I love this time of coronavirus for our national meetings. Nothing like being at home in your bunny slippers hearing our national colleagues speaking, instead of dressed up in chilly sterile convention halls.
This talk was by Dr. Dennis Hammond, a longstanding figure in the arena of breast surgery. He was talking about ALCL, the rare cancer associated with textured implants. As we know, Allergan brand had a much higher rate of ALCL than other brands of textured implants. If we can figure out the why of that, then we will know a lot more about how to prevent it and who is truly at risk.
He reiterated basic ALCL points we all take as truth now:
- ALCL is associated with textured implants.
- Biofilm, the low grade infection, is thought to be associated as well.
- ALCL is thought to be because of chronic inflammation. Whether this is due to biofilm and a low grade chronic infection, due to friction, or due to particles is of debate.
- No confirmed cases of a smooth walled implants have been associated with ALCL (in a few cases a patient had an unknown type of implant, or they had multiple different implant types over time.)
Then he went on to talk about WHY there are differences between brands of implants. The major companies (Sientra, Mentor, and Allergan) do not create texturing of their implants in the same way. This causes a difference in “roughness” and the surface characterization is different.
- Some use “imprinting” techniques to cause the texturing,
- others use a lost salt process,
- some do a multistep process, where there is lost salt, then the implant is redipped in silicone, and then scrub brushes are used to further increase the texturing.
Looking at the high risk texturing process, where the implant uses a lost salt process followed by abrasion, he focused on the face there are PARTICLES which can shed off. The size and shape of these particles matters.
- PARTICLES CAN SHED OFF.
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- When you remove capsules in a capsulectomy for these patients, we send it to pathology. He states the capsules from Biocell histologically show silicone particles embedded in the tissue. These particles are associated with a foreign body cell reaction. In the areas where there is a fold or crease in the silicone implant, the particles are abraded off even more.
- They did a study with a piece of tape, to see what came off the implant surface. With Biocell textured implants you can see silicone particles when you do this.
- They have taken capsules and dissolved them to look at the particles. They look at the quantity, the size of them, etc. When they do this with a smooth walled implant no particles are shed.
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- PARTICLE SIZE MATTERS. They theorize that large particles are encapsulated by the body, and super small particles are resorbed. The problem is with the “in between size”
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- They think multinucleated giant cells in your body try to deal with these.
- In an orthopedic journal article, they found silicone fragments, debris, and foreign body giant cells from a silicone joint arthroplasty. In the specimen they found multinucleated giant cells and an undifferentiated LARGE CELL LYMPHOMA. They said the silicone breakdown led to an inflammatory response, which eroded the patient’s joint. They postulated this was due to particle size of the silicone.
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So what was his conclusion of his talk? He had two points to conclude with. FIRST: That we need a rational guide for treatment: which means we need to do a total complete capsulectomy in patients with Biocell texturing to remove all of these particles. SECOND: When we make new textured implants, it will be important to have a stable surface, which resists abrasion, and cannot shed particles.
My thoughts?
I love science. Plastic Surgery is not the only specialty which places foreign objects into the body. Orthopedic surgeons use artificial joints and pads all the time. The fact there is a large cell lymphoma found in a joint patient with the same histology suggests we are onto a common thread.
I think chronic inflammation is bad. Period. It is why I am crazy about biofilm when placing implants, and why I have never liked things like chin and cheek implants or mesh. If I can avoid a foreign object, I do.
There seems to be a clear difference in the rates of issues based on implant brand. I am a huge Allergan fan, and thankfully did not used their Style 410 textured implant often, so I do not have lots of patients with the issue of what to do. Clearly their Biocell texturing process had issues.
I think the “particle” theory is interesting. It could explain some of the the reasoning behind why one brand has more issues.