For Soldier Disfigured in Afghanistan, a Way to Return to the World

AppId is over the quota AppId is over the quota So it began: the shock of recognition. Next came what burn doctors call “the mirror test.” As he was shuffling through a hallway at Brooke Army Medical Center in San Antonio, he passed a large mirror that he had turned away from before. This time he steeled himself and looked.

His swollen lower lip hung below his gums. His left lower eyelid drooped hound dog-like, revealing a scarlet crescent of raw tissue. His nostrils were squeezed shut, his chin had virtually disappeared and the top half of one ear was gone. Skin grafts crisscrossed his face like lines on a map, and silver medicine coated his scars, making him look like something out of a Terminator film.

“This is who I am now,” he told himself.

Every severe injury is disfiguring in its own way, but there is something uniquely devastating about having one’s face burned beyond recognition. Many burn victims do not just gain lifelong scars, they also lose noses and ears, fingers and hands. The very shape of their faces is sometimes altered, forged anew in heat and flame.

More than 900 American service members have been severely burned in Iraq or Afghanistan since 2001, typically from roadside bombs, the military says. Almost all receive extraordinary emergency care and rehabilitation at Brooke. But many will never have their faces restored.

Mr. Paulk, though, has come close. After leaving Texas, and the Army, in 2009, his mouth and eye still deformed, he returned home to California and became something of a recluse, hiding beneath hooded sweatshirts, baseball caps and dark glasses when he went out, if he went out at all.

But he found his way to a program at U.C.L.A. Medical Center called Operation Mend that provides cosmetic surgery for severely burned veterans at no cost — and the operations fundamentally realigned his face, restoring not just the semblance of his former visage, but also a healthy chunk of his self-confidence.

He is venturing out again, to bars, beaches and ball games. On Veterans Day last year, Mr. Paulk, 26, rode in the lead car of the New York City parade, his head bared for tens of thousands to see.

“The burns on a soldier’s face are huge: It’s your military uniform and you can’t take it off,” he said. “The surgery changed so much on my face that it completely changed my whole outlook on life.”

The story of Mr. Paulk’s cosmetic and emotional revival says much about the ways private philanthropy can complement the overtaxed military and veterans health care systems. Now in its fifth year, Operation Mend has provided free cosmetic surgery to more than 50 badly burned veterans of the current wars. The program estimates it spends $500,000 on each of its patients.

But the story also underscores the difficulties of bringing private care into the military world. Though Operation Mend’s founder envisioned the program as a model for public-private cooperation in treating wounded soldiers, it remains one of only a few such ventures, which include Center for the Intrepid rehabilitation centers and Fisher Houses for military families.

Part of the problem, said Gen. Peter W. Chiarelli, the outgoing Army vice chief of staff who has embraced Operation Mend, is that many military doctors remain uncomfortable referring patients out of their system, which they view as a protective cocoon for troops and their families. But that attitude is changing, said General Chiarelli, who is pushing for a private program similar to Operation Mend for treating traumatic brain injuries and post-traumatic stress disorder. “Our problems are so big, we have to reach out beyond ourselves,” he said.

Mr. Paulk, who grew up and still lives in the town of Vista in northern San Diego County, joined the Army a year out of high school in 2004, thinking it might help him get a job in law enforcement.

On his first deployment, with a military police unit in eastern Afghanistan in 2007, he was in a Humvee when it struck a buried mine that ignited the fuel tank and instantly killed his team leader. Mr. Paulk regained consciousness 20 feet from the truck, engulfed in flames.

In searing pain yet shivering with cold in the 90-degree heat, an odd question popped into Mr. Paulk’s head as he waited to be evacuated: Do I still have hair? Yes, another soldier said; his Kevlar helmet had saved it. “Maybe,” Mr. Paulk told himself, “the burns aren’t so bad, and I’ll still look like me.”

