Aesthetic outcome of breast implant removal in 85 consecutive patients

As we began to see increasing numbers of women concerned about their gel-filled breast implants, we became aware that we could not advise them with any degree of confidence what they might expect in terms of aesthetic result after implant removal. We decided to review the records and outcomes over a 2-year period of a number of patients who underwent implant removal. Eighty-five consecutive patients were reviewed, 69 of whom had undergone cosmetic augmentation and 16 of whom had breast reconstruction with silicone gel implant(s). Thirty-nine of the 69 cosmetic augmentation patients had removal of implants alone, and 27 had removal accompanied by mastopexy. Three had reaugmentation with saline-filled implants; one had replacement with saline-filled implants. Fifteen of the 16 reconstruction patients underwent autogenous tissue transfer. Preoperative and postoperative photographs of all patients were mixed randomly and rated by two independent raters in four aesthetic categories on a five-point scoring system. Repeatability was measured several weeks later, when each rater scored randomly selected photographs from this patient pool. The patients also performed their own outcome evaluations by means of questionnaire. We discovered that cosmetic augmentation patients who undergo implant removal only often suffer adverse aesthetic results. The postremoval appearance of many cosmetic augmentation patients actually will be improved over their preoperative appearance when mastopexy is performed in conjunction with implant removal. The study demonstrated that patients with certain body types could expect a particular outcome; i.e., women with asthenic builds and older patients with lax, striated breast skin generally had unsatisfactory aesthetic outcomes with implant removal only. Patients selected for autogenous breast reconstruction had favorable results, with extended latissimus dorsi and TRAM flaps yielding equally good outcomes. The study allows us to offer patients an optimistic view of postoperative results following breast implant removal. We have begun to advise selected patients that implant removal accompanied by mastopexy provides a more pleasing aesthetic outcome than implant removal alone.     

Superiority of the microvascularly augmented flap: analysis of 50 transverse rectus abdominis myocutaneous flaps for breast reconstruction

Our experience with 50 transverse rectus abdominis myocutaneous (TRAM) flap transfers was evaluated as to the types of TRAM flaps, indications for breast reconstruction with a TRAM flap, and complications. The TRAM flap was transferred as a free flap in 7 patients, a unipedicled flap in 14 patients, and a microvascularly augmented flap in 29 patients. Microvascular augmentation was performed through the contralateral inferior epigastric vascular system to the superiorly pedicled muscle in 10 patients who had undergone radical mastectomy and the ipsilateral inferior epigastric vascular system in 19 patients who had undergone modified radical mastectomy. In this series, the incidence of flap-site complications, including total flap loss, partial flap loss, and fat necrosis, was lowest in the microvascularly augmented flap group. Particularly, incidence of partial flap loss in the microvascularly augmented flap group was significantly lower than in the unipedicled flap group (p < 0.01). These outcomes demonstrated the superiority of the microvascularly augmented TRAM flap for breast reconstruction.     

Nipple-sparing total mastectomy of large breasts: the role of tissue expansion

Nipple-sparing total mastectomy remains an alternative for management of patients with high risk breast disease or patients with various types of symptomatic breast problems. In a patient with large breasts, however, achieving good cosmesis while still performing a thorough mastectomy remains a challenge. This report includes 10 patients who underwent unilateral nipple-sparing total mastectomy and 10 patients who underwent bilateral nipple-sparing total mastectomy. Tissue expansion was used as the reconstructive technique in this consecutive series done from 1985 through 1988. All expanders were placed in the submuscular position, and hyperbaric oxygen was used when intraoperative fluorescein administration identified marginally perfused areas. The average volume of breast tissue removed was 800 gm. The average permanent implant size was 767 cc. Complications included partial skin or nipple loss, infection, and problems related to the implants themselves. The complication rate, however, was not excessive, and results have been good as measured by cosmetic results, capsule grade, and lack of development of cancer in operated breasts. This reconstructive technique is recommended as an alternative in those patients undergoing nipple-sparing total mastectomy.     

