Tuesday, Sept. 2, 1997 / Star Telegram / Section D, Page 3
by Lisa Lytle – The Orange County Register

Breast ImplantsEvery year that passes for Ann Hart, 38, of Brea, California, is like the faint click of a revolver,s chamber in a game of Russian roulette. A 1994 mammogram found that the hardened silicone implant in her left breast had ruptured. The one in her right also was hard but intact. Although the link between silicone leakage and autoimmune disorders remains arguable, Hart, like hundreds of other women with ruptures, wants both 19-year-old implants replaced. But the figures quoted to her – $6,000 to $9,000 – are prohibitive, given that she is raising two children.

Still the verdict finding that Dow Chemical Corp. lied and hid information about the potential dangers of silicone breast implants did nothing to change her longtime perception that breast augmentation made her feel and look better. (The case resumes Sept. 29, when the jury must determine whether the women’s implant ruptures cause their illnesses.)

At best, the ruling in the Louisiana class-action lawsuit simply underscored what she knows is fundamental truth: You don’t just get silicone implants and forget about them.You keep tabs on them. Vigilantly.

So Hart is doing what she believes every woman with silicone implants should do: Live her live as usual, hope the left implant doesn’t leak and rely on the advances in technology – including the new and debatable endoscopic evaluation as well as mammograms, ultrasound tests and magnetic resonance imaging – to stay healthy.

Of these methods, none has more surgeons more divided than the endoscopic examination. It is lauded by a few practitioners as accurate but criticized by others as high-risk, especially when other, safer, noninvasive, methods are available.

Dr. Howard Tobin, Clinical Professor of Surgery at the University of Texas Southwestern Medical Center at Dallas, was an earlier user of the endoscope for examining breast implants for ruptures, after he read an article about endoscopic examinations before surgery. The endoscope is a small, pointed instrument inserted into the body through a tiny incision and hooked up to a visual monitor to allow the surgeon to see inside the body.

The instrument is inserted into a cut in the areola below the nipple, through the capsule of the implant. The capsule is a fibrous shell that the body naturally produces and wraps around any foreign object that is lodged or implanted in the body. When a silicone implant is put in place, the body isolates it by covering it with this layer.

“We found that we could see with absolute certainty whether the implant was intact or not, Tobin said. “This was quite important because all of the tests that have been used had failings. Even MRI, which was felt to be so valuable, often was erroneous. I have had personal experiences in which patients who were MRI-diagnosed as having ruptured implants actually had intact implants.

Dr. Guillermo Castillo, President of the American Academy of Cosmetic Surgery, hails the procedure as “one of the best advances in diagnosis of breast implant ruptures. Castillo has been using the endoscope for implant exams for a year.

“You can look at an implant and save yourself some headaches and save the woman the need to have surgery done. In cases in which you’re doubtful about the results of other exams, the endoscopic would absolutely tell you what’s going on rather than you interpreting the technology of the X-ray or magnetic resonance imaging, Castillo said. The examination takes less than an hour and won’t injure the implant if done correctly, he said. Afterward, the incision is sewn up and covered with a bandage, and the patient is ready to go home.

Tobin has taken the use of the endoscope further, combining it with a laser, to stop the hardening of the implant. The capsule can sometimes tighten around and constrict the soft implant, making it harden like a rock.

This capsular contraction can be uncomfortable and can make the implant look unnatural. Sometimes, it can lead to rupture and leakage. Tobin uses the laser attached to the endoscope to cut the capsule and free the implant, which returns to its normal softness. Although the use of the endoscope is safe, he said, he admits there is a possibility of damaging the implant with the laser. To prevent this, he said, he uses protective sleeves over the laser.

But some surgeons in Southern California said they would not use the endoscope even for examination because of the risks of puncturing the implants.

“There’s more of a risk of rupture than not when you put the endoscope in, said Dr. burr Von Maur, a plastic and reconstructive surgeon in Mission Viejo, California. “It doesn’t give you any more information than you get from an MRI.

An endoscopic examination is invasive and therefore exposes someone to the possibility of an infection, said Dr. Robert Kachenmeister, a plastic and reconstructive surgeon in Newport Beach, California. “The new imaging techniques are so specific and sensitive to the types of implant ruptures. And radiologists have become more and more experienced and have been good at reading MRI results. Dr. Winston Whitney, radiologist at Hoag Memorial Hospital Presbyterian in Newport Beach, says an MRI is the best way of evaluating a breast implant.

“An MRI is useful because it can differentiate the signals given off from the silicone breast, tissue and water, he said. “As a result, we can see the morphology of the breast implant quite well and determine ruptures with an accuracy greater than 95 percent. The other methods, such as mammography, are only 20 percent sensitive. There are varying numbers given for the accuracy of ultrasound, and there is controversy as to how accurate it is. The numbers seem to be around 45 percent to 50 percent accurate.

What happens after an exam reveals ruptures is up to the woman and her surgeon. In many cases, women choose to have their implants replaced. A few opt for removal alone. Some choose not to have anything done or, like Hart, postpone, for various reasons such as cost and because there is no leakage as the capsule holds the silicone in place. In most cases of replacements, women get saline implants, regarded by the Food & Drug Administration as less risky than silicone versions. Saline implants are less likely to develop capsules. When they tear, they deflate and the contents are absorbed by the body.

Whether silicone leakage can cause autoimmune disease is still being debated.

And because there is no certainty, the prudent first course of action for women with implants is to self-examine their breasts monthly, says Dr. Bruce Achauer, professor of surgery at UCI Medical Center in Orange and a plastic and reconstructive surgeon. Women should immediately get themselves checked by their physician if they notice or feel something different about an implant – whether it’s hardening, softening, rippling or has lumps. This applies also to situations in which there’s trauma to the chest, such as the impact of hitting an air bag in a car accident.

Women need to remember that silicone breast implants are not designed to last forever and they may have to undergo more than one surgery, according to the FDA, which has a general information line on breast implants: (800) 532-4440.