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Plastic surgeons' primary responsibility to patients is to inform them sufficiently to permit them to make the necessary decisions in the manner that best meets their own objectives. This makes adequate consultation a lengthy and often confusing experience for patients. One of the most confusing of these is also one of the most mandatory for discussion; that is, the issue of implant fill volume. A patient should be free to choose between an implant that must be overfilled to achieve the optimum, and one in which reaching the optimum does not require overfill or even staying within the manufacturers suboptimal fill volume. The patient must be explicitly informed of the consequences of each of these decisions and should be prepared to sign whichever consents are necessary to reflect her understanding of the compromises involved in any of these choices.

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Since its invention in 1991, the transumbilical breast augmentation (TUBA) technique has gained popularity, and it has been proven safe and effective. In addition, the technique has several advantages over other methods of breast augmentation. Nevertheless, the method has often been the subject of a great variety of criticisms. Careful examination of those criticisms reveals that most are, in fact, untrue; they are misconceptions at best and falsehoods at worst. In this article, the author examines the 20 most common misconceptions about this procedure, clarifies or corrects them as appropriate, and suggests possible reasons for their having arisen in the first place. In addition, the actual drawbacks of the technique are reviewed. The author also outlines what he considers to be the criteria necessary for a surgeon to criticize any technique being used successfully by others: the surgeon must have proper plastic surgical training and certification, have completed training in the specific technique, and have a personal experience with performing a minimum number of cases.

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This report deals with the question of performing mammography routinely after implant breast reconstruction. Mammography cannot be performed on the mastectomy flaps unless reconstruction is done. Successful mammography in this situation does require special techniques. The most probable location for a local recurrence is anterior to, rather than behind, an implant. Since only 6 to 10 percent of mastectomy patients would be expected to develop a local recurrence and only a small proportion of these would be nonpalpable, the yield of routine mammography could not be expected to be high. Three patients are presented whose occult local recurrences were detected by routine surveillance mammography. The author's opinion is that mammography should be a part of the standard follow-up care of breast reconstruction patients, particularly those whose original tumor contained microcalcifications.

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BACKGROUND: This retrospective study compared psychosocial adjustment, body image, and sexual function in women who had either breast conservation or reconstruction for early stage disease. METHODS: Questionnaires were completed at a mean of 4 years after surgery by 72 women who had partial mastectomy and 146 women who had immediate breast reconstruction after mastectomy. RESULTS: In general, fewer than 20% of women reported poor adjustment on the domains measured. The two groups did not differ in overall psychosocial adjustment to illness, body image, or satisfaction with relationships or sexual life. There was a specific advantage of partial mastectomy over breast reconstruction in terms of maintaining pleasure and frequency of breast caressing during sexual activity. Women who had undergone chemotherapy had more sexual dysfunction, poorer body image, and more psychological distress. Hormonal therapy and radiation therapy, however, did not measurably affect quality of life. Factors predictive of greater psychosocial distress included a troubled marriage, a poor body image, sexual dissatisfaction, less education, and treatment with chemotherapy. CONCLUSIONS: The choice of local treatment had little psychosexual impact, whereas chemotherapy was associated with long term impairments.

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This report presents seven women with breast implants who experienced systemic symptoms which resolved rapidly after implant removal. A hypothesis is that these symptoms (which have been labeled "silicone poisoning" or "silicone adjuvant disease") may actually be caused by periprosthetic bacteria which have generally been considered innocuous, e.g., Staphylococcus epidermidis. In these cases, systemic symptoms such as malaise, fatigue, diarrhea, muscle aches, and arthralgia rapidly resolved after an antibacterial regimen plus implant removal without capsulectomy. Of cultures taken by swab in four patients, all were positive; of those taken by irrigation in three patients, one was positive. I believe that these patients' symptoms were real and offer the hypothesis that treatment of periprosthetic bacteria might explain rapid clinical improvement following explantation.

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Until the development of implant endoscopy, the only method available to evaluate silicone-gel breast implants accurately for silicone leaks involved making a wide incision and visually inspecting the implant. Endoscopic magnification, however, allows an accurate diagnosis to be achieved rapidly and safely by using a tiny incision that does not endanger the implant. As breast implant endoscopy becomes more common, perioperative nurses should be able to discuss the procedure with patients. The information provided in this article is intended to educate nurses on the procedure and prepare them to counsel patients undergoing the procedure.