An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction

A conventional single pedicled TRAM (transverse rectus abdominis myocutaneous) flap is a musculocutaneous flap widely used for breast reconstruction. However, complications such as partial flap necrosis, fat necrosis, and fatty induration may occur as a result of unstable blood flow circulation to the flap. One major factor is venous congestion in the flap. In an effort to obtain more stable TRAM flap blood circulation, we anastomosed the ipsilateral deep inferior epigastric vein of a pedicled TRAM flap to the thoracodorsal vein. This procedure provides superdrainage by means of enhanced venous perfusion. This flap with superdrainage augmentation is referred to as a superdrainaged TRAM flap (12 patients). Changes in cutaneous blood flow were also assessed by measurement of cutaneous blood flow in zone IV using a laser blood flow meter (8 patients). The patients who underwent breast reconstructive surgery using this technique showed no evidence of postoperative complications such as flap necrosis, fat necrosis, or fatty induration. Satisfactory results were obtained during breast reconstruction in patients who had previously undergone a radical mastectomy with resultant large areas of tissue defects. In addition, the two patient groups, 12 patients with superdrainaged TRAM flap and 20 patients with single pedicled TRAM flap, were compared to assess differences in complications. The incidence of partial flap necrosis, fat necrosis, and fatty induration was lower among patients with superdrainaged flap than those with single pedicled flap.     

A reassessment of ticarcillin/clavulanic acid dose recommendations for infants, children and adults

Breast reconstruction is frequently performed for and requested by women with breast cancer. There are continued concerns about the safety of this procedure. We reviewed the Medical College of Georgia experience with immediate breast reconstruction to determine overall morbidity and whether premorbid risk factors could predict complications. Patients were reviewed with attention to epidemiologic characteristics, comorbid medical conditions, and risk factors; hospital and operative course; immediate wound complications; and patient survival. t test and chi-square analysis were performed to determine risk factors for developing wound complications. Between October 1990 and December 1996, 55 patients underwent 62 mastectomies and immediate reconstruction for breast cancer or contralateral prophylaxis. There were 13 stage 0, 23 stage I, 16 stage II, 4 stage III, and 1 stage IV tumors. There were 19 prosthetic and 43 autologous tissue reconstructions. Eighteen patients had 24 wound complications. Major complications occurred in eight patients and required reoperation for implant removal (two bilateral), ventral herniorrhaphy, and split thickness skin grafting for tissue loss. Patients who were obese were statistically more likely to develop surgical wound complications. Tobacco use, age, comorbid medical illness, operative blood loss, length of operation, and length of hospital stay did not predict for the development of wound complications. Patients who underwent prosthetic reconstruction had a significantly higher rate of major wound complications when compared with those who had autologous reconstruction. There was a single case of delay of chemotherapy secondary to surgical wound complication. There were no cases of autologous flap loss or local recurrence. Median survival is 23 months (1-72 months). At last follow-up, 53 patients are alive and without evidence of local recurrence. Breast reconstruction may be performed safely for most breast cancer patients. Autologous tissue reconstruction is preferred and carries significantly less major morbidity. Reconstruction should not delay adjuvant chemotherapy.     

Effect of different methods of internal thoracic artery harvest on pulmonary function

BACKGROUND: In several clinical studies, internal thoracic artery (ITA) grafting for myocardial revascularization has been identified as increasing the risk of postoperative pulmonary complications. This study was designed to determine whether the technique used to harvest the ITA has an effect on postoperative pulmonary function. METHODS: Seventy-nine consecutive patients undergoing coronary artery bypass grafting using the left ITA were compared with patients undergoing coronary artery bypass grafting using saphenous vein grafts only. Two methods of ITA harvesting were used: (1) incision of the endothoracic fascia dissected off the ITA as a skeletonized vessel (group 1, n = 33) and (2) mobilization of the ITA as a wide musculofascial pedicle (group 2, n = 46). Thirty-two patients underwent coronary artery bypass grafting using saphenous vein grafts only (group 3). Pulmonary function tests were performed between postoperative days 20 and 30. RESULTS: The postoperative values of forced vital capacity were reduced in patients in all groups (p < 0.0001). The ratios of postoperative to preoperative forced vital capacity were 84% in group 1, 77% in group 2, and 84% in group 3. The reduction in group 2 was significant compared with group 1 (p < 0.05) and group 3 (p < 0.05). CONCLUSIONS: Postoperative pulmonary dysfunction was significantly greater in patients who underwent wide musculofascial pedicle dissection of the ITA compared with skeletonization of the artery. Thus, of the two techniques, the latter may be the method of choice with regard to lowering the incidence of postoperative pulmonary dysfunction.     

