Breast Implants: Risks and Choices
Breast augmentation like all other forms of surgery is a real operation with real potential risks. The following is a summary of the most common complications that we feel every patient should acknowledge and understand prior to surgery. All of these do happen occasionally and are a function of the operation itself and how the human body reacts to this operation.
RIPPLING: Rippling describes visible ripples in the breast following breast augmentation. This is far more common with saline filled implants and relatively uncommon with silicone gel implants. The reason for rippling is that all implants are compressible, not rigid spheres and because of this they all have folds on the surface of the implant. With saline implants, since they contain just salt water inside, the implant folds are much sharper. They are easier to feel and see through the skin in patients with small breasts, very thin skin or in those who choose larger implants, exerting more pressure on the overlying skin. Silicone gel is much thicker and, while there are folds in a silicone gel implant, they are much more gradual and therefore rippling is less common. Rippling is a function of the amount of tissue you have to cover or hide the implant, not any kind of defect in the implant.
CAPSULAR CONTRACTURE: Once the implant is placed inside the body the healing process results in a thin layer of scar tissue surrounding the implant much like a cocoon forming around a caterpillar. This layer of scar tissue is called a capsule and in some individuals the healing process is more aggressive than others. If an individual’s scar capsule begins to tighten around the implant it can make the implant feel firmer, appear more round in shape and even begin to cause the implant to rise upwards as the implant is shifted in position within its normal pocket. The capsule of scar tissue can also thicken over time, which makes the capsular contracture even more uncomfortable and visible. There are many precautions with breast augmentation, which can minimize the risk of capsular contracture and we use all of these, including specific cleansing of the patient’s skin and the surgeon’s gloves prior to handling of the implant and the use of a triple antibiotic irrigation within the pocket. Using all of the current techniques to minimize this risk, it can be decreased to about 2% overall. Roughly half of the individuals who develop some capsular contracture will respond to an oral medication, which is intended for asthma. As a side effect, this medication seems to modify the cells which create scar tissue, causing the scar capsule to begin to soften. About half of the patients with early capsular contracture will achieve resolution with this medication. This leaves a small number of individuals who have enough unfavorable scar formation that they may benefit from surgery. There is no warrantee for capsular contracture since the implant company is very clear that it is the individual’s tissue response, not the implant becoming firm. When the implant is removed it can be seen to be perfectly normal. It is the scar tissue inside caused by the individual’s “overly aggressive” healing which results in capsular contracture. This is a risk that cannot be blamed on the surgeon or the implant manufacturer and one that every individual who wishes to undergo breast augmentation must accept.
HEMATOMA: Postoperative bleeding is a risk with nearly all surgeries. When the pocket for the implant is surgically created it is sculpted using a cautery. The cautery is a device that delivers an energy charge, which splits through tissues and seals them off, including muscle fibers, nerve fibers and blood vessels, as the implant pocket is formed. Any bleeding is visualized clearly using a brilliantly lighted fiberoptic retractor, allowing the cautery to be used accurately to stop all active bleeding. The pocket is flushed out with an irrigation solution and suctioned so that any bleeding can be visualized and stopped before the implant is placed. Nonetheless, after the surgery, if the tissues are traumatized in any way from over activity or if the blood pressure rises from emotions, pain or even just bad luck, bleeding can begin. Blood can collect around the implant causing the breast to enlarge and become somewhat sore and perhaps appear bruised; however because it is a closed space, the bleeding typically stops and is not an emergency situation. If you present to the clinic with an enlarged, tender, slightly bruised breast and we make the diagnosis of hematoma, it is best that you have surgery to remove the clot of blood around the implant or you will likely develop a deformity. Dr. Stagnone never charges any surgeon’s fee for the operation to treat a hematoma and performs this surgery at no charge. The anesthesiologist however, will charge you to go back under anesthesia for the surgery and you will be responsible for that fee as well as the operating room fee, covering all of the equipment, supplies and staff necessary to perform this operation. Dr. Stagnone feels very strongly that a surgeon should never charge or profit from surgery such as this but that the patient should also assume responsibility for their own activity after surgery. Most hematomas, when discussed truthfully, follow some type of “event” by the patient. The overall risk is very low and in our practice is approximately one-half of one percent.