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The effect of radiation therapy on the final result of breast reconstruction has been debated in the literature. We have had 4 patients with bilateral breast reconstruction who then received unilateral radiation therapy. We noted in all 4 that the irradiated side became contracted, whereas the nonradiated breast reconstruction remained soft. These 4 patients were compared with the bilateral breast reconstruction not receiving radiation therapy. The contracture rate in this control group was 10% (19 of 190 breasts). The difference in contracture rate between these two groups was significant (p = 0.05). A second group of patients was reviewed, unilateral reconstruction patients receiving radiation therapy to the reconstructed breast. This group was compared with bilateral reconstructions not receiving radiation therapy as a control group. The contracture rate in the unilateral reconstruction group receiving radiation therapy was 67% (7 of 11), versus the control of 10%. This difference is also significant (p = 0.001). We conclude that radiation therapy of prosthetic breast reconstruction does increase the rate of capsular contracture. Therefore, we counsel our implant reconstruction patients that the risk of capsular contracture is increased if subsequent radiation therapy is required.

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The treatment of potentially curable carcinoma of the breast has changed from one operation, radical mastectomy, to a flexible approach. At the Cleveland Clinic, we use four types of treatment for primary potentially curable carcinoma of the breast (Stages 0, I and II)--modified radical mastectomy, simple mastectomy, partial mastectomy with postoperative adjuvant radiation therapy and partial mastectomy without radiation therapy. The latter treatment (partial mastectomy without adjuvant radiation) is controversial. We recommend this procedure for patients with T(is) and T1 carcinomas that appear to be localized, without lymph node metastases, Stages 0 and I disease. The overall and disease-free survival rates are similar to those of patients having modified radical or partial mastectomy with radiation. Local recurrence is slightly higher at five years (11.0 percent) as compared with the other procedures, but at ten years, is only 16.1 percent, a figure comparable with patients having partial mastectomy with radiation (14.4 percent). For patients with Stages 0 and I carcinoma of the breast, the addition of postoperative radiation therapy after partial mastectomy seems to be unnecessary.

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This report outlines a simple clinical test for detection of a ruptured smooth, predominantly gel breast implant in a noncontracted capsule. The test is rapid and extremely simple to perform and has been used by me since 1979. Approximately 630 patients meeting these criteria have been examined with this method, many annually. Five ruptured implants were detected, and there were no false-positive results. There also were no false-negative results, although only 72 patients had surgical confirmation of implant integrity. The radiographic measures helpful for detecting a ruptured gel implant are also discussed. In this series, the clinical test was more accurate than mammography for detecting implant rupture in the absence of capsular contracture.

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Clinical use of breast endoscopy was begun 5 years ago for the purpose of internal endoscopic capsulotomy. This limited role for the endoscope has been entirely displaced by its use for inspection of implants for leaks or rupture. The materials and equipment are readily available, the proper techniques are safe for patient and implant, the method is easily learned, and the evaluation has been reliable. This report describes our first 50 breast endoscopies and details the technique and the means of learning it. The accuracy is far superior to that of mammogram or ultrasound, and to date, there have been no infections or damaged implants from the technique as described.

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Immediate breast reconstruction at the time of mastectomy, whether it involves prosthetic implantation or a myocutaneous flap procedure, has become a standard option for the care of breast cancer patients. The advantages of breast reconstruction are well understood: it helps to eliminate many of the psychological burdens with which mastectomy patients must contend and allows patients to participate in a normal lifestyle. Immediate breast reconstruction eases much of the initial psychological trauma of mastectomy. For patients who require postoperative radiation, reconstruction is often far less complex if done immediately than if delayed, even though radiation increases the chances of capsular contracture. The knowledge that immediate breast reconstruction is available may reduce patient's reluctance to seek medical advice when they find a breast lump.

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Melanomas may first present as nodal metastasis. Most of these cases have a discernible primary source. A proportion of these, however, have no apparent primary. A very few patients in this latter group actually have an identifiable primary source that regressed and disappeared. There is a set of stringent clinical and histologic criteria that must be met before a melanoma can be classified as complete spontaneous regression, and only 24 cases in the literature meet all these criteria. This report reviews those cases and presents the first report to provide sequential photographic documentation of a complete spontaneous regression of a cutaneous malignant melanoma. It also gives a 10-year follow-up, the longest in the literature.

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To evaluate the factors leading to success in immediate breast reconstruction after mastectomy, 176 consecutive immediate reconstructions done with implants or expanders over a 5-year period were analyzed. None of these 176 had "complete muscle coverage." There were only five failures: four with implant loss (one involving radiation) and one removed electively. The failures were 1 in 40 regular implants, 4 in 77 temporary expanders, and 0 in 59 long-term expanders. There is no other report in the literature comparing these different types of implants. Various hypotheses for failure are reviewed. It is concluded that failure in immediate reconstruction is not related to use of drains, bilaterality, or lack of "complete muscle coverage." It is concluded that failure is related to implant type, prior radiation, and most of all to suboptimal patient selection. Specific selection criteria and operative techniques are discussed.

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