Silicone breast implant litigation (Part 1)

Silicone breast implant litigation has escalated in the past couple of years with the Food and Drug Administration (FDA) investigation of silicone gel implants which resulted in finally removing the silicone gel implants from the market. Plaintiffs have linked various medical problems to the presence of silicone in the body. The FDA has stated that there is no medical evidence that silicone causes autoimmune disease. Silicone has never been shown to cause breast cancer. Breast implants can result in complications such as capsule contracture, gel bleed, implant rupture, calcifications around the implants, and possibly interference with mammography in the diagnosis of breast cancer. Plaintiffs have claimed that the implant manufacturers knew of the defects in the silicone shell implant covering, and covered up the facts. The product liability action has become a class action, and a proposed settlement has been made in terms of which implant recipients with any problems will be reimbursed. Furthermore, there will be coverage for future implant problems over the next 30 years. There will still be some litigation by those patients who have opted out of the settlement agreement.     

Silicon analysis of breast and capsular tissue from patients with saline or silicone gel breast implants: II. Correlation with connective-tissue disease

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.     

Treatment outcome with radiation therapy after breast augmentation or reconstruction in patients with primary breast carcinoma

BACKGROUND: Analyses were performed to determine local control and cosmetic outcome of breast carcinoma patients with prosthetically augmented or reconstructed breasts who had received radiation therapy (RT). METHODS: Twenty-one newly diagnosed breast carcinoma patients with prosthetically augmented or reconstructed breasts were treated with external beam RT. All patients received whole breast RT (median dose, 50.4 gray [Gy]) and 19 were boosted to a median dose of 60.4 Gy. A median dose of 50.4 Gy was delivered to the regional lymph nodes in 12 patients. Tissue equivalent bolus material was used in six patients. Seventeen patients received adjuvant systemic therapy. Cosmetic results were evaluated at 3-6-month intervals. RESULTS: With a median follow-up of 32 months, good/excellent cosmetic results were observed in 71% of patients (100% in those with augmented breasts and 54% in those with reconstructed breasts). Four patients (19%) with fair/poor cosmetic outcomes required implant removal and/or revision. Multiple clinical and treatment-related factors were analyzed for their impact on cosmetic outcome. A worsened cosmetic result was observed with increasing stage (P = 0.076), breast reconstruction (vs. augmentation) (P = 0.030), and bolus application (P = 0.016). All patients with fair/poor cosmetic outcomes had time intervals from implant insertion to RT ranging from 53-213 days. Two patients developed an isolated local recurrence within the augmented breast. CONCLUSIONS: Patients with prosthetically augmented breasts can undergo RT and expect good/excellent cosmetic results. Patients with reconstructed breasts are at a significantly greater risk for cosmetic failure. This risk may be related to the higher percentage of patients with advanced disease, those who received bolus application, and those who received earlier delivery of RT (after the cosmetic procedure) in reconstructed breasts.     

Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients

This article presents our technique of autologous breast reconstruction using the latissimus dorsi flap and studies the advantages, disadvantages, and results that can be expected. A consecutive sample of 100 patients was studied. The average length of follow-up was 20 months (range 8 to 44 months), and all of the subjects were reviewed in consultation without loss to follow-up. The supplementary volume of the latissimus dorsi was obtained from five fatty zones: fat on the cutaneous paddle, fat taken from the surface of the muscle, the scapular fat pad, the anterior fatty zone, and the supra-iliac fat pad. This technique must be measured against the transverse rectus abdominis muscle (TRAM) flap, free or pedicled, when the patient needs an autologous breast reconstruction. It can be used when the TRAM flap is contraindicated (this corresponds to 45 percent of patients of our sample) or when the dorsal donor site is preferred (55 percent of cases of our sample). The major complications are rare (1 percent partial necrosis and 1 percent total necrosis of the flap). The minor complications are represented mainly by the dorsal seroma. This is the main drawback of the technique, as it occurs in 79 percent of cases and regularly in obese patients. In view of this frequency, patients should be warned of its likely occurrence. The dorsal donor-site morbidity is relatively low; 4 percent of dorsal sequelae were classed as moderate, and 96 percent were considered low. The scapular sequelae have been classed as low in 97 percent of cases, and temporary scapular sequelae aggravation has been noted in 3 percent. Results of breast reconstruction using this technique are most encouraging. The level of patient satisfaction is high; 87 percent of them were deeply satisfied, 10 percent were satisfied, and only 3 percent were poorly satisfied. This group of poorly satisfied subjects (3 percent) consists of patients who suffered a serious postoperative complication. The aesthetic results have been judged excellent by surgeons in 85 percent of the cases, good in 12 percent of the cases, and poor in 3 percent of the cases; no result has been judged bad. This technique of breast reconstruction by autologous latissimus dorsi brings a major advance in breast reconstruction. The best indications of this technique are when one can bury the cutaneous paddle: cases of skin-sparing mastectomy, cases where the latissimus dorsi flap can be combined with an abdominal advancement flap, and cases of conversion of implant reconstruction to an autologous reconstruction.     