But it was not to be. By the time he awoke in San Antonio from a medically induced coma, he had already undergone numerous operations and skin grafts to patch his charred face, arms and legs. With his mother’s permission, a surgeon had removed all his fingers, which had been burned black and to the bone and were all but certain to become infected. He had lost 50 pounds in barely four weeks.

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Dr. Hank Chien, a King of Donkey Kong

AppId is over the quota AppId is over the quota That night, a well-rested Dr. Chien, 37, fired up the 30-year-old Donkey Kong arcade game that stands next to the television in his small apartment in Midtown Manhattan. He finished just after midnight with a score of 1,061,700.

“New world record,” Dr. Chien, a plastic surgeon, yelled while clapping for himself.

All this was captured by a video camera recording the game for proof of the record, which eclipsed the legendary Billy Mitchell’s longstanding high score, 1,050,200. But Mr. Mitchell struck back, and on July 31 he wrested the title back with 1,062,800. A month later, another Donkey Kong titan, Steve Wiebe, set a record with 1,064,500. In February, Dr. Chien set the current record, 1,090,400, at the Funspot arcade in New Hampshire, lifting him into the Guinness World Records 2012 Gamer’s Edition.

“It is a good feeling to know you’re the best in the world at something,” he said, “but one thing about Donkey Kong, you know there are people out there trying every day to break your record.”

Dr. Chien is the middle child among three boys, and moved here from Taiwan at age 2 with his family. He grew up in Forest Hills, Queens, and attended Stuyvesant High School and then Harvard, where he was a math and computer science major. He graduated from the Mt. Sinai School of Medicine and now has a private practice in Flushing, Queens, with a mostly Chinese-immigrant clientele.

Dr. Chien specializes in reshaping his patients’ eyes to create a crease in the upper eyelid. Some patients select him after hearing about his Donkey Kong prowess. This is not so silly, he said, since good gamers make good surgeons and vice versa. Also, compared to the pressure of competitive Konging, he said, eyelid surgeries and tummy tucks are a breeze.

“For both gaming and surgery, you have to have a focused personality and be very precise,” he said. “They both take foresight and good reflexes, and a lot of strategy and planning and timing.”

Still, Dr. Chien keeps no Donkey Kong machine in his office, a snazzy, spalike suite trimmed with frosted glass, high up in a building just off teeming Main Street.

He got hooked on Donkey Kong after seeing “The King of Kong: A Fistful of Quarters,” the popular 2007 documentary about competitive practitioners of this classic arcade game, which pits a large ape called Donkey Kong against Mario, Nintendo’s famous Italian-American plumber-hero. Dr. Chien started playing first on his home computer, and then on the only Donkey Kong machine he could find in the city: at Barcade in Williamsburg, Brooklyn, with its rows of retro video games and array of micro-brews.

There, on Wednesday night, he chatted with the bartender, Alexis Neophytides, who — this being Williamsburg — is also a filmmaker. She wound up making a short documentary about Dr. Chien last year: “Doctor Kong: Cutting Up the Competition.”

“Hank is royalty here,” said George Leutz, 37, a customer at Barcade. “When he walks in, you hear the whispers going around, ‘Hey, that’s Hank Chien.’ ”

Dr. Chien eyed the Donkey Kong game against the wall, and a woman at the bar seemed to automatically pull a quarter out of her handbag and press it into his palm. Dr. Chien pumped it into the machine and he was off, hurdling barrels rolled at him by Donkey Kong.

The woman with the quarters walked over — she was Dr. Chien’s girlfriend, Youmee Im, 33, a finance executive — and when Dr. Chien got too distracted, she finished his sentences for him.

His left hand jiggled the directional knob, and his right hand jabbed at the jump button, maneuvering the Mario character up a course of inclines and ladders to try to rescue the damsel in distress from the big gorilla. The way the game is set up, the player never gets the girl, but Dr. Chien did manage to win over Ms. Im, a pretty mean Centipede player herself, with his gaming prowess, after impressing her on dates two years ago.

