Extracorporeal shock wave treatment of capsular fibrosis after mammary augmentation - Preliminary results.

Extracorporeal shock wave therapy has undergone continuous development and has become a well-established therapy option both in urology and in orthopaedics/trauma surgery. Experimental and clinical studies have proved the effectiveness of extracorporeal shock wave therapy in the treatment of connective tissue diseases such as fibromatosis. The pathomechanism of capsular fibrosis after augmentation of the female breast with silicone implants presents a series of analogies with mechanisms that are generally recognised to be associated with fibroproliferative diseases. The starting point of the disease is the inflammatory reaction caused by the silicone and/or by the sub-clinical bacterial contamination of the implant surface and can create an inflammatory reaction and fibrosis. A total of 19 cases of capsular fibrosis in 12 patients following insertion of mammary implants were treated with extracorporeal shock wave therapy. The therapy was performed with the Duolith SD1 system manufactured by Storz Medical. Shock waves were applied with the C-Actor handpiece designed for planar shock waves. Extracorporeal shock wave therapy appears to be a non-invasive, well-tolerated and easy-to-use procedure for pain reduction and fibrotic tissue softening, especially after aesthetic breast implant augmentation.

Brava and autologous fat transfer is a safe and effective breast augmentation alternative: results of a 6-year, 81-patient, prospective multicenter study.

BACKGROUND: Breast augmentation by autologous fat transfer is an appealing alternative in need of scientific validation. METHODS: In a prospective multicenter study, 81 women (age range, 17 to 63 years) wore the Brava device, a bra-like vacuum-based external tissue expander, for 4 weeks and then underwent autologous fat injection using 10 to 14 needle puncture sites into each breast in a three-dimensional fanning pattern (average, 277 ml volume injected per breast). Patients resumed Brava wear within 24 hours for 7 or more days. Pretreatment and posttreatment breast volumes were derived from three-dimensional volumetric reconstruction of magnetic resonance imaging scans, and outcomes were compared with a meta-analysis of six recent published reports on autologous fat transfer breast augmentation without expansion. Follow-up ranged from 12 months to 6 years (average, 3.7 years). RESULTS: Breast volume was unchanged between 3 and 6 months. Seventy-one of the treated women were compliant with Brava wear and had a mean augmentation volume at 12 months of 233 ml per breast compared with 134 ml per breast in published series without Brava (p < 0.00001). Graft survival was 82 ± 18 percent compared with 55 ± 18 percent without Brava (p < 0.00001). There was a strong linear correlation (R = 0.87) between pregrafting Brava expansion and the resultant breast augmentation. There were no suspicious breast masses or nodules. Magnetic resonance imaging recognized a 16 percent incidence of fat necrosis easily identified at 1-year mammographic evaluation. CONCLUSION: : The addition of Brava expansion before autologous fat grafting leads to significantly larger breast augmentations, with more fat graft placement, higher graft survival rates, and minimal graft necrosis or complications, demonstrating high safety and efficacy for the procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The blue-eyes stereotype: do eye color, pupil diameter, and scleral color affect attractiveness?

BACKGROUND: Blue eyes have been the embodiment of attractiveness not only for decades but even for centuries. The primary aim of this study was to determine whether iridal color, particularly color blue, can increase the attractiveness of a person's eye area. As a secondary aim, the study examined the impact of pupil diameter and scleral color on the attractiveness of the eye area. METHODS: The stimulus material comprised images of the eye areas of 60 women ages 15-65 years. A total of 80 participants rated the attractiveness of each eye area on a 7-point Likert scale and estimated the age of the person. The color values of the iris and sclera were measured. As an additional subsample, 50% of the participants were asked what features of each eye area they found particularly appealing. RESULTS: Most surprisingly, no correlation was found between iridal color and rated attractiveness. However, the participants mentioned the color blue more often as a positive aspect than other iridal colors. A high inverse correlation was observed between attractiveness of the eye area and age. The larger the pupil diameter and the whiter the scleral color, the lower was the real and perceived age and the higher was the attractiveness. CONCLUSION: The data showed that the "blue-eyes stereotype" does exist. People consider blue eyes attractive, but in reality, blue is rated as attractive as other iridal colors. Bright scleral color and large pupils positively affect attractiveness because both features are significantly correlated with youthfulness.