Patient satisfaction and function after primary and revision total hip replacement

This study assessed and compared satisfaction and function before and after total hip replacement as reported by 531 patients who had primary and revision surgery and 1087 patients who had primary surgery only. All operations were registered by the Norwegian Arthroplasty Register during the years 1987 to 1993, with time from last surgery to followup ranging from 0.6 to 6.4 years. Sixty-one percent of the patients who underwent revision surgery and 84% of the patients who did not undergo revision surgery rated their overall satisfaction with the hip implant as good or very good. With adjustment for primary diagnosis, gender, age, bilaterality, and time since the primary operation, a substantial benefit of total hip replacement was observed in both groups with regard to pain, walking ability, and need of help. However, improvement was less among patients who underwent revision total hip replacement than among those who did not undergo revision surgery. A deterioration was seen among patients who underwent revision surgery with regard to employment status and exercise habits.     

Distribution of organosilicon polymers in augmentation mammaplasties at autopsy

Silicone-containing breast implants have been used since 1963 for cosmetic augmentation and breast reconstruction. Currently, there is intense debate regarding the extent and mechanism of migration of silicone from the area of implant. The current study compares tissue distribution of organosilicon polymers between women with and without silicone breast implants to determine the extent of silicone migration from breast implants. Samples were collected at autopsy from 15 individuals with bilateral breast implants with no known history of chest trauma and from 14 age- and sex-matched controls. Capsule, breast, axillary lymph nodes, abdominal fat, liver, lung, and spleen were collected for analysis of organosilicon polymers by atomic absorption spectrometry and for examination by light microscopy. Blood was collected for analysis of rheumatoid factor and antinuclear antibodies. Silicone was observed microscopically in at least one capsule section from all implant cases and in at least one lymph node in 8 of 15 implant cases. Silicone was not observed in lymph nodes from control cases. Organosilicon polymers were extracted from tissue using heptane, and the silicon content of the extract was quantitated by atomic absorption spectrometry. Silicon was detected in all capsules; statistically significant increases of organosilicon polymers were measured in axillary lymph nodes, breast, and abdominal fat from individuals with silicone breast implants when compared with the nonimplant group. Measurable amounts of organosilicon polymers were found in tissues from the nonimplant group. Suitable blood specimens were analyzed for the presence of rheumatoid factor and antinuclear antibodies. All nine implant cases tested were negative for the presence of antinuclear antibodies. Three implant cases which were tested for rheumatoid factor also were negative. We conclude that organosilicon polymers routinely migrate from the site of breast implantation to regional tissues near the implant site. Tissues from nonimplant cases often contained measurable amounts of organosilicon polymers, and tissue distribution was variable within any single individual: this is consistent with the wide-spread use and form of organosilicon polymers.     

Preservation of pectoralis minor in axillary clearance for breast cancer

BACKGROUND: There has been a gradual shift away from radical surgery towards conservation treatment for breast cancer. The pectoralis minor muscle is increasingly preserved in women undergoing axillary clearance as part of either breast conservation or mastectomy. METHODS: A retrospective study was conducted to determine the axillary node count in 578 patients who underwent axillary clearance, 276 with removal of pectoralis minor and 302 who had the muscle preserved. RESULTS: The mean number of nodes excised in the group who had pectoralis minor excised was 25.5 (range 8-50) compared with 24.5 (range 9-68) in the preservation group. CONCLUSION: For the majority of patients with operable breast cancer, retention of the pectoralis minor muscle is not associated with understaging or undertreatment of the axilla.     

