J. J. Hage

Pathology of silicone leakage from breast implants.

Silicone breast prostheses have been widely used for several decades. Until recently, about 150 000 women received these implants annually in the United States—80% for breast augmentation and the others almost exclusively for reconstruction after cancer surgery. There is little doubt about the beneficial psychological eVects of breast implants, but there is increasing awareness of alleged adverse eVects of implants containing silicone. These mainly concern local reactions to silicone “sweating” from the implants (gel bleed) and frank rupture, but silicone leakage has also been associated with locoregional eVects such as histiocytic necrotising lymphadenitis and with systemic disorders such as autoimmune and connective tissue diseases. These side eVects have led to discussion about whether silicone breast implants should be removed from the market. 2 In this leader we review the specific pathological locoregional aspects of (leakage from) silicone breast implants. It is beyond the scope of this paper to discuss the pathology of silicone leakage in other parts of the body.

Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility.

The surgical aim of genital reassignment surgery in male-to-female transsexuals is to create a perineogenital complex as feminine in appearance and function as possible. In this paper, we present a review of the various methods to line the neovagina in male-to-female transsexuals. These methods may be classified in five categories involving, respectively, application of nongenital skin grafts, penile skin grafts, penile skin flaps, nongenital skin flaps, and pedicled intestinal transplants. Based on this review and our extensive personal experience, we come to certain recommendations regarding the eligibility of these methods.

Fibula free flap phalloplasty: Modifications and recommendations

Radial forearm flap phalloplasty should be regarded as the gold standard. The large forearm donor site scar, however, has led to the search for other donor areas. We present our modifications and recommendations for addressing the ideal goals of phalloplasty better when applying the fibula free flap. We recommend preconstruction and secondary anastomosis of the neo‐urethra. Preoperative infiltration of the cutaneous nerve is recommended for planning of the sensate flap. The osseous part of the flap should be long enough to be fixed to the tunica albuginea. We recommend a longitudinal, rather than a transverse, design for the flap. For aesthetic reasons, the flap should include two triangular tongues. Even so, secondary surgery will be needed. The patient may be left with functional loss in the donor region. A case report illustrates all of these points. We conclude that the sensate fibula free flap has a place in phalloplasty in case the patient refuses a forearm scar.

Augmentation mammaplasty in male-to-female transsexuals.

Hormonal therapy and gender-confirming surgery are the treatments of choice in appropriately selected male-to-female transsexuals. Penectomy and vaginoplasty are the paramount surgical requests of the male transsexual, but breast enlargement greatly increases subjective feelings of femininity. There are only limited reports on augmentation mammaplasty in male transsexuals, and hardly any attention has been paid to the differences between the female mammary anatomy and its male counterpart. The basic anatomic and surgical considerations of augmentation mammaplasty for 201 male-to-female transsexuals who were operated on from 1979 to 1997 are reviewed and discussed. They include the differences between male and female anatomy and how to feminize the male chest, the results of hormonal therapy and the proper timing of surgery, the choice of implant size and surgical approach, the results that may be expected after surgery, and the implications of all mentioned on the long-term outcome and follow-up after augmentation mammaplasty. Because the referring doctor may not check on the breasts or may not be trained to examine augmented breasts for pathologic conditions, the mammaplastic surgeon has an obligation to ensure the proper follow-up of these patients.

Three-dimensional video analysis of forearm rotation before and after combined pronator teres rerouting and flexor carpi ulnaris tendon transfer surgery in patients with cerebral palsy.

The effect of combined pronator teres rerouting and flexor carpi ulnaris transfer on forearm rotation was prospectively studied by comparison of pre- and postoperative three-dimensional analysis of forearm range of motion in ten patients with cerebral palsy. One year postoperatively, surgery had improved maximal supination of the forearm in all patients by an average of 63°, but there was also a mean loss of 40° pronation. Forearm range of motion increased by a mean of 23°. The centre of the range of motion on average shifted 52° in the direction of supination. Based on these results of objective forearm range of motion analysis, we conclude that the common combination of pronator teres rerouting and flexor carpi ulnaris transfer in patients with cerebral palsy effectively facilitates active supination but impairs active pronation.

Augmentation mammaplasty: the story before the silicone bag prosthesis.

Czerny from Heidelberg is generally accepted to have performed the first augmentation mammaplasty in 1895. Since then, a variety of nonsilicone materials have been injected or implanted to augment or to reconstruct the hypoplastic female breast, including autologous tissues, intramammary- or submammary-injected alloplastic materials, and preformed alloplastic materials other than silicone. For various reasons outlined in this review, none was fully acceptable. The introduction of the medical-grade silicone bag prosthesis in the early 1960s improved the results of mammary augmentation dramatically and reduced the incidence of fibrous contracture and implant extrusion. Other methods of breast augmentation became obsolete.

Exceptional presenting conditions and outcome of augmentation mammaplasty in male-to-female transsexuals.

