Every year that passes for Ann Hart, 38, of Brea, Calif., is like the faint click of a revolver’s chamber in a game of Russian roulette.
A 1994 mammogram found 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 the 19-year-old implants replaced. The figures quoted her–$6,000 to $9,000–are prohibitive, given that she is raising two children.
Still, last month’s verdict finding that Dow Corning 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.
At best, the ruling in the Louisiana class-action lawsuit 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 life as usual, hope the one implant doesn’t leak, and rely on the advances in technology–including the new endoscopic evaluation as well as mammograms, ultrasound tests and magnetic resonance imaging–to stay healthy.
Of these methods, none has surgeons more divided than the endoscopic examination–lauded by a few practitioners as accurate, criticized by others as risky, especially when other safer, non-invasive methods are available.
Dr. Howard Tobin, clinical professor of surgery at the University of Texas Southern Western Medical Center in Dallas, was an early 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 an 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 absolutely 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.”
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.
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 sometimes can tighten around and constrict the soft implant, making it harden. This capsular contraction can be uncomfortable and can make the implant look unnatural. Sometimes, it can lead to ruptures and leakage.
Tobin uses the laser attached to the endoscope to cut the capsule and free the implant, which in turn, 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.
Some surgeons in Southern California said they would not use the endoscope even for examination because of 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, Calif. “It doesn’t give you any more information than you get from an MRI.”
An endoscopic exam is invasive and therefore exposes someone to the possibility of infection, said Dr. Robert Kachenmeister, a plastic and reconstructive surgeon in Newport Beach, Calif. “The new imaging techniques are so specific and sensitive to the types of implant ruptures. And radiologists have become more experienced and have been good at reading MRI results.”
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 and Drug Administration as less risky than silicone versions. Saline implants are less likely to develop capsules. When they tear, they deflate and are absorbed by the body.