Covering extensive soft tissue defects in infected knee endoprostheses by gastrocnemius flap

Total knee arthroplasty has become a routine procedure in surgery. Deep infections have an incidence of 2-5%. Major risk factors are large prostheses, rheumatoid arthritis, diabetes mellitus and postoperative wound-healing complications. In large soft-tissue defects with skin necrosis, local wound care shows poor results, especially if loosening of the prosthesis and necrosis of the patellar ligament are evident. In these cases, no standard surgical therapy has been developed yet. Thus, we consider meticulous débridement with synovialectomy to be mandatory. Exchange of the prosthesis may be necessary. Soft-tissue coverage ought to be performed with a gastrocnemius muscle flap covered with a split-thickness skin graft. In the last three years, 11 patients with large soft-tissue defects and necrosis of the ligament were treated according to this concept. In all cases the muscle flap healed primarily and soft tissue coverage was excellent. Two patients who underwent single-stage removal and reimplantation of the prosthesis showed reinfections of the prosthesis. Reconstruction of the ligament was performed with the flap tendon. The patients with two-stage removal and reimplantation of the prosthesis and those who retained their implants had a good functional outcome. The gastrocnemius muscle flap provides easy and reliable soft-tissue reconstruction in large defects. In our patients a two-stage operation for reimplantation of the prosthesis was superior to a single-stage procedure. The reconstructed ligament should be reinforced with autologous material to prevent a secondary rupture. Early reconstruction with sufficient soft-tissue coverage and reconstruction of the ligament offers the patient the best chances of obtaining a good functional result and prevents arthrodesis or amputation. In addition, reconstructive surgery reduces the length of hospital stay and costs.     

Clamp subunit dissociation dictates bacteriophage T4 DNA polymerase holoenzyme disassembly

A large series of women who had undergone bilateral, pedicled TRAM flap reconstructions were compared with women who had had unilateral, unipedicled TRAM flap procedures to determine whether a bilateral TRAM flap breast reconstruction had significant additional morbidity. The records of all women who underwent either a bilateral or unilateral pedicled TRAM flap breast reconstruction through the Emory Clinic from 1987 to 1994 (n = 257) were retrospectively analyzed with respect to general, breast (fat necrosis, flap loss, and cellulitis), and abdominal (hernia, skin loss, and cellulitis) complications. By using logistic regression, risk factors for these complications were determined. The incidence of fat necrosis and partial flap loss was not significantly different among bilateral patients compared with patients with unilateral TRAM reconstructions (10.0 percent versus 12.6 percent, p = 0.64 and 3.8 percent versus 5.5 percent, p = 0.74, respectively). The rate of hernia formation in the bilateral TRAM flap patients (5.4 percent) was similar to that of unilateral patients (3.9 percent, p = 0.80). Significant factors for any complication in both patient populations included obesity, smoking, and prior irradiation. The type of breast reconstruction was not a significant factor for any breast or donor-site complication. A bilateral TRAM reconstruction showed a weak association with general complications. Review of the Emory Clinic experience with unilateral and bilateral pedicled TRAM flap reconstructions from 1987 to 1994 was able to detect no significant additional rate of complications for bilateral pedicled TRAM flap breast reconstructions compared with unilateral unipedicled TRAM flap procedures.     

Reconstruction of the breast after mastectomy for carcinoma

During the last 5 years, 80 patients underwent reconstruction of the breast as a primary or secondary procedure after mastectomy for carcinoma. Breast mounds were reconstructed with the silicone breast implant. A Silastic implant corrected the infraclavicular axillary deformity after radical mastectomy. The nipple-areolar complex was created either with a nipple-areolar graft from the contralateral breast or with a labial free graft in a bilateral breast reconstruction. If the contralateral breast was large or ptotic, reduction mammoplasty or mastopexy was performed. Subcutaneous mastectomy or total mastectomy of the other breast with insertion of the silicone breast implant was the method of choice for a group of high-risk patients.     

Short- and long-term treatment with indometacin causes renal phospholipid alteration: a possible explanation for indomethacin nephrotoxicity

The authors report their experience of the use of a latissimus dorsi myocutaneous flap in reparative surgery after total or partial mastectomy for invasive breast cancer. The series, including 101 cases, was separated into four groups on the basis of the context: I--thoracic radionecrosis (5 cases); II--chest wall cover (24 cases); III--immediate breast reconstruction (57 cases); deferred breast reconstruction (15 cases). The well-known vascular reliability of this pediculated flap was confirmed here by the low incidence of necrosis (3%), always marginal. Other complications were not attributable to the flap itself but to concomitant radiodystrophic skin lesions and the presence of the prosthetic implant in the case of breast reconstruction.     