At the bar, Mr. Leutz said he was inspired by Dr. Chien to go after one of the most enduring marks in gaming: a 1983 world record of 33,273,520 points on one quarter in Q*bert, which requires about 70 hours of continuous play. He recently logged 57 hours straight before collapsing, but for his next attempt, he wants Dr. Chien to surgically implant a catheter to reduce the need for bathroom breaks. They discussed other surgical procedures that might help hardcore gamers.

“Cut my eyelids off,” Mr. Leutz yelled, and everyone laughed — Dr. Chien loudest of all.

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France Recommends Removal of Suspect Breast Implants

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While trying to dampen fears that the implants were linked to any kind of cancer, the French health minister, Xavier Bertrand, recommended that recipients have an “explant” procedure as a preventive, nonemergency measure, even if there were no clinical indications that the implants had been leaking substandard silicone. Medical experts said they were unable to think of any prior action on implants on the scale of the French decision.

The implants — made by a French company, Poly Implants Proth?ses, that was closed last year — used an inferior, industrial-grade silicone and are more likely to rupture or ooze than those made from surgical silicone. The French authorities stressed that the leaked gel carries no known link to cancer, focusing instead on how it can irritate body tissues and cause damaging inflammation.

Questions over how low-grade silicone could have gone undetected in hundreds of thousands of implants sold in Western Europe, Australia and South America come on the heels of France’s largest public health scandal in years. That involves a diabetes medication, Mediator, that was also used as a diet drug. It remained in circulation despite at least a decade of warnings, and health officials say it may have caused as many as 2,000 deaths. The maker, Servier, has been charged with defrauding the health-care system and is being investigated for consumer fraud and manslaughter.

No PIP implants were known to have been used in the United States, but there are concerns over an unknown number of women who traveled to South American for less-expensive implants. So far, no country has reported a rupture rate as high as France’s — 5 percent — and most have issued statements meant to reassure implant recipients.

Anxieties rose sharply last month when a French woman whose implant had ruptured died from a rare cancer called anaplastic large-cell lymphoma, and French media reported that she was the eighth woman with the PIP implants to have died of cancer, a figure for which the statistical significance is unclear.

On Friday, the health authorities in Britain, where some 40,000 women received the implants, said it was not recommending “routine removal. ”

“We recognize the concern that some women who have these implants may be feeling, but we currently have no evidence of any increase in incidents of cancer associated with these implants and no evidence of any disproportionate rupture rates other than in France,” the British agency said in a statement.

In Brazil, where about 25,000 implants were used, the National Agency of Sanitary Vigilance recommended that recipients be examined by their doctors. Chile’s Public Health Institute asked doctors who performed implants to contact patients to explain the emerging concerns.

The healthy ministry in Venezuela, one of the region’s largest plastic surgery markets, did not comment, nor did that in Colombia, where nearly 15,000 women have had PIP implants.

Breast implants have had a contentious history, with critics saying they are overused and that women in the pursuit of a narrowly defined ideal of beauty end up subject to uncertain dangers from silicone leaks, including auto-immune problems and what animal studies suggest are possible links to cancer. In the United States, a 14-year moratorium in the United States on all silicone implants was lifted only in 2006, after two decades of litigation in American courts failed to show a conclusive link to cancer in humans. The United States Institute of Medicine and the Food and Drug Administration eventually determined that there was no evidence that standard silicone implants were harmful.

A spokeswoman for the French health products safety agency, known as Afssaps, said it was possible that the rupture rates in other countries were lower because reporting was still low, or because complaints had not yet reached some governments.

“We began in March 2010 to alert the authorities in the countries that had imported those implants,” she said. “But the question is whether they passed on the information to the population. We don’t know.”

France will foot the bill for the implant removals, but will only pay for new implants in women who had them for reconstructive surgery after breast cancer. Women who choose not to undergo the removal should have an ultrasound examination every six months, the authorities said, and should remove any implant that ruptures.

Some foreign doctors expressed approval for the French approach.

Ravi Somaiya contributed from London, Simon Romero from S?o Paulo, and Gardiner Harris from Washington.

