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Name: Breast reconstruction after cancer

Description: Plastic surgery, breast implants

This casebook is published and has been read 1278 times.

The author of this casebook has identified the following medical topics as being highly relevant to this casebook.

  • Malignant neoplasm of breast -- A primary or metastatic malignant neoplasm involving the breast. The vast majority of cases are carcinomas arising from the breast parenchyma or the nipple. Malignant breast neoplasms occur more frequently in females than in males. -- 2003
Notes

Breast Reconstruction

Some women who plan to have a mastectomy decide to have breast reconstruction. Other women prefer to wear a breast form (prosthesis). Others decide to do nothing. All of these options have pros and cons. What is right for one woman may not be right for another. What is important is that nearly every woman treated for breast cancer has choices.

Breast reconstruction may be done at the same time as the mastectomy, or later on. If you are thinking about breast reconstruction, you should talk to a plastic surgeon before the mastectomy, even if you plan to have your reconstruction later on.

There are many ways to reconstruct the breast. Some women choose to have implants. Implants may be made of saline or silicone. The safety of silicone breast implants has been under review by the Food and Drug Administration (FDA) for several years. If you are thinking about having silicone implants, you may want to talk with your doctor about the FDA findings. Your doctor can tell you if silicone implants are an option. You also can read information from the FDA on breast implants at http://www.fda.gov/cdrh/breastimplants/.

You also may have breast reconstruction with tissue that the plastic surgeon moves from another part of your body. Skin, muscle, and fat can come from your lower abdomen, back, or buttocks. The surgeon uses this tissue to create a breast shape.

Which type of reconstruction is best depends on your age, body type, and the type of surgery you had. The plastic surgeon can explain the risks and benefits of each type of reconstruction.

You may want to ask your doctor these questions about breast reconstruction:

  • What is the latest information about the safety of silicone breast implants?
  • Which type of surgery would give me the best results? How will I look afterward?
  • When can my reconstruction begin?
  • How many surgeries will I need?
  • What are the risks at the time of surgery? Later?
  • Will I have scars? Where? What will they look like?
  • If tissue from another part of my body is used, will there be any permanent changes where the tissue was removed?
  • What activities should I avoid? When can I return to my normal activities?
  • Will I need follow-up care?
  • How much will reconstruction cost? Will my health insurance pay for it?

Breast Implant Questions and Answers

Table of Contents

General Information About Breast Implants

  1. What are breast implants?
  2. What types are approved by FDA?
  3. How are breast implants used?
  4. Are there any age limits with respect to who can get breast implants?
  5. Why is the age minimum different for augmentation for saline-filled and silicone gel-filled breast implants?
  6. Are clinical studies of breast implants still being conducted?
  7. How can I participate in a clinical study?
  8. What are the risks of breast implants?
  9. How long do breast implants last?
  10. What causes breast implants to rupture?
  11. How will I know if my breast implant has ruptured?
  12. If my breast implant ruptures, should I have it removed?
  13. Will the platinum in silicone breast implants harm me?
  14. What are some of the important factors I should consider when deciding whether or not to get breast implants?
  15. What are “gummy bear” gel breast implants? .
  16. How can I report problems with my breast implants?
  17. Where/how can I find the adverse event reports for silicone gel-filled breast implants?
  18. Why do companies file summary reports of adverse events, instead of individual MDR reports for breast implants?
  19. What guidance does FDA provide to the companies that make breast implants?

Details about the approved Silicone Gel-Filled Breast Implants

  1. What was the basis for FDA’s decisions to approve silicone gel-filled breast implants made by Allergan and Mentor? .
  2. Who can get Mentor and Allergan silicone gel-filled breast implants?
  3. What were the most frequent complications seen in the Core Studies for the Allergan and Mentor silicone gel-filled breast implants?
  4. What did the Core Studies show regarding the rate of rupture and the consequences of rupture?
  5. What conditions of approval did FDA place on these implants?
  6. If silicone gel-filled breast implants are safe, why is FDA requiring such large post-approval studies?
  7. What if the post-approval studies uncover unexpected problems?
  8. How will FDA ensure that Allergan and Mentor complete their post-approval studies?
General Information About Breast Implants
  1. What are breast implants?

