Breast Implants and Anaplastic Large Cell Lymphoma (ALCL). Only recently described, breast implant–associated ALCL (BIA-ALCL) usually presents as an effusion-associated fibrous capsule surrounding the implant and less frequently as a mass.  To the best of my knowledge, this is the first video to demonstrate the unexpected diagnosis of BIA-ALCL.

Little is known about the natural history and long-term outcomes of such a disease. What we do know so far is that BIA-ALCL occurs at a mean of 8 years post implantation and is most commonly a T-cell lymphoma, is CD30 receptor protein positive and does not have an anaplastic lymphoma kinase gene translocation (ALK -). The exact cause of BIA-ALCL is still unknown and not possible to determine if it’s specific to any manufacturer or breast implant type. What we do know is that it may involve a combination of genetic predisposition, biofilm and textured implants

Current recommendations for the diagnosis, treatment and monitoring of BIA-ALCL include:

  1. Any patient presenting with late peri-implant seroma (>1 year), consider U/S (if inconclusive do PET CT or MRI) to rule out effusion, mass +/- lymph nodes and send seroma for culture, flow cytometry and cell block. Note 1 in 8 cases present with lymphadenopathy. There is no role for mammography.
  2. Send tissue samples for CD30 and ALK to haematologist experienced with ALCL.
  3. Confirmed localized BIA-ALCL requires explantation and total capsulectomy (surgical oncologist recommended). Consider removal contralateral breast implant as several bilateral cases detected incidentally. Monitoring by oncologist for surveillance every 6 months for 5 years with annual U/S +/- PET CT for 2 years. Advanced disease requires surgery (mass, lymph nodes), chemotherapy (CHOP: cyclophosphamide, doxorubicin, vincristine, prednisolone), targeted immunotherapy (Brentuximab vedotin) and chest wall radiation for unresectable tumours or positive margins. BIA-ALCL has a more favourable prognosis than systemic forms of ALCL. BIA-ALCL with mass has higher but significant disease recurrence and progression.
  4. Reconstruction suggested >1 year surveillance. Replacement with smooth implants has been performed without reported progression or recurrence of disease but ongoing safety of this strategy is still being investigated. Autologous reconstruction favoured when possible.

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Breast Augmentation Part 2 of 4: The Procedure

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The things you need to know to make better choices regarding breast augmentation are the following:

1) Match your desires with reality

The surgeon can only work with the tissues you bring him. If you want the best result, you have to balance what you want with what the tissues will allow you to have and what they can support over time. Also, no woman has two breasts that are the same, and no surgeon can create two breasts exactly the same. Cup size is extremely variable and inconsistent from one brand of bra to another and women buy a bra that they can fill (or to push breast tissue where they want it to go to create a specific appearance), not necessarily a bra that fits. Last of all, the bigger the breast you request (ie. the bigger the breast augmentation), the worse it will look over time and you can’t pick out a breast from a book or magazine and expect the same result unless the woman in the picture looked exactly like you before surgery.

2) Know about the implants

Breast implants are not perfect, don’t last forever, and require some maintenance. If you can’t accept these facts, don’t have a breast augmentation. If you do, then you need to think about:

  1. Implant pocket location. Implants can be placed in front of, or behind muscle. There is less capsular contracture rates when the implant is placed behind the muscle and you can obtain better or more accurate mammograms too. Also, in thin women, behind the muscle is preferable because adequate tissue coverage is most important. Think when you lie in bed, if you are covered by a bed sheet only, then one can see the contours of your body a lot beer, than if you were to be covered by a doona, they are less distinct. Having said that, an implant placed in front of the muscle will always more predictably control breast shape. How do you decide whether to go in front or behind the muscle? If you pinch the breast tissue in the upper pole and it’s < 2 cm, consider going beneath the muscle, otherwise, you run risks of seeing the edges of the implant. One aspect that often gets overlooked is the way the pocket is created. Blunt dissection techniques are fast and efficient but create more tissue trauma, tear tissues, create more bleeding, and result in longer recovery time. Electrocautery dissection techniques use an electric current to seal blood vessels and are thus, less traumatic and have shorter recovery times.
  2. Implant shape. Shapes of implants can either be round or tear drop (anatomical). There is a trend today of women wanting more upper pole fullness and therefore opting for round implants. Given that the breast is constantly evolving and that over time there is loss of upper pole fullness as the breast tissue ”melts away”, breast augmentation with round implants may be a good option for maintaining upper pole fullness in the long term. The other added advantage is that if it rotates, it doesn’t affect the shape of the breast. In contrast, a tear drop implant which is fuller at the bottom and tapers at the top, will give an odd shape to the breast if it does rotate. However, breast augmentation with tear drop implants may be better in women who have odd shaped chests (either long or wide for example) because you can tailor the dimensions of the implant more specifically to fit the breast ”foot print” on the chest. Tear drop implants may also be beneficial in women with mild sagging breasts who do not want scars on their breast from elevating the nipple. The tear drop implants have a ”bucket-handle” effect on the nipple, elevating them to a higher position on the breast.
  3. Implant surface (or shell)The surface of the implant is made of a silicone rubber and can be textured or smooth. Textured implants have a lower risk of capsular contracture than smooth implants.
  4. Implant ”stuffing”. The stuffing or filler of the implant can be silicone or saline. Saline is salt-water and is harmless if the implant ruptures. It’s biggest disadvantage is rippling and that it takes up the ambient temperature, so that if you went to the beach for a swim, when you get out, your implants will feel cold. Silicone gel filler on the other hand is more natural, more predictable and it is safe. There are grades of silicone gel that range from ”jelly” consistency to that of ”gummy bears”.
  5. Implant size. Remember, the larger the implant, the more tradeoffs and risks you’ll encounter, especially long term.
  6. Incision location. The scar can be placed in three areas. The breast fold incision offers the best degree of control for the wide range of breast types and is the the commonest type used by far. The periareolar incision (around the nipple-areola) usually heals well because it’s located in thinner skin but is limited and can’t be used if the areola is not large enough for access. The biggest problem is the increased exposure of the implant to bacteria if any of the breast ducts were to be cut. The armpit (axillary) incision places no scar on the breast but takes longer to perform and harder to control the position of the breast fold.

3) Get well acquainted with the tradeoffs, problems and risks

Tradeoffs always depend on the details of each specific case, the characteristics of your tissues , the experience of your surgeon with different options. Every breast augmentation operation carries inherent risks and medical complications are not totally preventable by you or your surgeon. Remember, don’t have a breast augmentation unless you thoroughly understand and accept the potential risks and trade-offs of the procedure.

4) Know about the recovery

The more tissue trauma caused by your surgery, the longer and more difficult your recovery. That is why it takes longer to recover from a pocket created behind the muscle. Excessively large implants can produce excessive stretch marks that cause more discomfort and temporary or permanent sensory loss. Most women return back to normal duties within four weeks and athletic activities by six weeks.

 

Question: Do you think that the benefits far outweigh the trade-offs for breast augmentation? You can leave a comment below.

 

Cosmetic Surgery Tip #20: Any breast surgery can have a small effect on breast cancer screening in the future

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Breast health is important. Before the surgery, have a proper breast exam with your GP or gynaecologist. If you’re of age, get a mammogram. Most mammographers don’t have an issue if the implant is placed behind the muscle, but it is important to discuss this with your plastic surgeon. The x-rays used for mammographic imaging of the breasts cannot penetrate silicone or saline implants well enough to image the overlying or underlying breast tissue. Therefore, some breast tissue (approximately 25%) will not be seen on the mammogram, as it will be covered up by the implant. In order to visualise as much breast tissue as possible, women with implants undergo additional views as well as the standard images taken during diagnostic mammography. In these additional x-ray pictures, called Eklund technique or implant displacement (ID) views, the implant is pushed back against the chest wall and the breast is pulled forward over it. This allows better imaging of the forward most part of each breast. Sometimes it is more difficult to perform the Eklund technique in women who have severe scar tissue or capsular contracture and women who have very dense or fibrous breasts. Implants placed above the muscle can also make it more difficult to determine microcalcifications. Scar tissue around the capsule can be difficult to differentiate from calcification, which could be associated with cancer and thereby require an actual biopsy. The ID views are easiest to obtain in a women whose implants are placed underneath (behind) the chest muscle.