Driven by a persistent and unchangeable need to undo the discrepancy between reality of the body and gender of the mind, most male-to-female transsexuals seek physical feminization through hormonal and surgical treatment. The authors report some rare presenting conditions and exceptional results of augmentation mammaplasty in 11 male-to-female transsexuals treated between January 1979 and January 1998, as well as describe how to treat these conditions. In patients in whom gynecomastia was treated previously, the remaining subcutaneous fatty tissue may be insufficient to cover the implants safely, and subpectoral implantation should be considered. Augmentation after unilateral correction of gynecomastia requires different sizes of implants. Although exceptional in male-to-female transsexuals, mastopexy is the treatment of choice to correct any mammary ptosis, but the patient may request augmentation mammaplasty to fill out the breasts. Previous stacking mammaplasty may have been performed subglandularly, subpectorally, or both. Stacking may not have been noticed prior to corrective surgery. Extrusion of the implant may be associated with avascular necrosis or infection, but also with the use of high concentrations of steroid placed within the lumen of fluid-filled implants. The correction involves removal of the implant, with skin graft or flap reconstruction of the affected area. Replacement of the implant may have to be delayed. Symmastia results from overzealous medial dissection coupled with overaugmentation. Combined restoration of the presternal subcutaneous integrity, and medial closure of the pocket by subcutaneous approach only, leads to satisfactory reconstruction of the presternal median cleavage. Galactorrhea may be the result of hyperprolactemia but is more often caused by stimulation of the intercostal nerve by the implants.

Life span of silicone gel-filled mammary prostheses.

&NA; The discussion on possible side effects of implanted silicone has resulted in a growing number of patients inquiring whether or not their mammary prostheses are intact and when failure of the prostheses is to be expected. Between November 1988 and May 1995, 182 patients had their silicone mammary prostheses replaced, repositioned, or removed one to three times. Capsular contraction, dislocation, pain paresthesia, and/or suspected rupture were common indications for surgery. To try and be able to provide an indication as to the correlation of implant age and integrity, we recorded the status of all 426 prostheses observed during secondary surgery. In this selected group of patients, approximately 50 percent of the mammary prostheses with an implant age of 7 to 10 years showed gel bleed or rupture. Applying the survival Kaplan‐Meier curve, 50 percent of implants may be expected to bleed or be ruptured at the age of 15 years. Rupture was observed more frequently than gel bleed. It seems that there is no chronologic relation between gel bleed and rupture. (Plast. Reconstr. Surg. 100: 1723, 1997.)

Validity of a structured method of selecting abstracts for a plastic surgical scientific meeting

In 1999, the European Association of Plastic Surgeons accepted a structured method to assess and select the abstracts that are submitted for its yearly scientific meeting. The two criteria used to evaluate whether such a selection method is accurate were reliability and validity. The authors previously established this method to be reliable on the basis of a prospective evaluation of the selection process used for the 2000 meeting of the European Association of Plastic Surgeons. It is more difficult to assess the validity of this method because there is no objective standard of quality of a scientific abstract against which the accuracy of selection can be assessed. This study statistically evaluated the accuracy of the meeting participants’ assessment of presentations made during the meeting as the criterion standard for abstract selection on the basis of data obtained from the 2002 selection process. The authors evaluated the interobserver repeatability among five meeting participants of selecting the best presentations, the validity of the method of abstract selection after this criterion standard had been established, and the validity of reviewers’ rating of abstracts as indicators of the scientific value of the actual presentations. The authors conclude that the assessment of platform presentations at a plastic surgical meeting is reliable. Accepting this assessment as the criterion standard, however, they could not prove the validity of their selection method or the validity of the reviewers’ rating of abstracts as an indicator of the scientific value of the actual presentations.

RUPTURE OF SILICONE GEL FILLED TESTICULAR PROSTHESIS: CAUSES, DIAGNOSTIC MODALITIES AND TREATMENT OF A RARE EVENT

PURPOSEnRupture of the envelope of silicone gel filled testicular prostheses is rare and alleged to be unlikely without intraoperative needle puncture. We observed that it may be caused by chronic intermittent trauma or a single acute increase of pressure, and report diagnostic and therapeutic modalities.nnnMATERIALS AND METHODSnFour cases treated by us during the last 10 years are presented. One patient had testicular implants for Klinefelters syndrome, whereas the other 3 had been treated for female-to-male transsexualism. Diagnosis was confirmed by ultrasonography and magnetic resonance imaging. The fibrous capsule surrounding the ruptured prosthesis was left intact to allow en bloc surgical extirpation. Histological evaluation of the resected specimen was performed.nnnRESULTSnRupture of silicone gel filled testicular implants may be caused by acute or chronic pressure without intraoperative needle puncture.nnnCONCLUSIONSnMagnetic resonance imaging offers superior diagnostic accuracy and should be regarded the gold standard in the evaluation of implant rupture. Ultrasonography is an acceptable alternative. In cases when gross symptoms of scrotal inflammation are lacking replacement of implants is facilitated by the fibrous capsule that forms around any prosthesis. Transcapsular migration of silicone particles was observed even when the fibrous capsule was intact.