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8 International Journal of Cosmetic Surgery Vol. 7, No.1, 1999
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ORIGINAL ARTICLES
The Alternative Breast Implant
GERALD W. JOHNSON, M.D.*
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Abstract
Introduction: The silicone controversy has resulted in a search for new types of breast implants for augmentation. The author hypothesized that polyprolene string, already used in Marlex mesh and Prolene suture, would be nonbiode-gradable and would make a satisfactory material for breast augmentation without the use of an external shell.
Materials and Methods: Nineteen patients received im-plants of polypropylene strands for breast augmentation. The strand diameter was changed during the study from 1.5 mm to 0.75 mm because of the decrease in string palpability with the smaller diameter.
Results: Deformity of the breast occurred in one patient because of incomplete capsulectomy when saline implants were removed and replaced with string. There was one infection when the implant pocket was injected multiple times postoperatively with saline and povidone-iodine to obtain a softer breast by stimulating serum output into the pocket. One patient had an expanding hematoma that became organized and required removal of the implant.
Conclusions: Polypropylene string is a satisfactory alter-native implant materialfor breast augmentation.
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T he silicone gel implants controversy has made some patients and even physicians concerned about the use of silicone, even with saline implants using a silicone shell. A variety of different fillers have been proposed, but the problem of capsule contracture remains.
A study was started to evaluate the use of the polypropylene string in breast augmentation. It was hypothesized that because this substance is used in Marlex mesh and Prolene suture, the material would be nonbiodegradable and would make a satisfactory material for breast augmentation without the use of an external shell.
Materials and Methods
Nineteen female patients received implants of polypropylene strands.
The patients were given the opportunity to select their own type of implant, including
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Received December 12, 1998; accepted for publication February 22, 1999.
* Houston, Texas.
the potential alternative implant material. The patients first viewed generalized informational videos showing standard augmentations, endo-scopic augmentations,1 and realistic expectations. Each patient then had a nurse consultation followed by a physician consultation to cover what she had already seen, to answer questions, and to provide her with specific informa-tion on the polypropylene. She was then given a 2.5hour video with much more detailed information on the altema-tive implant that included preoperative and postoperative views of previous alternative implant patients. Finally, the patient was given an edited version of printed information about biomaterials in surgery.
Every patient was given the option to replace the implants after 3 months with saline implants for either no charge or the cost of the implants. No specific reason for the replace-ment of the implants needed to be given. Any patient dissatisfaction was considered reason enough.
Strand Volume
Before performing the first augmentation using the polypropylene string, the weight or volume of string was determined that, when inserted into the breast, would produce the size of breast the patient wanted.
Compaction studies were performed on the string using containers calibrated in cubic centimeters. The pressure inside a breast with a soft silicone implant is about 20 cm H20.2 The shortening of fibers, cross-linked around an implant, can increase the internal pressure of the implant to 50 to 55 cm H20. Because no serious or frequent problems were anticipated with the string implants, the postoperative internal pressure inside the breast was calculated that would approximate that of a soft gel implant.
Twenty centimeters of water pressure equates to approximately 0.4 lb/in2. The 1.5-mm polypropylene string was compacted under 0.4 lb/in2 to the point that a volume of 100 mL of string compacted to 0.4 lb/in2. That volume of string was weighed, and we found it took 0.9 oz of string to yield 100 mL volume under a pressure of 0.4 lb/in2. After gaining experience with the first 10 to 12 patients, it became clinically apparent that despite the compaction studies and calculations, we were falling 10% to 15% short of the patient’s desired volume after 2 to 3 months postoperatively. We empirically increased the weight of polypropylene from 0.9 oz per 100 mL to 1.0 oz per 100 n-L.
The density (specific gravity) of polypropylene is 0.905, which means that 100 mL of the string is 10% lighter than water. It also should be remembered that the patient’s serum,
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International Journal of Cosmetic Surgery Vol. 7, No.1, 1999 9
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which has a specific gravity slightly higher than that of water, will fill the spaces within the string implant. In the small series of alternative implant patients, there has not been any consistent pattern or common denominator to predict how much serum will enter the breast cavity in each patient. However, it has become obvious that, within reason, the more fluid the patient has in the cavity with the string, the softer and more natural the breasts feel.
Technique
The operative technique in primary mammary augmentation or after capsulectomy for capsule contraction requires development of an adequate pocket or total resection of the capsule.1 The polypropylene stands were brought up to medical grade by the author by careful cleaning (to remove alcohol) and by sterilization. At first 1.5mm string was used, but because of the palpable sensation of feeling the string rub against itself, 0.75mm string was substituted. The strand is fed into the pocket until the predetermined volume is reached.
Once the implant has been placed into position above the pectoralis major muscle and beneath the breast tissue, a short intravenous extension tube is positioned beneath each
implant. The incision is closed in layers with 3-O Vicryl sutures, and the skin is reinforced with Steri-strips. One hundred milliliters of saline/povidone-iodine solution is instilled into each breast, the intravenous tubing is pulled out, and a Steri-strip is used to close the opening. The patient is wrapped with a compressive bandage. Every patient is given a broad-spectrum antibiotic when the intravenous fluid line is started before surgery, and a prescription is given postoperatively for an oral broad-spectrum antibiotic to be taken for 5 days.
Results
The feel of the string-augmented breast, in the opinion of the author, is equal to or better than that of a soft silicone-augmented breast as long as there is an adequate amount of serum in the breast. In cases in which the breast has less serum in the string, the feel is more like that of a young, fibrous, and firm breast, but not like the firmness in an encapsulated silicone-augmented breast. Even in most firm string-implanted breasts, the firmness is not like the encapsulated silicone-augmented breast and the appearance of the breast remains, cosmetically, very good (Figures l-3).
There were several postoperative complications, two of which were probably the result of inexperience
Figure 1. (A) A 48-year-old patient with capsule contracture of silicone implants. (B) Two months postoperatively with polypropylene string implants.
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