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silicone shell implants for augmentation and reconstruction, which constitute the subject of this report. The use of autogenous tissue is reported to have begun in 1887 with part of a healthy breast transferred on a pedicle to reconstruct the other breast (Verneuil, 1887) and continued in 1895 with the transplantation of a lipoma from the hip to repair a surgical defect in the breast (Czerny, 1895). A pectoral muscle flap for immediate reconstruction and a latissimus dorsi flap were described shortly thereafter (Ombredanne, 1906; Tansini, 1906). Since transfer of fat alone is usually unsuccessful (Hinderer and Escalona, 1990) because it is substantially reabsorbed unless injected in quite small quantities (Bircoll and Novack, 1987), efforts continued with pedicle or dermis flaps or dermis-fat-fascia grafts (Bames, 1950, 1953; Berson, 1944; Watson, 1959). These early efforts were reviewed by Watson (1976) who described the tendency to long-term shrinkage of the dermis-fat grafts. Continued development culminated in musculocutaneous flaps, primarily from the abdomen (transverse rectus abdominis musculocutaneous [TRAM] flaps) but also from other sites (e.g., the latissimus dorsi or superior and inferior gluteus muscles, among others), and microsurgical free flaps. These events were reviewed in Kincaid (1984) in a chronological listing of surgical advances with citations to the literature and in 1995 by Wickman. About one-third of modern breast reconstructions are performed using autogenous tissue. Such reconstructions are performed more and more frequently and are often combined with implants (ASPRS, 1996, 1997; Trabulsy et al., 1994).

Alloplastic Implants

Also since the late 1800s, foreign substances have been injected or implanted to augment or reconstruct the breast, although sporadic efforts of this kind apparently date back centuries. Gersuny reported experimentation with paraffin injections beginning in 1889 (Gersuny, 1900). Although paraffin enjoyed some early acceptance, others later described disastrous results such as fistulas, granulomas, pulmonary emboli, and tissue necrosis (Letterman and Schurter, 1978). Subsequently, in the early to mid-1900s, a number of other substances were tried, including ivory, glass balls, ground rubber, ox cartilage, Terylene wool, gutta percha, Dicora, polyethylene chips, polyvinyl alcohol-formaldehyde polymer sponge (Ivalon), Ivalon in a polyethylene sac, polyether foam sponge (Etheron), polyethylene tape (Polystan) or strips wound into a ball, polyester (polyurethane foam sponge) Silastic rubber, and teflon-silicone prostheses (Broadbent and Woolf, 1967; Brown et al., 1960a,b; Edgerton et al., 1961; Edwards, 1963; Letterman and Schurter, 1978; Lewis, 1965; Lilla and Vistnes, 1976; Liu and Truong, 1996; Smahel et al., 1977). These early implants were unsuccessful and were not pursued seriously. The later



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