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This systematic review and meta-analysis were undertaken to determine whether reduction mammaplasty improves measurable outcomes in women with breast hypertrophy. A systematic review of the literature in 5 languages from 1985 until March 1999 was performed, and data were compared for meta-analysis. Eligible studies were both experimental and observational and involved women with preoperative physical and/or psychosocial signs and symptoms who underwent reduction mammaplasty for breast hypertrophy. Outcomes assessed were postoperative physical signs and symptoms such as shoulder pain, shoulder (bra strap) grooving, and quality-of-life domains, such as physical and psychological functioning, and were expressed primarily as risk differences (RDs). Twenty-nine studies of 4173 patients met all eligibility criteria. Reduction mammaplasty was associated with a statistically significant improvement in physical signs and symptoms involving shoulder pain (RD, 0.71 [95% confidence interval (CI), 0.62-0.80]); shoulder grooving (RD, 0.69 [95% CI, 0.60-0.78]); upper/lower back pain (RD, 0.59 [95% CI, 0.48-0.70]); neck pain (RD, 0.50 [95% CI, 0.37-0.64]); intertrigo (RD, 0.44 [95% CI, 0.34-0.54]); breast pain (RD, 0.36 [95% CI, 0.17-0.55]); headache (RD, 0.28 [95% CI, 0.11-0.46]); and pain/numbness in the hands (RD, 0.11 [95% CI, 0.04-0.18]). The quality-of-life parameter of physical functioning was also statistically significant (RD, 0.58 [95% CI, 0.44-0.71]), while psychological functioning was not significant (RD, 0.46 [95% CI, 0.00-1.00]). The evidence suggests that women undergoing reduction mammaplasty for breast hypertrophy have significant postoperative improvement in preoperative signs and symptoms, quality of life, or both.

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The silicone breast implant controversy rages on. Recent work has demonstrated that normal or baseline breast tissue silicon levels in women who had had no prior exposure to any type of breast implant may be as high as 446 microg/gm of tissue. These data ranged from 4 to 446 microg/gm of tissue, with a median of 27.0 microg/gm of tissue. In addition, numerous other epidemiologic and rheumatologic studies have demonstrated no association between silicone breast implants and any connective-tissue diseases. Despite these reports, the use of silicone implants remains restricted. The present study measured breast and capsular tissue silicon levels from 23 breasts in 14 patients with saline implants, and from 42 breasts in 29 patients with silicone implants. No patient in the saline implant group presented with signs or symptoms of connective-tissue disease. Patients with silicone implants, however, were divided into three groups based on the presence or absence of signs or symptoms of connective-tissue disease: group I, no symptoms or signs; group II, + symptoms, no signs; and group III, + symptoms, + signs. Six patients in group III were diagnosed with a specific connective-tissue disease, including systemic lupus erythematosus, rheumatoid arthritis, or scleroderma. The most common indications for implant removal or exchange were capsular contracture and implant rupture, although 41 percent of patients with silicone implants expressed media-related concern over the implant issue. The most common symptoms described by patients in groups II and III were joint pain and stiffness, arm pain and numbness, and fatigue. In all groups, capsular tissue silicon levels were significantly greater than breast tissue levels. This finding may indicate that the capsule serves as a barrier to the distribution of silicone from the implant into adjacent breast tissue. Although breast tissue silicon levels in patients with silicone implants were not significantly greater than those in patients with saline implants (p = 0.48), capsular tissue levels in patients with silicone implants were, indeed, significantly greater than those in patients with saline implants (p < 0.001). However, no statistically significant differences in tissue silicon levels were observed with relation to the presence or absence of connective-tissue disease signs or symptoms in patients with silicone implants (groups I to III). Therefore, these data strengthen the conclusion that there is no association between tissue silicon levels and connective-tissue disease.