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Non-Specialists Expand Into Lucrative Cosmetic Surgery Procedures

AppId is over the quota Vad hon inte inser var att hans certifiering i ?NH — ?ra, n?sa och hals — inte plastikkirurgi. Resultatet var mindre ?n idealisk: tjock ?rr p? hennes tempel och en v?gig buken.

"Jag var tvungen att anv?nda mitt sparande f?r att f? verkliga plastikkirurg att fastst?lla vad han gjorde till mig," sade Joan, som bad att hennes efternamn inneh?llas f?r att skydda sin integritet. "Jag har en M.B.A. Jag ?r inte dum. Men n?r l?karen har en trevlig klinik och alla dessa examensbevis och certifieringar p? v?ggen, du tror att han vet vad han g?r.

Med fallande f?rs?kring ?terbetalningar, utvidgar fler l?kare, oberoende av specialitet, sin praxis att inkludera lukrativa kosmetiska f?rfaranden som betalas ut av kontant av patienter. Nu ?r det vanligt att hitta gynekologiska erbjuder breast augmentation, ?gonl?kare g?ra Fettsugning, ens familj praxis l?kare ger Botox injektioner.

Resultatet ?r enligt certifierade plastikkirurger, ett ?kande antal missn?jda, ?ven vanst?llda, patienter.

"Allm?nheten beh?ver skyddas fr?n l?kare som inte ?r uppriktiga om vad styrelsen certifieringar de har," sade Dr. Malcolm Z. Roth, chef f?r plastikkirurgi i Albany Medical Center i Albany och ordf?rande i det amerikanska samh?llet av plastikkirurger.

Medlemmar av samh?llet som h?vdar det har funnits en v?g i patienter beg?r revisionary kirurgi – ?tg?rder f?r att ?ngra skador som orsakats av klantiga f?rfaranden. "Jag ser fall s? h?r en vecka nu, n?r ett par ?r sedan jag knappast s?g n?gon," sade Dr. Patti Flint, plastikkirurg i Mesa, Ariz.

Men m?nga av dessa nya alternativa ut?vare s?ga att traditionella plastikkirurger helt enkelt f?rs?ker skydda sina lukrativ handel. "F?r en viss grupp att f?ra en turf slaget och s?ga av ekonomiska sk?l att de ?r de enda som p? ett s?kert s?tt kan utf?ra kosmetiska f?rfaranden ?r hyckleri och grovt osant," sade Dr. Angelo Cuzalina, rival American Academy of kosmetisk kirurgi, ordf?rande best?r fr?mst av l?kare som inte ?r inriktning plastikkirurger.

Cirka 80 procent av licensierade l?kare f? en specialitet certifiering av en av 24 styrelser som godk?nts av amerikansk styrelse av medicinska specialiteter. Detta kr?ver en minst tre?rig vistelse i omr?det valda koncentrationen, plus omfattande muntliga och skriftliga examina.

Det finns inga lagar i USA som kr?ver l?kare praxis endast inom f?lten specialitet i vilken de har utbildats. Dr. Cuzalina, till exempel var f?rst inriktning som en oral och maxillofacial kirurg och sedan avslutat ett yearlong stipendium p? en kosmetisk kirurgi klinik.

-Med min erfarenhet jag inte tror mig som en muntlig kirurg l?ngre,"sade han.

Bara Texas, Kalifornien, Louisiana och Florida mandat att l?karna vara best?mda i sin reklam om vilka specialitet styrelsen certifieringar de har. N?gon annanstans f?r s?ger bara att de ?r "inriktning".

Ingen vet hur m?nga l?kare praktisera utanf?r deras specialitet; de beh?ver inte rapportera till den myndighet som tillsyn att de g?r s?. Och l?kare som utf?r kosmetiska f?rfaranden ?r inte skyldiga att rapporten komplikationer.