Quantifying female bodily attractiveness by a statistical analysis of body measurements.

BACKGROUND: To investigate what makes a female figure attractive, an extensive experiment was conducted using high-quality photographic stimulus material and several systematically varied figure parameters. The objective was to predict female bodily attractiveness by using figure measurements. METHODS: For generating stimulus material, a frontal-view photograph of a woman with normal body proportions was taken. Using morphing software, 243 variations of this photograph were produced by systematically manipulating the following features: weight, hip width, waist width, bust size, and leg length. More than 34,000 people participated in the web-based experiment and judged the attractiveness of the figures. All of the altered figures were measured (e.g., bust width, underbust width, waist width, hip width, and so on). Based on these measurements, ratios were calculated (e.g., waist-to-hip ratio). A multiple regression analysis was designed to predict the attractiveness rank of a figure by using figure measurements. RESULTS: The results show that the attractiveness of a woman's figure may be predicted by using her body measurements. The regression analysis explains a variance of 80 percent. Important predictors are bust-to-underbust ratio, bust-to-waist ratio, waist-to-hip ratio, and an androgyny index (an indicator of a typical female body). CONCLUSIONS: The study shows that the attractiveness of a female figure is the result of complex interactions of numerous factors. It affirms the importance of viewing the appearance of a bodily feature in the context of other bodily features when performing preoperative analysis. Based on the standardized beta-weights of the regression model, the relative importance of figure parameters in context of preoperative analysis is discussed.

Effect of tissue inhibitors of metalloproteinases and matrix metalloproteinases on capsular formation around smooth and textured silicone gel implants.

BACKGROUND: Capsular contracture is one of the most distressing complications after cosmetic breast augmentation. Evidence suggests that matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) may play a key role in the onset or progression of several fibrotic disorders. In this study we used quantitative reverse-transcription PCR methodology to profile the expression of TIMP-1, TIMP-2, MMP-2, and MMP-9 in the tissue of patients with capsular contracture after breast augmentation with smooth and textured silicone breast implants. METHODS: The study included 20 female patients (average age = 37 +/- 15 years) with capsular contracture after bilateral subglandular cosmetic breast augmentation with smooth silicone implants. Ten patients developed grade II capsule contracture, 8 grade III contracture, and 1 grade IV contracture. Twenty other female patients (average age = 41 +/- 9 years) with capsular contracture after breast augmentation with textured silicone implants were also included (Baker grade II = 10 patients, grade III = 8, grade IV = 2). Expression of mRNA in capsular tissue was calculated using a relative quantification method (Pfaffl). Statistical analysis was performed using the Mann-Whitney test. The level of significance was considered to be p < 0.05. RESULTS: The expression of MMP-2 was significantly increased in tissue of patients with textured implants and capsular contracture grades II and III/IV in comparison to grade I (p < 0.05). In comparison to grade I, the capsular tissue from patients with Baker II and III/IV fibrosis showed a significant increase for TIMP-1 and TIMP-2 (p < 0.05) in both smooth and textured silicone implants. The expression was significantly higher in tissue from patients with severe contracture (Baker III/IV) and smooth silicone implants compared with that in tissue from patients with textured implants (p < 0.05). CONCLUSION: The decrease in MMP-to-TIMP expression can cause increased synthesis and deposition of collagen surrounding alloplastic breast implants, leading to a profibrotic state. The higher expression of TIMPs in capsular tissue of patients with smooth silicone gel implants might be a reason for the observed higher rates of capsular contracture. In the future, a nonoperative treatment that decreases TIMPs but increases the activity of MMPs may be an appropriate therapy for patients with capsular contracture.

Flow cytometric analysis of peripheral blood lymphocyte subsets in patients with silicone breast implants.