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Outcome studies of the value of reduction mammaplasties have only recently appeared in the literature. Medical directors of insurance companies and managed care plans have been reluctant to pay for reduction mammaplasties, citing the uncertainty of the medical necessity of the procedure. They have defended their position by stating that the medical literature is devoid of studies documenting that reduction mammaplasty is medically beneficial to the patient. For this reason, reduction mammaplasty is often excluded from health care benefit plans. Because of the need for outcome studies for this procedure, the charts of 363 consecutive patients who had reduction mammaplasty at the Mayo Clinic from January of 1986 to December of 1993 were reviewed. Questionnaires were sent to all these patients asking them to evaluate their outcome, and 328 responded (90.4 percent response rate). Of the respondents, 94.2 percent believed that the procedure was completely or very successful, and only 1.5 percent believed that it was not very successful or completely unsuccessful. The symptoms most frequently reported by patients preoperatively were as follows: uncomfortable feeling about their body, 97.0 percent: inability to find clothes that fit, 95.7 percent; pain in bra-strap groove, 92.4 percent; shoulder pain, 86.0 percent; inability to run, 79.3 percent; upper back pain, 79.0 percent; inability to participate in sports, 77.4 percent; neck pain, 70.7 percent; lower back pain, 64.0 percent; and intertrigo, 61.0 percent. The symptoms least frequently reported by patients preoperatively were as follows: pain or numbness in the hands, 22.6 percent; headaches, 30.2 percent; arm pain, 35.4 percent; and breast pain, 58.2 percent. These symptoms were either relieved or partially relieved in 88 percent or more of the patients. Of the 328 patients, 97.3 percent responded that they definitely or probably would have the procedure again, and only 1.2 percent definitely or probably would not have the operation again. Evaluation of medical treatment used to relieve symptoms showed a marked decrease in the need for such measures after reduction mammaplasty. Study of the charges for the procedure revealed that the setting of practice parameters for the procedure and the use of an ambulatory surgery center significantly decreased the charges for the procedure. This outcome study supports the hypothesis that reduction mammaplasty is an effective procedure and the treatment of choice for symptomatic mammary hyperplasia.

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A method for analysis of silicon in tissue was developed to determine silicon content in breast parenchymal and periprosthetic capsular tissues of patients with silicone or saline implants and to compare levels in tissues from normal (nonaugmented) breasts. It is of interest to determine whether increased silicon content in tissues can be associated with morbidity in patients who have received silicone implants. This manuscript addresses the issues involved in analysis of breast tissue samples for silicon and compares silicon levels with tissue histologic findings and patient morbidity. One hundred sixty tissue samples were obtained for silicon analysis from 72 patients during augmentation, capsulectomy with or without replacement mammoplasty, mastectomy, or biopsy procedures and were frozen in acid-washed polystyrene tubes at 220 degrees C until analysis. Samples were thawed, sectioned to approximately 0.1 g (dry weight), and digested in nitric acid before analysis by inductively coupled plasma emission spectroscopy, monitoring emission intensity at 251.6 nm. Tissue silicon levels (breast parenchymal and periprosthetic capsular tissue) in patients with silicone gel implants were much higher (mean, 9,287 micrograms/g, n = 106) than in patients with saline implants (mean, 196 micrograms/g, n = 37) or nonaugmented breasts (mean, 64 micrograms/g, n = 17). Histologic examination was performed on 54 tissue samples stained with hematoxylin-eosin. Tissue samples were rated as to degree of inflammation and calcification, and amount of giant cells, foamy histiocytes, and vacuoles containing a colorless refractory material. Vacuolization and foamy histiocyte ratings correlated significantly with tissue silicon concentration. No correlations were found between tissue silicon concentration and inflammation, calcification, or giant cell rating. Implant age (number of years an implant was in place before sampling) correlated with capsular tissue silicon concentration in patients with intact implants but not in those with ruptured implants. No difference in tissue silicon concentration was found between patients with or without signs or symptoms of morbidity. Using 0.1 g of tissue, the method was linear to 1,000 micrograms/g, and sensitivity was 3.7 micrograms/g. Precision between runs (mean, 5.1 micrograms/g; coefficient of variance, 13.7%; n = 13) was calculated from multiple analyses of a bovine liver standard (National Bureau of Standards, reference material 1577a). Significant biologic variability (21.4% to 52.5%) was seen in tissues with high silicon levels. Paraffin-embedded, formalin-fixed tissues are not amenable to silicon analysis by this method, because of leaching of silicone from the tissues during preparation. Thus only fresh frozen tissue samples were used.