Breast implants are medical devices that are implanted either under breast tissue or under the chest muscle for breast augmentation or reconstruction. There are two major types: saline-filled and silicone gel-filled. Saline-filled breast implants are silicone shells that are either prefilled or filled with saline during surgery, and some of these allow for adjustments of the filler volume after surgery. Silicone gel-filled breast implants are silicone shells prefilled with silicone gel. Breast implants vary in profile, size, and shell surface (smooth or textured).

  2. What types are approved by FDA?

FDA has approved four breast implants for marketing in the U.S.:

  • In May 2000, Mentor and Allergan (formerly Inamed) received approval for saline-filled breast implants. These implants were approved for breast augmentation in women 18 years or older and for breast reconstruction in women of any age.
  • In November 2006, Allergan and Mentor received approval for their silicone gel-filled breast implants. These implants were approved for breast augmentation in women 22 years or older and for breast reconstruction in women of any age.

All breast implants other than these four approved devices are considered investigational devices, including the more-cohesive (“gummy bear”) implants. For a woman to receive an investigational breast implant in the U.S., she must enroll in a clinical study.

  3. How are breast implants used?

Breast implants are used for:

  • primary augmentation (to increase breast size for cosmetic reasons)
  • revision-augmentation ( revision surgery to correct or improve the result of an original breast augmentation surgery)
  • primary reconstruction (to replace breast tissue that has been removed due to cancer or trauma or that has failed to develop properly due to a severe breast abnormality)
  • revision-reconstruction ( revision surgery to correct or improve the result of an original breast reconstruction surgery).
4. Are there any age limits with respect to who can get breast implants?

Mentor and Allergan (formerly Inamed) saline-filled breast implants are approved for: (1)reconstruction (primary reconstruction and revision-reconstruction) in women of any age and (2) augmentation (primary augmentation and revision-augmentation) in women 18 years or older.

Mentor and Allergan silicone gel-filled breast implants are approved for: (1) reconstruction(primary reconstruction and revision-reconstruction) in women of any age and (2)augmentation (primary augmentation and revision-augmentation) in women 22 years or older.

FDA restricts the marketing of breast implants for augmentation to women of a minium age because young women’s breasts continue to develop through their late teens and early 20s and because there is a concern that young women may not be mature enough to make an informed decision about the potential risks. However, there is there is no age restriction on the marketing of these products for reconstruction, so as to allow young women to have access to breast implants to replace breast tissue that has been removed due to cancer or trauma or that has failed to develop properly due to a severe breast abnormality.

As for devices that are not approved for marketing, there are various age criteria and other restrictions for women who receive breast implants as part of a clinical study. Contact one of the companies conducting a study for more information. See the company contact information atBreast Implants Resource Groups.

  5. Why is the age minimum different for augmentation for saline-filled and silicone gel-filled breast implants?

FDA approved saline-filled breast implants for augmentation in women ages 18 and older. FDA approved silicone gel-filled implants for women ages 22 and older. The age restrictions are different because the risks are different for the two products.  For example, silicone gel-filled implants will require frequent MRI monitoring to detect silent rupture (a rupture that can go undetected by you or your doctor).  There is no risk of silent rupture for saline-filled implants. In addition, the health consequences of a ruptured saline-filled breast implant are different from those of a ruptured silicone gel-filled breast implant.

  6. Are clinical studies of breast implants still being conducted?

There are several ongoing clinical studies (i.e., investigational device exemption (IDE) applications) of saline and silicone gel-filled breast implants. These studies include those for the more cohesive silicone gel-filled breast implants manufactured by Mentor and Allergan (formerly Inamed), as well as studies conducted by other manufacturers. These devices are still in research and have not been approved for marketing.

In addition, Mentor and Allergan will are conduct studies on patients who get silicone gel-filled breast implants after they are approved.

7. How can I participate in a clinical study?

Information about participation in a clinical study can be obtained from the companies conducting the study. See the company contact information at Breast Implants Resource Groups.

 8. What are the risks of breast implants?

Some of the risks of breast implants include:

  • reoperations (additional surgeries), with or without removal of the device
  • capsular contracture (hardening of the area around the implant)
  • breast pain
  • changes in nipple and breast sensation
  • rupture with deflation for saline-filled implants
  • rupture with or without symptoms for silicone gel-filled implants
  • migration of silicone gel for silicone gel-filled breast implants.