BACKGROUND: As there is still controversy regarding the effects of silicone breast implants on the immune system, the current study investigated the composition of peripheral blood lymphocytes of patients after augmentation mammaplasty with silicone breast implants. METHODS: The authors' prospective study included 41 female patients (average age, 40 +/- 12 years) with unilateral/bilateral capsular contracture (Baker types I through IV) after cosmetic breast augmentation. Other fibrosing or autoimmunologic diseases were excluded at the time of implantation. Peripheral blood samples from all patients were examined (n = 41). Cells positive to antigens CD3, CD4, CD8, CD19, and CD16/CD56 were assessed by flow cytometric analysis and compared with a reference range of hematologically normal adults. RESULTS: The vast majority of the peripheral blood lymphocytes were T lymphocytes (CD3+; mean, 74.4 percent; range, 21.1 to 76.6 percent). The mean percentage of B lymphocytes (CD3-/CD19+) was 11.3 percent (range, 9.9 to 12.6 percent). A small percentage (mean, 11 percent; range, 9.1 to 12.9 percent) consisted of natural killer cells (CD3-/CD16+/CD56+). The peripheral blood T-lymphocyte subsets were CD3+/CD4+ with a mean of 45.7 percent (range, 42.9 to 48.5 percent) and CD3+/CD8+ with a mean of 22.1 percent (range, 19.8 to 24.3 percent), similar to those in healthy controls. CONCLUSIONS: No statistically significant difference in the distribution of peripheral blood lymphocytes could be detected in patients with silicone breast implants in comparison with other Caucasian adults. As far as lymphocytes are concerned, there was no evidence of systemic proinflammatory effects of silicone breast implants.

Psychological features in a german sample of female cosmetic surgery candidates.

BACKGROUND: Psychological processes are vitally important to understanding the rationale for cosmetic surgery. This study focused on three core psychological issues (self-esteem, body image, and psychopathology) in its investigation of patients undergoing cosmetic surgery preoperatively. Furthermore, it aimed to provide some data especially for a German sample of female cosmetic surgery patients concerning this subject. METHODS: A cross-sectional design was used to investigate and compare a sample of female cosmetic surgery candidates (n = 35) and a nonsurgical control group (n = 35) matched for central sociodemographic features (gender, region, confession) and controlled for age. These factors are known as covariates of body image. All psychological features were assessed by widely used self-report measures: the Rosenberg Self-Esteem Scale (RSES), the Evaluation of the Own Body Questionnaire (FBeK), and the Symptom Checklist 90 Revised (SCL 90-R). RESULTS: The results indicate no statistically significant differences between the two groups in any of the scores, except for the FBeK Accentuation of the Body subscale. CONCLUSIONS: According to the findings, this lack of evidence for group differences in general psychosocial scales corresponds widely to findings of other empirical studies.

Bacterial colonization is of major relevance for high-grade capsular contracture after augmentation mammaplasty.

Many studies indicate that subclinical bacterial colonization plays a pivotal role in capsular contracture. Nevertheless, it has not been clarified whether bacterial stimuli are only associated with high-grade (Baker III/IV) or low-grade (Baker I/II) capsular contractures. The study included 45 female patients suffering from unilateral capsular fibrosis following augmentation mammaplasty with silicone implants (smooth: n = 28; textured: n = 17). In total, there were 16 (35.6%) bacterially contaminated swabs. No significant difference could be detected between colonization rates of smooth (52.9%) and textured (25.0%) implants (z = 1.575, P = 0.115). Interestingly, no colonization was detected for Baker I/II contractures, but the colonization rate for Baker III/IV contractures amounted to 66.7%, showing a highly significant difference between the 2 groups (z = 4.351, P < 0.001). Our study shows significant differences in bacterial contamination rates between high-grade and low-grade capsular contractures. One might speculate that bacterial stimuli accelerate the process of inflammation and fibrosis in patients who tend to develop capsular fibrosis.

Clinical and morphological conditions in capsular contracture formed around silicone breast implants.

