Sunday, October 10, 2004

Silicone Mastitis: Management Guidelines and Autologous Tissue Reconstruction

Gordon Lee, MD, Babak Mehrara, MD, Andrew Da Lio, MD, and William W Shaw, MD.

PURPOSE: Free silicone injection was a popular method of breast augmentation in the 1960’s, which was performed on a countless number of patients. However, reports of its adverse and often deforming effects led to the termination of this procedure nearly a decade later. To this day, patients who underwent this procedure present with pain, inflammation, skin discoloration or frank ulcerations, and firm irregular masses—a constellation of symptoms collectively termed “silicone mastitis.” Not only can a true malignancy be masked on clinical exam, but mammography is distorted and early cancer detection is nearly impossible. The purpose of our study was to review the treatment of patients with silicone mastitis and to put forth management guidelines and optimal methods of reconstruction.

METHODS: We performed a retrospective chart review of patients treated by the senior author for silicone mastitis at the UCLA Medical Center from 1990 to 2002. Treatment modalities were noted, and specifically, methods of breast reconstruction involving autologous tissue, implants, or a combination were evaluated. We reviewed operative details and noted any unusual problems encountered during surgery, as well as post-operative complications.

RESULTS: Fourteen patients underwent treatment for bilateral silicone mastitis during the study period. Two patients with focal areas of disease were successfully treated with excision and local breast parenchyma flaps. The majority of patients (12 of 14) required total mastectomies to eliminate the silicone-infiltrated tissues. All patients elected to undergo immediate breast reconstruction. Five patients underwent bilateral TRAM flaps, one patient underwent TRAM plus implant, two patients had gluteal flaps, one patient had latissimus and implant, one patient had latissimus alone, one patient had implant only, and one patient underwent staged reconstruction with tissue expander and implant. In our series, post-operative complications included seroma (40%), nipple necrosis (10%), skin flap necrosis (10%), infection (10%), and wound breakdown (20%). In cases of free tissue transfer, infiltration of silicone precluded the use of recipient thoracodorsal and internal mammary vessels in 3 of 16 flaps (19%), and therefore, alternative means of revascularization were used.

CONCLUSION: Free silicone migrates and permeates surrounding tissues. In managing silicone mastitis, the only effective means of eliminating silicone-infiltrated tissues is to completely excise it, which in most cases entails a total mastectomy. The presence of residual silicone compromises skin and nipple vascularity, and may preclude the use of the thoracodorsal or internal mammary as recipient vessels in free tissue transfers. In our series, post-operative complications were increased, which can be partly explained by the presence of a persistent inflammatory milieu due to free silicone. Such pitfalls are important to note if further complications are to be avoided, and may make an argument for delayed breast reconstruction. Whereas implant-based reconstruction has been traditionally fraught with complications and need for multiple operations, we believe that autologous tissue is the preferred method of breast reconstruction, and is much more resilient to the hostile tissue environment induced by silicone mastitis.

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