For a more complete description of the possible risks and complications of breast implants, seeBreast Implant Consumer Handbook: Local Complications and Reoperations.

You can also find a list of complications for each approved breast implant in the patient labeling; see Labeling for Approved Breast Implants.

  9. How long do breast implants last?

Breast implants do not last forever.  If you decide to get breast implants, you will likely need additional surgeries on your breasts over your lifetime due to rupture, other complications (for example, capsular contracture, breast pain), or unacceptable cosmetic outcomes (for example, asymmetry, unsatisfactory style/size, wrinkling/rippling).

For information on rates of complications for approved breast implants, see the Labeling for Approved Breast Implants.

  10. What causes breast implants to rupture?

We do not know all of the causes of breast implant rupture. We do know that breast implants can rupture from:

  • damage during implantation or during other surgical procedures
  • folding or wrinkling of the implant shell
  • trauma or other excessive force to the chest
  • compression of the breast during mammography.
  11. How will I know if my breast implant has ruptured?

If your saline-filled breast implant ruptures, you or your doctor will be able to tell. When saline-filled breast implants rupture, they deflate and the saline solution leaks into your body immediately or over a period of days. You will notice that your implant loses its original size or shape.

If your silicone gel-filled breast implant ruptures, it is likely that neither you nor your doctor will know. This is known as a silent rupture. This is why MRI is recommended at three years after implantation and then every two years thereafter to screen for rupture. However, sometimes there are symptoms. These symptoms include hard knots or lumps surrounding the implant or in the armpit, change or loss of size or shape of the breast or implant, pain, tingling, swelling, numbness, burning, or hardening of the breast.

  12. If my breast implant ruptures, should I have it removed?

The patient labeling for the Mentor and Allergan (formerly Inamed) silicone gel-filled breast implants recommends removal of ruptured implants. For more information, see the Labeling for Approved Breast Implants.

You and your doctor will need to decide whether or not to have a ruptured implant removed.

  13. Will the platinum in silicone breast implants harm me?

Platinum is a metal used in the manufacture of the shell and gel components of silicone breast implants.  FDA fully evaluated the scientific literature on platinum. Based on the existing literature, FDA believes that the platinum contained in the implant shell and gel is in the zero oxidation state, which poses the lowest health risk. This is further supported by the available biocompatibility testing, gel bleed testing, and clinical data on these implants.

We will continue to review the literature on breast implant-related issues, including platinum, as part of our continuing oversight of the safety of breast implants. For more information, see theFDA Backgrounder on Platinum in Silicone Breast Implants.

14. What are some of the important factors I should consider when deciding whether or not to get breast implants?

Some important factors to consider include:

  • Breast implants do not last forever. If you decide to get breast implants, you will likely need additional surgeries on your breasts over your lifetime due to complications or unsatisfactory cosmetic outcomes.
  • Many of the changes to your breasts following implantation cannot be undone. If you later choose to have your implants removed and not replaced, your breasts will not change back to the way they looked before your implant surgery. You may have permanent dimpling, puckering, wrinkling, or other cosmetic changes.
  • When you have your implants replaced (revision), your risk of complications increases compared to your first (primary) surgery.
  • Routine mammograms to screen for breast cancer will be more difficult with breast implants.
  • Breast implants may affect your ability to breast feed, either by reducing or eliminating milk production.

Factors to consider specifically about silicone gel-filled breast implants include:

  • If your silicone gel-filled breast implant ruptures, you may have no symptoms. This is called a silent rupture because, most of the time, neither you nor your doctor will know that your implant has ruptured.
  • The best way to determine whether or not your silicone gel-filled implant has ruptured is with an MRI examination. You should have your first MRI three years after your implant surgery and every two years thereafter.
  • Over your lifetime, the cost of MRI screening may exceed the cost of your initial surgery. This cost may not be covered by medical insurance.

For additional factors to consider, see the Labeling for Approved Breast Implants.

  15. What are “gummy bear” gel breast implants?

The so-called “gummy bear” implants are more cohesive silicone gel-filled breast implants made of a firmer silicone gel filler to help maintain the shape of the implant. At this time, these breast implants are available only through clinical studies being conducted by Mentor and Allergan (formerly Inamed).  To contact one of those companies for more information, see company contact information at: Breast Implants Resource Groups.