BACKGROUND: A study was performed to investigate histological changes in capsules formed around silicone breast implants and their correlation with the clinical classification of capsular contracture defined by the Baker score. For histological classification, the authors used the classification introduced by Wilflingseder, which identifies four grades of contracture. METHODS: The study included 24 female patients (average age, 40 +/- 12 years) with capsular contracture after bilateral cosmetic breast augmentation with smooth silicone gel implants (Mentor, Santa Barbara, Calif.). The Baker score was determined preoperatively for each patient. Samples of capsular tissue were obtained from all patients for histologic and immunohistochemical analyses. Capsular thickness, age of the collagen fibers, presence of synovia-like metaplasia on the inner surface of the capsule, number of histiocytes, giant cells, and other inflammatory cells, amount of silicone, foreign body granulomas, and capsule calcification were evaluated. RESULTS: There was a positive correlation between capsular thickness (p < 0.05) and Baker score. Silicone-containing deposits were found in all four histological capsule types. A trend toward greater capsular thickness was documented in patients with severe inflammatory reaction. These patients also had more clinical symptoms. Greater capsular thickness was associated with a higher number of silicone particles and silicone-loaded macrophages in the peri-implant capsule. CONCLUSIONS: The authors demonstrated a positive correlation (p < 0.05) between the clinical classification (Baker score I to IV) and the histological classification introduced by Wilflingseder (Wilflingseder score I to IV). An exact histological classification is needed to describe precisely the morphological changes in capsular contracture.

Modification of the second stage of auricular elevation in Nagata's technique for treating microtia.

The ultimate goal in treating congenital microtia is the reconstruction of an auricle with a natural appearance as close as possible to the healthy one in terms of shape, contour, size, texture, position, and projection. Here we present another option to the second stage of raising the ear in Nagata's technique for treating microtia. The first step includes implantation of a cartilaginous framework and transposition of the ear lobe. Raising the cartilage leaves a skin defect behind the auricle. Instead of using a superficial temporoparietal fascia flap as described by Nagata, we raise a simple rotation flap from the mastoid and neck to close the defect with a minimal scar. The advantages of this technique include firm elevation, good frontal projection, and a natural appearance of the auriculo-cephalic sulcus with a normal retroauricular hairline. In addition, the procedure fast and practical, creates no additional scars on the scalp, and preserves the superficial temporoparietal fascia.

Attractiveness of eyebrow position and shape in females depends on the age of the beholder.

BACKGROUND: Great diversity exists among individuals with respect to eyebrow position and shape, and the notion of an "ideal" eyebrow has changed quite significantly over the past several decades. METHODS: This study compared three different variations of eyebrows. One variation was the arched eyebrow with the maximum height in the middle. The other two variations had their maximum height in the lateral third, but differed in their position (high vs low). For each of the seven female portraits presented, three variations were generated using morphing software. A total of 357 subjects 12 to 85 years of age compared these variations and ranked each woman individually with respect to perceived attractiveness. RESULTS: The data show that the preference for a specific eyebrow shape depends on a person's age. Young subjects up to 30 years of age preferred eyebrows in a lower position, and ruled out arched eyebrows. Subjects older than 50 years stated exactly the opposite preference. CONCLUSION: First, there is not one single beauty ideal for eyebrows, but at least three. The ideal a person prefers depends on his or her age. Second, because trends are generally introduced by young people and not by older individuals, and the young tend to prefer eyebrows in a lower position, it seems plausible to assume that the trend currently appears to be moving away from arched eyebrows toward lower positioned eyebrows with a maximum height in the lateral third.

Surgical treatment of chronic phantom limb sensation and limb pain after lower limb amputation.

BACKGROUND: Therapy for phantom sensation and phantom limb pain following amputation is still difficult, because pathophysiologic mechanisms have not been clarified. This report illustrates a simple and useful surgical intervention. The authors propose that changes at the peripheral nerve site can influence the central feeling of phantom sensation and pain. METHODS: Fifteen patients (mean age, 56 years) with lower limb amputation were included in the study. In all patients, the sciatic nerve was split at a point approximately 3 cm proximal to the popliteal fossa, and the two parts were reconnected in a sling fashion using an epiperineurial technique under microscopic vision. The nerves were covered with a fibrin patch and anesthetics were applied by means of a local pain catheter. Frequency, duration, intensity, and quality of phantom pain were compared preoperatively and 1 week, 3 months, 6 months, and 1 year postoperatively. RESULTS: Fourteen of 15 patients defined the procedure as very helpful. Average, maximum, and minimum pain intensity were significantly reduced 1 week, 3 months, 6 months, and 1 year postoperatively (p < 0.001). Pain intensity scores decreased significantly over the long term after surgical intervention (median visual analogue scale score: preoperatively, 7; 1 year postoperatively, 4) (p < 0.001). The duration of pain attack shortened from approximately 120 minutes to 5 to 10 minutes. CONCLUSIONS: This study shows that accurate treatment of the peripheral nerve can help to successfully reduce phantom limb pain. The authors feel encouraged to perform future investigations to test their operative method in a prospective, randomized, matched control study including electrophysiologic tests for more objective pain assessment.

