Safer Breast Implant Surgery

There are specific risks that relate to breast implants:

It is usual that breast implants can be felt at different locations on the breast particularly in the lower part of the breast both in the centre in the cleavage, in the fold beneath the breast and along the side of the chest and up towards the armpit. Larger implants and for women with very little subcutaneous fat and breast volume the implants will be more evident.

Although it is not usual for cosmetic breast surgery, nipple sensation is frequently reduced in the short term and usually recovers to normal over time. It is uncommon but possible to have a permanent reduction or even absence. This is normal following breast cancer reconstruction.

Some of the complications that are encountered relate to bacteria from the skin or breast tissue contaminating the surface of the implant and increasing in number. When a threshold number is reached the body can respond to this causing capsular contracture. Capsular contracture has historically been one of the commonest reasons for reoperation on breast implants but the rates of this problem have dramatically reduced with time. We have developed a greater understanding about how to minimise this problem and reduce the degree of bacterial association with implants. This has been demonstrated to dramatically reduce the incidence of problems such as capsular contracture and the rare complication of textured breast implants, Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). This is called the 14 point plan which is an integral part of A/Prof Magnusson’s breast implant practice to facilitate low rates of complication and enduring outcomes. His results are published in the peer reviewed literature. This is a routine part of Dr Magnusson’s practice and he is a concept champion for the 14 point plan. More information on this can be found on the safer breast implants website. http://saferbreastimplants.org/

As the rate of hardening around implants reduces and the body’s response to implants becomes softer and less perceptible the incidence of implant pocket instability becomes a little higher and is different from one person to the next according to the characteristics of their breast tissues at the start.

For example, patients with loose tissues that have stretched in response to weight fluctuations or pregnancy will tend to stretch again at a later time especially under the expansion stress of an implant. As a consequence the implant pocket may become less stable over time. In contrast, a woman who has firm skin and no tendency towards droop may tend to have a more stable implant position although the risk is not entirely removed. Implant migration or movement out of position is another cause for reoperation on breast implants in the medium to long-term.

The final outcome from breast implant surgery will develop over 6 to 9 months as the body’s tissues respond to the presence of the implant. There will always be a degree of asymmetry/difference and breasts should be considered more like sisters than twins although obviously the goal is to have them as close as possible to the same. Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare association with breast implant surgery. The commonest presentation of this problem is a painless swelling of one breast from 2 to 12 years (average seven years) after breast implant surgery. As long as the diagnosis is considered it is readily diagnosed by examining the fluid that has collected around the implant under ultrasound control. It is also readily treatable when detected early usually with surgery alone that removes the implant and the capsule of the body has developed around this.

BIA-ALCL is a rare disease and there may only be around 1,500 women reported in the world who have had this problem even though breast implants have been used now for over 50 years in over 35 million women. Our current concept is that there is a combination of textured breast implants, bacterial colonisation and a response from the body that in genetically susceptible people may lead to a lymphoma. This all takes time. This adds further importance to the 14 point plan. The incidence of this disease is possibly one in 500 to 1 in 15,000 for textured implants. The rate of bacteria related complications of breast implants have been reduced using the 14 point plan leading to a reduction in the incidence of capsular contracture from as high as 15 to 50% and down now to as little as 2%. A/Prof Magnusson has a published capsular contracture rate around 2% at 10 years. It is possible that these same antibacterial steps at surgery will also reduce further the incidence of BIA-ALCL. A/Prof Magnusson is also involved in collaborative published data on this issue showing a reduced incidence of BIA-ALCL when utilising the 14 point plan.

There are different rates of these various problems that arise with different implant types. Consequently there are reasons for choosing a specific implant type for any one individual taking into account the amount of breast tissue already present, the degree of activity is normally undertaken, the patient’s goal and the nature of the breast that is already present which can be large or small, soft or firm and high or hanging low. This choice may not be the same choice that is best for the next lady, your friend or even your relative. Finally, although about 1 in ten will still have implants at 10 years and half at 15 years, half of these reoperations will be due to changes in the breast tissue, a change of goal or a personal decision such as a size change rather than a specific problem with the implant.

Smooth implants have historically had a higher rate of capsular contracture and implant migration which are the commonest reasons for reoperation.

Textured implants of different types have lower rates of capsular contracture and migration but will have the potential for other concerns such as double capsule formation, greater degrees of breast animation, delayed seroma and BIA-ALCL.

With good surgical technique and use of the 14 point plan the capsular contracture rate for smooth implants has dropped and may now be very close or the same as textured implants. Implant stability remains less reliable with smooth implants. In contrast, there have been no patients develop BIA-ALCL who have only ever had smooth implants alone in Australia. The combined rate of reoperation for capsular contracture and implant migration may be one in 20 at 10 years for smooth implants. By comparison the risk for developing BIA-ALCL in textured implants may be one in 15,000 (for the only textured breast implants still on the Australian market), may be reduced by the 14 point plan and different types of textured implants appear to have different rates of risk some of which may be as low as one in 30,000.

The perfect implant does not yet exist and everybody does not respond the same however implant surgery is safer than ever before, results are more reliable now than they have ever been and a treatment plan needs to be created for the individual and not come from a cookie cutter approach.

Training, meticulous technique and adherence to recommended guidelines are going to give you the safest and most enduring outcome from breast implant surgery.