowly than the normal peroneus longus muscles. In spite of the unphysiological placement of the muscles in the abdomen where they have no natural function to fulfil, they became reinnervated and contracted as late as five months after transplantation.

The effect of split skin allografts on wound epithelialization from autologous patch grafts. An experimental study in rabbits.

To compare the healing time of standardized wounds partly covered with autologous patch skin grafts, and wounds totally covered with a combination of allografts and autologous patch grafts 10 rabbits, each with two standardized wounds, were used. On each rabbit one wound was partially transplanted with 6 autologous patch grafts 9 mm in diameter. The patches covered 6% of the wound area. The second wound was covered with a rabbit skin allograft with six holes 7 mm in diameter. In these holes 6 autologous patch grafts, 9 mm in diameter were placed (intermingled transplantation of auto- and allografts). The average healing time for the ten wounds treated with autografts only was 39.8 days and for the wounds covered with auto- and allografts 21.6 days. This shows that the same amount of autologous skin epithelialized a wound area about 17 times larger than itself nearly twice as fast if the wound surface between the autografts was covered with allografts than if it was protected by a dressing only.