The Gerszten and Gerszten review of silicone implants and their impact on cancer patients is quite thorough. It certainly is true that in the majority of patients, silicone implants have little or no adverse affect, particularly with regard to autoimmune disease, cancer detection, and carcino- genesis. However, over the 30-year history of silicone implants, many different types of silicone have been used. The implants differ with regard to manufacturer, fill (some are filled purely with silicone and some with silicone and saline in two different pockets within the implant), shell composition, and thickness, as well as where they are implanted (subglandular or submuscular). These differences may account for some of the variability seen in the data on silicone implants.
Restrictions on the Use of Silicone
Since the 1992 FDA moratorium, the use of silicone implants in the United States has been restricted to women undergoing breast reconstruction after mastectomy and those requiring secondary surgery after breast augmentation. Patients receiving silicone implants must also be included in an ongoing study undertaken by the manufacturer in conjunction with the FDA. Initial breast augmentation procedures must be performed using saline, not silicone, implants.
There is certainly no evidence that silicone exacerbates an existing cancer or causes cancer itself. The initial conclusion is that there is no reason to avoid the use of silicone implants in patients for whom they are deemed necessary. However, one must ask whether silicone implants offer any particular advantage over saline implants. The primary value of silicone implants is that their texture or feel is more natural than that of saline implants. Silicone implants also cause less rippling of the skin, although if immediate reconstruction is performed with skin-sparing mastectomy, the skin shapes more naturally, thus avoiding any rippling.
Problems Associated With Implants
The main reason to avoid the use of silicone implants is that if the implant ruptures, silicone infiltrates the soft tissue and causes an extensive inflammatory reaction with granulation tissue that feels very much like a cancer recurrence. Silicone granules can also travel to the nodes, making them feel hard as well. Finally, such granulation can be difficult to remove (particularly when the majority of the soft tissue is gone), and the removal process may cause damage to the skin. The newer saline and silicone implants have thicker shells and better valves and, thus, should have lower rupture rates.
The issue of capsular contracture poses another significant problem. The authors correctly point out that the degree of a contracture can range from asymptomatic to severe.[1-3] Contractures are also much more common in patients undergoing mastectomy and reconstruction than in those undergoing breast augmentation, as the authors note. The capsular contracture rate may be as high as 30% in mastectomy patients, leading to the issue of the use of autologous tissue rather than an implant for reconstruction.
Autologous Tissue for Reconstruction
Although the initial surgical recovery time may be longer, a transverse rectus abdominus muscle (TRAM) flap can be completed in one stage by an experienced plastic surgeon, a 3- to 5-day hospital stay is required; however, no trips to the office to fill the implant are necessary. In the hands of a good plastic surgeon, TRAM flap reconstruction is extremely reliable, and the cosmetic outcome can nearly always be guaranteed, which is not the case for implants. It is not possible to predict who will have a reasonable outcome and who will have significant contractures that require revisions and capsulectomy.
Furthermore, a careful comparison of the cost of the TRAM flap and implant reconstruction suggests that the TRAM flap is not more expensive in the long term after one factors in all of the follow-up procedures. Lastly, TRAM flap reconstruction is much more natural; it enlarges when the patient gains weight and shrinks when the patient loses weight, therefore preserving symmetry. Most importantly, it does not preclude the option of radiation therapy. If one radiates an implant that does not have autologous tissue on top of it, such as a latissimus flap, it will almost invariably contract significantly, which is painful and disfiguring. If a latissimus flap is used in conjunction with an implant, even if a contracture develops, a capsulectomy can still be performed and the contracture often will not recur.
Strategies forAvoiding Contractures
Patients with long-standing implants tend to develop fewer problems if they undergo breast conservation followed by radiation therapy. However, the authors correctly point out that contractures are a major complication, and although they do not always compromise the cosmetic result, they can be painful and require capsulectomy. Certainly, a patient who undergoes breast conservation and has a poor cosmetic result can still have a tissue-flap reconstruction (either a latissimus or TRAM flap) with a good cosmetic result. Therefore, the patient who would like to avoid a mastectomy could try the simpler procedure, since all patients do not have a poor cosmetic outcome.
Patients with previously existing implants placed submuscularly have fewer contractures than those with implants placed subglandularly. However, the majority of patients who have had implants prior to receiving radiation therapy will require additional surgical procedures, such as capsulectomy and implant exchange, following radiation therapy.
We agree with the authors that, for patients with silicone implants, there is no oncologic reason or indication to remove them unless they produce symptoms or rupture. Patients who develop cancer in the presence of previously placed implants are not precluded from undergoing breast-conservation therapy, but must be aware of the significant likelihood of capsular contracture. Tissue flap reconstruction is an excellent salvage procedure. Given the safety of saline implants, there is no advantage to a silicone over a saline implant. For a patient undergoing mastectomy, silicone implants have a significantly higher rate of contracture than saline implants. Autologous tissue reconstructions avoid these problems.