Photo Credit: Saul Steinberg “Masquerade”

Breast Augmentation Part 3 of 4: The Plastic Surgeon

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I am amazed how many patients spend more time shopping for a TV or washing machine than they spend selecting a plastic surgeon. Selecting your surgeon should be the single most important thing that you can do to assure an optimal result.

You should have a checklist of essential things to look for in a plastic surgeon:

  1. Be a Fellow of the Royal Australasian College Of Surgeons (RACS), the only college recognised by the Australian Medical Council that can train surgeons in Australia
  2. Be a Member of the Australasian Society Of Aesthetic Plastic Surgery (ASAPS)and the Australian Society of Plastic Surgeons (ASPS)
  3. Has hospital privileges to do breast augmentation at an accredited hospital or day surgery facility
  4. Subspecialises in cosmetic surgery
  5. Superspecialises in breast augmentation
  6. Recommended by a knowledgeable friend or doctor
  7. Curriculum vitae documents scientific presentations and publications

There are also a few less reliable points that I would like to address when choosing a plastic surgeon. Advertisements and media coverage are paid for by the plastic surgeon and does not necessarily reflect how knowledgeable, competent or experienced they are. Your local doctor may not be in the know of who is best to do breast augmentation and may not have an interest in cosmetic surgery to find out either. Some just refer to surgeons who are their friends from medical school, are in the local area and thus convenient or who may be paid for by the surgeon to refer you. Never listen to recommendations from anyone who is an “armchair expert” or who has no in-depth knowledge of breast augmentation. At the end of the day, look at the plastic surgeon’s results to see how good they are. Be very careful with “glamour shots” that can deceive because of lighting, patient positioning and camera angle. They may even be “photoshopped” or airbrushed. Some plastic surgeons may have models as patients that they have operated on their face but not their breasts (which was performed by another surgeon) and use them for advertising breast augmentation.

There are a further number of “red flags” that you should take notice of. These are:

  1. Completed training in a specialty other than plastic surgery
  2. Certified in an unrelated college
  3. Not a member of ASAPS and ASPS
  4. No hospital privileges
  5. If you are given false or misleading information- claims that are too good to be true.
  6. Unwilling to provide you answers to questions regarding credentials or curriculum vitae
  7. When the office staff are not courteous, knowledgeable or don’t spend enough time with you and don’t tell you what you need to know. Beware of staff who give you all fluff, but no substance and don’t offer to send you any information. Always insist that the price be broken down into the following categories: surgeon fees, anaesthetist fees, costs of implants, operating room fees, hospital stay fees, laboratory fees, mammogram or ultrasound fees, any other fees. Ask how long the prices on the quote last for. Remember, there is no such thing as bargain surgery. Have you ever seen top-quality surgery for bargain price? How is the bargain surgeon able to offer such a good price? When visiting the plastic surgeons rooms, look around and take notice of the little things. It should be a quiet, comfortable and modern, an atmosphere that reflects the good taste of the plastic surgeon. The organisation, function and flow of the plastic surgeon’s office is a reflection of the surgeon’s personality and habits. Think about it. If the office looks messy and unclean, doesn’t it reflect badly on the surgeon who accepts this scenario? Most of the time, you will recognise a good plastic surgeon without the surgeon having to tell you. If they have integrity, are caring and thorough, then this will definitely contribute to what you will get in the operating room and after.

Question: What factors do you consider important when choosing a plastic surgeon to perform a breast augmentation? You can leave a comment below.

Is CoolSculpting® An Alternative To Liposuction?

CoolSculpting is a non-invasive, clinically proven procedure to selectively reduce fat layers in problem areas using a patented cooling technology. It is a safe procedure that gently cools unwanted fat cells in the body to induce a natural, controlled elimination of fat cells. This reduces bulges in treated areas of the body without harming surrounding tissue.

CoolSculpting Female Pic