  16. How can I report problems with my breast implants?

If you have a problem related to your breast implants and you are part of a clinical study, then it is important that you report the problem to your doctor so he/she can treat you, as well as report the problem as part of the clinical study.

If you have a problem related to your breast implant and your breast implant has been approved for marketing, then you should report the problem to your doctor and ask your doctor to report the problem to FDA. You can also report your problem to FDA yourself through FDA’s MedWatchsystem or by calling 1-800-332-1088. When you or your doctor makes a report to MedWatch, t he information is entered into a database that FDA uses to monitor safety trends to determine if follow-up is needed. If you report the problem yourself to FDA, y ou will receive an acknowledgement from FDA after we receive your report. You will be personally contacted only if we need additional information. We recommend that you k eep a copy of the MedWatch form completed by you or your doctor for your records.

17. Where/how can I find the adverse event reports for silicone gel-filled breast implants?

Individual reports are on FDA’s MedWatch website. To access these reports, follow the links for: “Medical Device Reporting,” “Access to FDA Safety Data,” and “Manufacturer and User Facility Device Experience Database (MAUDE).”

Submissions under the Alternative Summary Reporting Program (ASR) can be obtained by following instructions under the Freedom of Information Act (FOI), available via access to the main FDA website (www.fda.gov). FOI requests can also be faxed to 301-443-1726 or mailed to: Food and Drug Administration, FOI Staff, HFI-35, 5600 Fishers Lane, Rockville, MD 20857.

18. Why do companies file summary reports of adverse events, instead of individual MDR reports for breast implants?

Summary reporting is an alternative way of reporting to FDA for well known and well documented adverse events. It has been in effect for silicone gel-filled and saline-filled breast implants for many years. Summary reporting for these types of events promotes more efficient processing and analytic review for FDA and the companies.

On the other hand, companies are required to file individual MDR reports for any unexpected or unusual adverse events that may be related to breast implants. Deaths must always be reported individually.

  19. What guidance does FDA provide to the companies that make breast implants?

FDA publishes guidance documents that describe FDA’s current thinking on a topic and contain recommendations for companies . Although guidance documents are often helpful to companies, they do not create legal requirements, and their recommendations do not bind or require a company to take any specific steps. Many guidance documents advise companies how to test their products. Other guidance documents describe how companies should prepare their applications and how FDA monitors products once they are on the market.

FDA issued a guidance document on breast implants called "Saline, Silicone Gel, and Alternative Breast Implants." It describes the types of information that breast implant companies should submit to FDA when seeking approval of a breast implant so that we can assess whether or not there is a reasonable assurance that the device is safe and effective. The latest version of the breast implant guidance document was published in November 2006 and reflects information learned from two Advisory Panel meetings, over 50 comments on the 2004 draft version of the guidance document, and FDA’s review of two silicone gel-filled breast implant premarket approval applications (PMAs).

Details About the Approved Silicone Gel-Filled Breast Implants
  20. What was the basis for FDA’s decisions to approve silicone gel-filled breast implants made by Allergan and Mentor?

Scientific information in the PMAs demonstrated that there is a reasonable assurance that Allergan (formerly Inamed) and Mentor’s silicone gel-filled breast implants are safe and effective and that there is adequate information about these products to enable women to make informed decisions about whether to get them.

FDA’s decision was based on:

  • a thorough review of the companies’ Core Studies, including three years of data for Mentor and fours years of data for Allergan
  • a thorough review of the companies’ other clinical information, such as data from the Adjunct Studies (open access studies for reconstruction and revision patients), and international studies
  • a thorough review of the companies’ laboratory testing data
  • a thorough review of the published scientific literature on silicone gel-filled breast implants
  • inspections of the manufacturing facilities of both companies to ensure that the implants will be manufactured according to the Quality System Regulations
  • deliberations of the October 2003 and April 2005 Advisory Panels
  • the laws regulating medical devices.
 21. Who can get Mentor and Allergan silicone gel-filled breast implants?