Determination of serum fibrosis indexes in patients with capsular contracture after augmentation with smooth silicone gel implants.

BACKGROUND: Several studies have confirmed a correlation between the concentration of serum hyaluronan and progressive fibrotic disorders such as liver cirrhosis. The aim of this study was to explore the relationship between serum hyaluronan levels and capsular contracture after aesthetic breast augmentation. METHODS: The study included 25 female patients (average age, 40 +/- 12 years) with capsular contracture after cosmetic breast augmentation with smooth silicone gel implants (Mentor, Santa Barbara, Calif.). The implants were placed in a submuscular position through an inframammary fold incision. The implant removals were prompted by development of capsular fibrosis (Baker grades I through IV). Samples of capsular tissue were obtained from all patients for standard histologic and immunohistochemical analysis. Blood samples were drawn from all patients immediately before operation. Sera from 20 healthy female patients (average age, 34 +/- 9 years) were used as control. RESULTS: : Capsular tissue revealed significantly higher thickness in patients with grade III/IV contracture than in women with grade II contracture, according to Baker's classification. There was a moderate (n = 15) or severe (n = 10) chronic inflammatory reaction in the capsules around the implants. Fibroblasts, fibroblast-like cells, and macrophages represented the major cell populations found within the fibrous capsules, along with scattered polymorphonuclear leukocytes, lymphocytes, plasma cells, and mast cells. In addition, activated CD4+ cells were detected. An inner layer with synovia-like metaplasia and multinucleated giant cells was found. There was a significantly higher level (p < 0.05) of hyaluronan serum concentration in patients with capsular contracture (26 +/- 14 microg/liter) compared with control subjects (12 +/- 6 microg/liter). There was a positive correlation between the grade of capsular contracture (Baker grades I through IV) and the hyaluronan serum concentration (Baker grade II, 15 +/- 3 microg/liter; Baker grade III, 34 +/- 13 microg/liter; Baker grade IV, 42 +/- 11 microg/liter) (r = 0.73; p < 0.05). CONCLUSIONS: Serum hyaluronan levels were significantly elevated in patients with capsular contracture after breast augmentation, and there was a positive correlation with stage of capsular contracture. Further study is necessary to determine whether hyaluronan might be useful as a predictor for the development and progress of capsular fibrosis.

Increased levels of transition metals in breast cancer tissue.

OBJECTIVES: High levels of transition metals such as iron, nickel, chromium, copper, and lead are closely related to free radical generation, lipid peroxidation, formation of DNA strand breaks, and tumor growth in cellular systems. In order to determine the correlation to malignant growth in humans, we investigated the accumulation of heavy metals in 20 breast cancer biopsies and compared the findings to the levels found in 8 healthy biopsies. METHODS: The concentration of transition metals in breast cancer and control biopsies was assessed by a standardized Atomic Absorption Spectrofotometry technique with acidic hydrolysis for sample preparation. Additionally, heavy metal analysis in control biopsies was also performed with an Inductive Coupled Plasma--Mass Spectroscopy technique. For statistical analysis of the results, the Mann-Whitney U Test was applied. RESULTS: A highly significant accumulation of iron (p<0.0001), nickel (p<0.00005), chromium (p<0.00005), zinc (p<0.00001), cadmium (p<0.005), mercury (p<0.005), and lead (p< 0.05) was found in the cancer samples when compared to the control group. Copper and silver showed no significant differences to the control group, whereas tin, gold, and palladium were not detectable in any biopsies. CONCLUSIONS: The data suggest that pathological accumulation of transition metals in breast tissue may be closely related to the malignant growth process.