Kosmetisk kirurgi oreglerat art ?r fortfarande, att h?ja oro. Michael Freedland, medicinsk felbehandling advokat i Weston, Fla., sade att han hade sett en stadig ?kning av antalet patienter arbetsof?rm?gna eller ens f?rolyckas av kosmetisk kirurgi som utf?rs av okvalificerade l?kare sedan 2008.

-Inte bara utbildas l?karna inte korrekt i plastikkirurgi, men de ?r ocks? verksamma i anl?ggningar, liksom garvning salonger och med SpA, som inte ?r utrustade f?r att hantera en medicinsk n?dsituation,"s?ger han. "Det b?sta de kan g?ra f?r dig om saker g?r fel ?r samtal 911, och ibland de g?ra ens inte."

Statliga medicinska myndigheter ?verensst?mmelsen inte d?dsfall eller skador p? vilken typ av l?kare deltar. M?nga plastikkirurgi patienter ?r hur som helst, liksom Joan, alltf?r generad ?ver att filen formella klagom?l.

"En l?kare kan vara bra och v?lutbildade inom hans eller hennes specialitet, men det tar mer ?n ett helgen seminarium att uppn? h?jdpunkter i plastikkirurgi," sade Dr. Joel Aronowitz, plastikkirurg i Los Angeles som ocks? ?r en klinisk Adjungerad professor p? University of Southern California.

Han noterade att blivande kosmetiska kirurger f?r delta i helgen fortsatta medicinska utbildning kurser, vissa h?lls ombord p? kryssningsfartyg, d?r de l?rs att utf?ra Botox och fyllnadsmedel injektioner, Fettsugning och breast augmentation. Kurserna ?r ofta l?rt av l?kare som sj?lva inte ?r certifierade av den amerikanska styrelsen av plastikkirurgi, sade han.

M?nga s?dana l?kare h?vdar certifiering av styrelser som har namn som liknar till den amerikanska styrelsen av plastikkirurgi men inte godk?ndes av amerikansk styrelse av medicinska specialiteter. -De har l?gre krav och ?r inte s? str?nga, sade Dr. Aronowitz. "Det finns en anledning som de inte ?r erk?nda styrelser."

Dr. Cuzalina sade att lobbying fr?n plastikkirurger f?rhindras grupper som hans fr?n ansluta till styrelsens medicinska specialiteter.

Dr. John Santa, en l?kare och chef f?r konsumenten rapporter h?lsa omd?men Center, som r?ntesatserna f?r sjukhus och ger r?d om hur du v?ljer l?kare, designad att blivande patienter kontrollera staten medicinska styrelser f?r eventuella disciplin?ra ?tg?rder, och s? ser du om en l?kare har ocks? full drift, beh?righeter p? ett visst sjukhus.

"Framf?r allt jag tror sunt f?rnuft ?r i ordning," sade han. "Jag skulle vara misst?nksam mot alla som ?r verksamma s?tt utanf?r hans eller hennes specialitet, och alltid f? ett andra yttrande.

"N?r det finns n?gon f?rs?kring," tillade han, "?r det verkligen vilda v?stern och det finns ingen sheriff i stan."

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From Eye and Hair Surgery to Toasty Toes - Beauty Spots

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Frenchwomen Worry About Suspect Breast Implants

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Rachel Rodriguez, a 35-year-old mother who sells shoes in this quiet city on France’s Atlantic coast, has stopped exercising. And, she said, she developed psoriasis on her scalp from anxiety and lost 24 pounds in a month.

“She is glued to the Internet, doesn’t sleep or enjoy life anymore,” said her husband, Jean-Marc, a security guard. “We’ve fallen into real paranoia.”

Ms. Rodriguez is one of the 30,000 Frenchwomen who were given the implants, which were filled with an industrial-grade silicone and are more likely to rupture or ooze than those made from surgical silicone. About 300,000 women across 65 countries received the implants.

The problems with the implants were first revealed in 2010, when the French government ordered their withdrawal from the market, though at the time it did not recommend their removal from those who already had them. But women with the implants got a fresh jolt in November news broke that a woman whose suspect implants had leaked had died of a rare form of lymphatic cancer.