Glaucoma drainage implants in Asian eyes

OBJECTIVE: Previous studies have suggested that there are racial differences in the outcome of conventional filtration surgery. This study aims to evaluate the outcome of glaucoma drainage implants in Asian eyes with complicated glaucoma and to determine whether there are racial differences in the results of such implant surgery compared to previous reports in non-Asian patients. DESIGN: The study design was a retrospective review of all patients with more than 6-months' follow-up after glaucoma implant surgery at the Singapore National Eye Centre between January 1993 and August 1996. PARTICIPANTS: A total of 83 Asian patients with uncontrolled complicated glaucoma participated. INTERVENTION: A total of 29 patients received Molteno implants and 54 received Baerveldt implants. MAIN OUTCOME MEASURES: The surgical outcome was assessed in terms of final intraocular pressure (IOP), visual acuity outcome, and incidence of complications. Success was defined as final IOP less than 22 mmHg with no medications and qualified success as an IOP less than 22 mmHg with medication. RESULTS: With mean follow-up of 13.41 months, success in IOP control was achieved in 73.5% of patients and qualified success in 12%. Visual acuity remained stable or improved in 85.5%. There were no patients who encountered intraoperative complications, and the incidence of serious postoperative complications was low. The most frequently observed short- and long-term postoperative complication was hyphema in 14 eyes (16.9%) and bullous keratopathy in 7 eyes (8.4%), respectively. CONCLUSIONS: Glaucoma drainage implants have good outcome and visual stabilization in Asian eyes with success rates for IOP control comparable to those reported in previous studies in non-Asian eyes.     

Amyloid beta-peptides inhibit Na+/K+-ATPase: tissue slices versus primary cultures

BACKGROUND: Urinary bladder augmentation is gaining popularity for the treatment of dysfunctional bladders in renal transplant patients. Although reported cases of adult and pediatric transplants into the augmented bladder have been favorable, the potential risk of urinary tract infection and graft failure under immunosuppression is still disputable. We report our experiences with 4 patients who underwent renal transplantation into an augmented bladder. METHODS: Between 1971 and 1996, 1275 renal transplants were performed at our institution. Of these transplants, 4 patients underwent renal transplantation into an augmented urinary bladder. Augmentation cystoplasty was performed before transplantation in 3 patients and 7 years after transplantation in the other patient. The bladder was augmented with an ileal segment in 3 patients and a ureter in the fourth patient. Graft function was assessed by the serum creatinine level. Fluorocystometrograms were performed in all patients at fixed intervals. RESULTS: Posttransplant renal function was satisfactory overall and no patient exhibited proteinuria. All patients except 1 acquired a large capacity low pressure bladder and remained continent with clean intermittent catheterization. One patient who underwent ureterocystoplasty is still incontinent because of his relatively small bladder capacity. Posttransplant pyelonephritis was documented in 3 patients during the follow-up period, but no other complications were observed. CONCLUSIONS: Our study demonstrates that renal transplantation into extensively reconstructed bladders can be safely performed with good success. Although urinary tract infection is a major consideration, we recommend pretransplant reconstruction not only to preserve graft function, but also to achieve urinary continence.     

Breast implants and risk of neurologic disease: a population-based cohort study in Sweden

OBJECTIVE: To examine the risk of neurologic disorders among women with breast implants. BACKGROUND: Case reports in the literature have raised concern about a possible link between silicone breast implants and some types of neurologic disorders, but there is a dearth of epidemiologic studies in this area. METHODS: Through the nationwide Swedish hospital discharge register, we identified a population-based cohort of 7433 women with breast implants. A similarly identified cohort of 3351 women who underwent breast reduction surgery served as a comparison. The women were followed from 1972 (or date of breast surgery if it occurred later) through 1993 by means of record linkages and review of inpatient medical records. Ratios of observed to expected numbers, and relative risks (RR) with 95% confidence intervals (CI), were calculated as measures of the risk of neurologic diseases among women with implants. RESULTS: A direct comparison of the exposed (implant) versus comparison (breast reduction) groups, after exclusion of patients with pre-existing disease or incorrect neurologic diagnoses, showed no excess risk among implant patients (RR = 0.8; 95% CI = 0.5 to 1.4). When external rates derived from the background population were used as comparison, we found a small, statistically nonsignificant excess of neurologic disorders both in the breast implant (RR = 1.3; 95% CI = 0.9 to 1.9) and the breast reduction (RR = 1.5; 95% CI = 0.9 to 2.4) cohorts. CONCLUSION: Our results provide no support for the conjecture that breast implants cause neurologic disease.