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The ubiquitousness of silicon is well known. Recent work has demonstrated measurable baseline levels of silicon in nonaugmented cadavers, subsequent to numerous reports of significant elevations of such levels within patients with silicone breast implants and even more reports alleging a causal relation between silicone gel prostheses and connective-tissue diseases. Despite the lack of scientifically substantiated data that such a relation exists, the calamitous silicone breast implant controversy has ensued. Saline-filled breast implants are constructed with a silicone elastomer envelope that remains in direct contact with periprosthetic capsular tissue following implantation. Although there is no evidence to link saline implants with any disorders, it is important to know if saline breast implants contribute any silicon to human body baseline silicon levels. The present study measured tissue silicon levels in 28 breasts of 16 patients with saline-filled implants to determine if the silicone envelope of these prostheses can contribute to the elevation of such levels. These data were compared with data from 116 breasts of 65 patients with silicone gel-filled prostheses as well as breast tissue from 17 patients (controls) who had never been exposed to either type of implant. Samples of breast tissue and periprosthetic capsular tissue were obtained from patients with both intact and ruptured implants. Silicon levels of breast tissue specimens from patients with saline-filled implants were within the range of the controls if the implants were intact. Silicon levels in periprosthetic capsular tissue from patients with intact saline-filled implants were significantly higher than controls (p < 0.02); however, they were still 100-fold less than capsular tissue levels from patients with intact gel-filled implants. Silicon levels measured in both types of tissue were significantly elevated in patients with silicone gel-filled implants compared with controls (p < 0.01). In the case of ruptured gel implants, breast tissue demonstrated higher silicon levels than did similar specimens from patients with intact implants (p < 0.054); periprosthetic capsular tissue levels also were elevated, although the differences were not statistically significant (p = 0.54). These findings are independent of the implant brand or length of exposure to the particular prosthesis. The finding of elevated levels of silicon in both breast and periprosthetic capsular tissue in patients with silicone gel-filled implants in no way implies or substantiates any claim of a causal relationship between silicone and any reported illnesses.

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Hematoma remains a problematic complication of face lift surgery. Sequelae of hematomas may include temporary skin irregularities, a prolonged postoperative recovery period, skin necrosis, and a compromised final result. Attempts to maximize intraoperative and postoperative hemostasis and thus prevent postoperative hematoma formation have focused on the use of local anesthetics with epinephrine modifications, topical thrombin, bed rest, blood pressure control, local anesthetics with intravenous sedation rather than general anesthesia, and the use of the "second-look" technique popularized 30 years ago. When initially practiced by the senior author, the second-look technique resulted in a dramatic decrease in the incidence of hematoma formation from 21.7 to 6.7 percent. It was concluded at that time that the second-look technique was responsible for the reduced incidence of this face lift complication. However, the present series of 82 face lifts performed using a modification of the original Marcaine/epinephrine infiltration technique without the second-look technique demonstrates an overall incidence of hematoma formation of 7.3 percent. These results demonstrate no advantage of the second-look technique over the traditional technique when epinephrine is infiltrated in the fashion described and meticulous hemostasis is obtained.

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Three cases of striae distensae of the breast after augmentation mammoplasty are presented. The patients were all in their early 20s and nulliparous. The striae developed in the first few months after surgery. A review of the literature on striae distensae is presented. To the best of our knowledge, striae distensae occurring after augmentation mammoplasty have not previously been described.