While French health officials said the gel carried no known link to cancer, the news had many women here hurrying to have their implants removed, lest they rupture and spread a potentially toxic gel in their bodies.

?milie Germain, who received the faulty implants in 2009, said she had noticed several lumps in her breasts and often felt a burning sensation. But she was not sure what to make of it.

“I feel like I’m having symptoms that aren’t real,” she said. “It certainly comes from anxiety.”

In December, French health officials recommended that women have the implants removed as a preventive measure. The government has said that it will cover the cost, but that it will pay for new implants only for women who had them for reconstructive surgery after breast cancer.

“Many women who come to us can’t pay for new breasts,” said Muriel Ajello, who leads a group defending affected women. “Those people are our priority.”

The women primarily fear for their health. Even so, many also joined Ms. Ajello’s association to be recognized as victims and fight against the perception that they were somehow at fault for having had the surgery in the first place. They pointed out that many women have implants after a mastectomy, or after extensive breastfeeding that can shrink the breast, and not just for vanity.

“We aren’t bimbos,” Ms. Rodriguez said. “We aren’t psychologically weak people, either.”

Ms. Rodriguez and the others criticized health officials and surgeons for not immediately alerting them to the potential risks. Some women even said that their surgeons had been absent or on vacation since news of the scandal broke. Others held the government responsible for waiting more than a year after the offending gel was withdrawn from the market before taking preventive measures.

They often compare the implant scandal to the outrage in the 1990s over contaminated blood, when the news media discovered that France’s National Center of Blood Transfusion had knowingly distributed AIDS-contaminated blood products to hemophiliacs in 1985. That case brought criminal prosecutions.

“We found out the truth only 15 years after it happened,” Ms. Rodriguez said. “I fear that this is going to happen with the implants.”

Many surgeons have tried to calm fears, saying that there was no evidence that the gel was harmful. But women with the implants said that they knew very little about the product.

“There hasn’t been any reliable medical expertise about it,” Ms. Germain said of the gel, adding that her surgeon had on his desk the files of 200 women waiting to have their implants removed.

“There are many rumors, and sometimes nonsense,” said a surgeon who had given several women the implants. “What struck me most is that no one until recently asked us to keep the implants with us for further analysis,” he said. He agreed to speak only if his name was not used, because of the possibility of litigation over the issue.

Annie Mesnil, a 65-year-old graphic designer and mother of three, had her right breast removed after she received a diagnosis of breast cancer in 1999.

“I couldn’t imagine myself living with one of my breasts missing,” she said.

She happily accepted her surgeon’s suggestion to have implants and asked no questions. “He said they had satisfying results, and I trusted him.”

In March 2010, when she found out that the company had stopped its production of implants, she had a scan that showed nothing wrong. But because she had already suffered from heavy chemotherapy and wanted to take no chances, she picked another surgeon and had her implants removed in June.

But the implants had already leaked. “They had ruptures of more than 10 centimeters deep in different places,” said Dr. Benjamin Pulvermacker, the surgeon who operated on Ms. Mesnil. “The gel had leaked, and I had to clean up the entire space where the implant was placed.”

Ms. Mesnil said that she felt like she has had a sword of Damocles over her head for the past six months, anxious about the consequences of the leakage. “The gel can infiltrate the body tissues, and no one knows if we can take all of it out,” she said.

Ms. Rodriguez has been coping with the same feeling of helplessness. She is counting the days before she has her surgery on Jan. 25. This time, she said, her surgeon told her of a Web site where she could choose different varieties and brands of implants.

“I’ll pick ones made of physiological salt solution,” she said. “They are translucent, and you can easily see through them.”

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Health breast implants concerns over suspected French spread abroad

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It is unclear whether there are health risks posed by the substandard silicone used in the implants, and the French government is expected to decide soon whether to require as many as 30,000 women in France to have their implants removed.

If the government mandates the removals, it will also pay for the procedures, though not for replacements. Regulators will have to weigh whether the known risks associated with removing the implants outweigh the uncertain risks and modern associated with leaving them intact.