The Mentor and Allergan (formerly Inamed) implants were approved for:

  • Breast reconstruction in women of any age. Breast reconstruction includes:
    • primary reconstruction to replace breast tissue that has been removed due to cancer or trauma or that has failed to develop properly; and
    • revision-reconstruction to correct or improve the result of breast reconstruction surgery.
  • Breast augmentation in women 22 years or older. Breast augmentation includes:
    • primary augmentation to increase the breast size; and
    • revision-augmentation to correct or improve the result of breast augmentation surgery.
22. What were the most frequent complications seen in the Core Studies for the Allergan andMentor silicone gel-filled breast implants?

In the Mentor and Allergan (formerly Inamed) Core Studies, the most frequent complication was reoperation (additional surgery). Capsular contracture was another frequent complication. Other frequent complications included implant removal, breast pain, nipple sensation changes, and asymmetry.

For both Core Studies, some women experienced more than one complication. In addition, the complication rates were typically higher for revision (reoperation) implants than for primary (first time) implants.

For a summary of the Core Study data for each company, see the Labeling for Approved Breast Implants.

23. What did the Core Studies show regarding the rate of rupture and the consequences of rupture?

Rupture rate and consequences of rupture were characterized for each Core Study. Consequences of rupture include intracapsular rupture (when the gel remains within the scar tissue capsule surrounding the implant), extracapsular gel (when the gel moves outside the capsule but remains within the breast tissue), migrated gel (when the gel moves beyond the breast), and clinical consequences.

Rupture rate was assessed for patients who had scheduled MRIs to screen for non-symptomatic, or silent, rupture (the MRI cohort), as well as for those who did not have scheduled MRIs to screen for silent rupture (the non-MRI cohort).

  • For the Mentor Core Study, all reported ruptures were from patients in the MRI cohort. The rupture rates were 0.5% for primary augmentation, 7.7% for revision-augmentation, 0.9% for primary reconstruction, and 0% for revision-reconstruction through 3 years. There were 8 ruptured/suspected ruptured implants in 6 patients through 3 years. Two of the implants were explanted and confirmed to be ruptured; the remaining 6 were considered suspected ruptures based on MRI evaluation. Of the 8 ruptured/suspected ruptured implants, 4 showed intracapsular gel and 4 showed extracapsular gel. There were no cases of migrated gel.
  • For the Allergan (formerly Inamed) Core Study, the reported ruptures were from patients in both the MRI and non-MRI cohorts. The rupture rates in the MRI cohort were 2.7% for primary augmentation, 4.0% for revision-augmentation, 0% for primary reconstruction, and 0% for revision-reconstruction through 4 years. For the non-MRI cohort, rupture was reported in 1 primary augmentation, 1 revision-augmentation, 0 primary reconstruction, and 1 revision-reconstruction patient. Across all patients in the study, t here were 9 ruptured/suspected ruptured implants in 9 patients through 4 years. Five of the implants were explanted and confirmed to have ruptured; the remaining 4 were considered suspected ruptures based on physical or MRI evaluation. All 9 ruptured/suspected ruptured implants showed intracapsular gel, and one intracapsular gel progressed into an extracapsular gel following exploratory surgery to confirm the rupture. There were no cases of migrated gel.

It is important to note that FDA performed an extensive review of all available data, both clinical and preclinical, to characterize rupture rate and consequences of rupture (i.e., intracapsular rupture, extracapsular gel, migrated gel, and health consequences of rupture). The Core Study was not the only source of information used to characterize rupture. Please refer to the Summary of Safety and Effectiveness Data (SSED) for each company for more information ( Mentor SSED - http://www.accessdata.fda.gov/cdrh_docs/pdf2/P020056b.pdf).

 24. What conditions of approval did FDA place on these implants?

FDA is requiring each company to do the following:

  • Continue its Core Study until all patients have completed their 10-year evaluation in order to assess the long-term clinical performance of its product. This involves:
    • collecting data via annual physician follow-up evaluations
    • giving all patients MRIs every other year
    • evaluating all patients whose breast implants were removed without replacement through 10 years.
  • Conduct a separate 10-year large post-approval study that will:
    • involve a large number of silicone gel-filled breast implant patients (approximately 40,000)
    • involve a control group of saline-filled breast implant patients
    • provide information about certain endpoints: local complications; rates of connective tissue disease and its signs and symptoms; rates of neurological disease and its signs and symptoms; potential effects on offspring of women with breast implants; potential effects on reproduction and lactation; rates of cancer; rates of suicide; potential interference of breast implants with mammography; and patient compliance with MRI recommendation and rupture rates
    • survey patients annually using web, mail, or telephone questionnaires
    • have physician evaluations at years 1, 4-6, and 9-10 for Mentor and years 1, 4, and 10 for Allergan (formerly Inamed) to collect local complication data.
  • Continue its laboratory studies to continue to further characterize the modes and causes of failure of explanted (removed) devices over a 10-year period.
  • Have an independent group conduct a focus group study of the format and content of the approved patient labeling.
  • Distribute approved patient labeling to women considering silicone gel-filled breast implants as part of a formal informed decision process, and monitor the process to ensure that patients are being informed of the risks and benefits.
  • Stop new patient enrollment into the Adjunct Studies and continue to follow all currently-enrolled patients through the final 5-year study timepoint.
  • require participation in the company’s physician training program for physician access to the product
  • Comply with FDA’s requirements for tracking these devices from their manufacture through the distribution chain to implantation. The purpose of mandatory device tracking is to ensure that companies can promptly locate devices in commercial distribution as well as those that have been implanted. Tracking information may be used to facilitate notifications and recalls ordered by FDA in the case of serious risks to health presented by the devices. For additional information on mandatory tracking, see Medical Device Tracking.

FDA intends to present an update on the status of the conditions of approval at public Advisory Panel meetings in five and 10 years, and at any other FDA decides is appropriate.

 25. If silicone gel-filled breast implants are safe, why is FDA requiring such large post-approval studies?

FDA determined that there were adequate data to support the approval of the Mentor and Allergan (formerly Inamed) products. Now that the products have been determined by FDA to be safe and effective, we will continue to monitor their safety and effectiveness by requiring each company to conduct a study of approximately 40,000 women through 10 years. The large post-approval studies will gather data on long-term local complications, connective tissue disease and its signs and symptoms, neurological disease and its signs and symptoms, reproductive issues, offspring issues, lactation issues, cancer, suicide, mammography issues, and MRI compliance and rupture results. FDA anticipates that data from these long-term studies will provide important information for patients and physicians and may lead to improvements in device labeling.

  26. What if the post-approval studies uncover unexpected problems?

If the post-approval studies uncover any new risks or unexpected problems, FDA can pursue a range of regulatory options, as appropriate. For example, FDA could require the companies to change the patient and physician labeling, or contact all patients through the mandatory tracking program.

 27. How will FDA ensure that Allergan and Mentor complete their post-approval studies?

To assure that Mentor and Allergan (formerly Inamed) complete these studies, FDA will:

  • Track the post-approval studies, using a new electronic tracking system
  • Provide guidance on how and when companies should report the status of their post-approval studies
  • Post the status of the studies on our website to help keep the public informed
  • Hold open public Panel meetings on the status of the conditions of approval five and 10 years after approval, as well as any other time FDA decides is necessary (e.g., if significant new information from the post-approval studies becomes available).

Bookmarks The following information, which has been distilled by the casebook author from this and other websites is particularly relevant to this casebook.
Bookmarks - Web
Web Page Notes Concepts
 ACS :: Breast Reconstruction After Mastectomy Breast reconstruction after mastectomy, includes glossary (Malignant neoplasm of breast)
 
 Reconstruction Breast cancer information and support (Malignant neoplasm of breast)
 
 Dr. Susan Love Research Foundation | Menopause & Women's Health - Breast reconstruction Dr. Susan Love Research Foundation (Malignant neoplasm of breast)
 
 Adult Stem Cell Research Helps Breast Reconstruction After Lumpectomy « The Stem Cell Blog Stem Cell Blog, breast reconstruction after lumpectomy (Malignant neoplasm of breast)
 
 Breast Cancer Surgery Choices - National Cancer Institute Surgery choices for early stage breast cancer (Malignant neoplasm of breast)
 
 Breast Implants U.S. Food and Drug Administration (FDA) information about breast implants (Malignant neoplasm of breast)
 

This web-site is for informational purposes only and is not intended as a substitute for advice from your doctor. It should not to be used for self-diagnosis or treatment.