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A 58-year-old woman developed multiple, recurrent abscesses and subcutaneous nodules over both buttocks during a 12-year period. Microbiological studies of surgical biopsy specimens were inconclusive for a specific infectious cause, but histochemical preparations on several separate occasions revealed an exuberant foreign body reaction to raw cotton fibers. Interestingly, the patient gave a detailed history of sliding down piles of cotton hulls during her childhood, some 45 years earlier. With a probable cause-and-effect relationship established, we postulate a dramatically delayed foreign body granulomatous reaction to cotton fibers.

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Ninety-two of 220 plastic surgeons submitted information from 600 women (the last 15 to 20 reduction mammaplasties by each surgeon) regarding height, weight, and amount of breast tissue removed. In a second survey to estimate percentages of women who sought reduction mammaplasties for purely cosmetic reasons, for mixed reasons, and for purely medical reasons, 132 of the same 220 surgeons responded. All women whose removed breast weight was less than the 5th percentile sought the procedure for purely cosmetic reasons, and all women whose breast weight was greater than the 22nd percentile sought the procedure for medical reasons. Those women whose removed breast tissue weight was between the 5th and the 22nd percentiles had mixed reasons for requesting the procedure.

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In this case, after augmentation mammaplasty without infection or gross inflammatory reaction, Etheron implants decreased to a small volume of densely hyalinized tissue, leaving essentially no breast augmentation.

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In a prospective, random, double-blind, and concurrently controlled clinical study of 124 patients having augmentation mammaplasty, using multiple independent subjective judges as well as objective compressibility measurements, the use of a variety of local antibacterials in or around inflatable retromammary prosthetic implants reduced the early postoperative onset of class III to IV capsular contracture by sevenfold (85 percent) and the final incidence by more than half (50 percent) (p less than 0.01). We believe this study provides the most unequivocal evidence to date that the cause of capsular contracture in retromammary augmentation is periprosthetic bacterial contamination. Irrigation with a 5 percent povidone-iodine (50 percent Betadine) solution was as effective as other techniques and is currently our procedure of choice.

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Staphylococcus epidermidis, a normal cutaneous inhabitant previously shown to be present in 67 percent of nipple secretions, has been cultured from 55 percent of surgical mammary pockets prior to implant insertion and from the interior of 71 percent of fibrous capsules explored at open capsulotomy. Cephalothin and gentamicin placed within the lumen of inflatable breast implants in vitro have been shown to diffuse outward through the silicone shell. The use of intraluminal cephalothin and gentamicin in vivo has significantly reduced our incidence of capsular contracture following both primary mammary augmentation and secondary open capsulotomy. The authors believe that the cause of fibrous capsular contracture may be a low-grade periprosthetic infection, and that the unique permeability characteristics of the silicone shell may permit sustained antimicrobial activity at the surface of the prosthesis.

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Charts of 120 patients who have undergone face lifts in a single practice have been reviewed for objective evidence of postoperative hematoma formation following traditional or second-look face lift surgery. The respective rates of hematoma formation-21.7 percent, as compared with 7 percent-were found to be significantly different (P less than 0.025) by chi-square analysis, and no extraneous factors can be asserted to explain this difference. The authors therefore conclude that the second-look technique is responsible for reducing postoperative complication from face lift and that it is a worthwhile modification to the traditional procedure.

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The problem in diagnosis of keratoacanthoma versus squamous cell carcinoma has been reviewed, and 13 patients are presented to illustrate the difficulties in differentiating between these two lesions. If the pathologist is in doubt, the lesion should be called "probable keratoacanthoma, but squamous cell carcinoma cannot be ruled out." We should all be aware that even the most careful pathologist, using all the information and material available, may still erroneously diagnose a lesion as a benign keratoacanthoma--one which, if inadequately treated, may metastasize or recur as a squamous cell carcinoma. Therefore, it is important for the clinician to treat most keratoacanthomas by adequate removal and close follow-up.

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