The British health authorities on Wednesday sought to calm the women's fears, saying that there was no evidence that the suspect implants, which were manufactured by Poly Implants Proth?se, a company known as PIP, had caused cancer. They urged women who had received them to take any concerns to their surgeons, but they also said, "There is currently no evidence to support routine removal" of the implants.

Britain's surgical Association also tried Wednesday to "soothe anxiety. "The message here is not to panic," said a consultant plastic surgeon, Mr Douglas McGeorge, who spoke for the British Association of Aesthetic Plastic Surgeons.

Silicone implants have had a contentious history, with the United States imposing a 14-year moratorium on their use that ended in 2006, after years of lawsuits contending that they had caused cancer. None of PIP's implants appear to have been sold in the United States.

The Institute of Medicine and the Food and Drug Administration eventually determined that there was no evidence that silicone implants were harmful.

Concerns over the silicone in the suspect implants began to build last year, when PIP was shut down and prosecutors began investigating the company for possible fraud. The French authorities said the implants had been rupturing at a rate double the industry average, the French media reported.

But the concerns over the company's implants caught the attention of European health officials after a woman whose implants had ruptured died last month from a rare cancer called anaplastic large-cell lymphoma.

The French media reported that she was the eighth woman with an implants manufactured by the company to have died of cancer, although the statistical significance of that is unclear.

French prosecutors have said that Poly Implants Proth?se substituted a cheap, industrial-grade silicone for medical-grade silicone that is the industry standard. The French authorities have said the substandard product causes inflammation to body tissues when implants are compromised. But so far, they have emphasized, there is no evidence linking it to cancer.

"In case of rupture, you'd have a dangerous quantity of silicone into your body," said Laurent Lantieri, a plastic surgeon at a hospital near Paris.

H?l?ne Guillois, 29, a nutrition student who lives in northern France, said she had the company's devices implanted seven years ago.

"I'm worried, because of the possible damage this could cause," Ms. Guillois said. "No one is really capable of saying" what will be the effects. Maybe we'll see in 10 years or so. Like all the big French medical scandals. "

Breast implants, which are essentially small silicone rubber bags filled with a material, typically silicone or a saline solution, are used after breast cancer surgery or simply for cosmetic purposes.

More than 1,000 of the estimated 30,000 French women fitted with the devices have experienced ruptures or leakage. Tens of thousands more in other countries have had the company's devices implanted, because PIP exported 80 percent of its products, many of them to Britain, Spain and Latin America.

More than 40,000 British women are estimated to have received the company's implants.

The implants were also used in Brazil, Argentina, Chile, Colombia and Venezuela. In Brazil, the National Agency of Sanitary Vigilance trade-off prohibited the importation and use of the implants in April 2010, after concerns about their safety emerged in France.

Chile's Public Health Institute asked the estimated 1,000 or so women thought to have implants from the French company to contact their doctors so the implants could be removed if ruptures occurred. Otherwise, Chilean officials asked the women with the implants to undergo annual exams.

Sebasti?o Guerra, the director of the Brazilian Society of Plastic Surgery, said, "We do not have significant reports of either ruptures or rejections or even cancer associated with those PIP implants, and we don't know why there is this difference with respect to the French news."

Prosecutors in Marseille have been investigating the company for possible fraud and reckless endangerment. They say it cut costs over the last decade by using an industrial silicone gel that was not approved for medical use and that cost a fraction of the medical-grade materials.

Several hundred thousand of the implants had been manufactured by the time issues were raised early last year about their quality.

Yves Haddad, a lawyer for the company's founder and chairman, Jean-Claude Mas, said there was no evidence that the product, "even if it was unapproved, is dangerous for health."

The Marseille prosecutor's office declined to comment.

Reporting was contributed by Ravi Somaiya from London; Simon Romero from S?o Paulo, Brazil; Gardiner Harris from Washington; and Jon Moriconi from Rio de Janeiro.

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