- Loss of sensation or numbness: When the space or “pocket” is created for the breast implant, tissues which are adherent or stuck together are split apart in order to create that space. Among the tissues which will be split free are some nerve fibers. It is common to have numbness or decreased sensation around the incision and sometimes in other areas on the breast. Occasionally the nipple itself may lose sensation. This is more common when the patient chooses very large breast implants since more tissues must be split apart to create the necessarily larger “pocket”. Also, the larger implant may exert more pressure on the adjacent nerves which causes the numbness in some cases. Many cases of numbness resolve spontaneously since the nerve fibers are stretched or cauterized but not irreversibly injured. Nonetheless, some cases of sensory loss are permanent. This is a non-negotiable risk of breast augmentation and must be accepted to be a candidate for this operation.
- B. Hypersensitivity: In some cases sensation is elevated and the breast becomes hypersensitive. Even the pressure and temperature of showering can be uncomfortable and this too is an inherent risk which cannot be eliminated. This generally passes with time as the swelling and healing processes evolve. Although uncommon, there are reported cases of permanent hypersensitivity.
SAGGING: There is no technology to secure the breast implant internally to a rigid structure such as a rib. The pocket which is created for breast implants typically follows the shape of the normal breast fold and is designed to mimic the shape of the breast once the implant is placed inside. The implant however is not “wired down” or fixed to anything internally. It simply sits inside that pocket similar to putting your cell phone in your shirt pocket. The breast implant sits on the breast fold which acts as the shelf supporting the implant. If your tissues are lax and loose, the implant may stretch your tissues and settle lower. It is important to understand this and to accept that you cannot always select any type of breast you wish with augmentation and why augmented breasts must be supported just like real breasts. When you lie on your back, the implants can move to the side under the force of gravity almost like a ball on a hill. Thus over time, the space between the breasts can widen as sagging occurs in that direction. There is no way for the doctor to prevent this so we emphasize that support is typically necessary with breast implants just as it is with natural breasts. This is most important in patients with very loose, lax tissues or those who select very large implants, which exert more weight or pressure on your skin. Implants over 350-400cc are considered to be in that category by many plastic surgeons.
DEFLATION OR RUPTURE:
- Saline implants can develop cracks in the surface over time or failure of the valve used to fill them with saline. Even the tiniest pinhole in a saline implant will result in leakage causing the implant to go flat. This creates, in some sense, a social emergency due to the sudden mismatch of an augmented breast on one side and a flat breast on the other. The material, which leaks out is just salt water and therefore there are no issues or concerns regarding safety. However, the potential to deflate or go flat suddenly is certainly a disadvantage of saline filled implants.
- Silicone gel implants are now currently a fourth generation device which has been modified over the years to decrease the risk of failure or rupture. Fourth generation implants have thicker more resilient rubber surfaces. Also, the silicone gel on the inside is now thick enough that if the implant is sliced in two, it maintains its form and cannot “flow away”. Thus if there is a tiny crack in a current silicone gel implant it will not go flat. It will typically maintain its shape and size and will often be undetectable. There is no pain or deformity or disease from exposure to silicone. In fact silicone is already present in the body in concentrations much higher than the concentrations caused by an implant. Many products such as lipstick, underarm deodorant, hair spray, Mylanta, etc. contain silicone and it is a substance, which exists in everyone’s body in a measurable amount. Numerous scientific studies relating to silicone gel have confirmed that it does not cause any type of disease. Interestingly, if a puncture is made in a breast implant even with something substantial, and the implant is compressed, the gel will bulge out, but when it is released the gel is drawn back into the implant, behaving more like Jell-O than any type of liquid. Given the fact that there is no medical consequence of such minute exposure to silicone gel, and the implant maintains its shape, it is difficult for me to strongly advise the need for frequent MRI studies to look at the surface of the implant. When the FDA removed their restrictions on silicone gel implants in 2006, one of its recommendations was that women consider monitoring the implant with MRI scans to look at the implant through the body at intervals of every two years. Besides the evidence showing that silicone is harmless and already present in the body from other products, my biggest concern over this recommendation is that the MRI scan itself is not perfect. A certain percentage of MRI scans are “false positive”. What this means is that the MRI scan may be inconclusive or may suggest to the radiologist that there is a problem with the implant even though it is intact. This is certainly problematic if the patient becomes concerned enough to want to have surgery for reassurance. If an operation is performed and the implant is normal there will be no warrantee coverage whatsoever. Thus the patient assumes the financial responsibility for exploratory surgery in the event that the MRI scan looks suspicious but the implant is not defective. It is my opinion that, particularly early on, if the breast is soft and ideal and unchanged in its shape, appearance and feel and has no symptoms of discomfort, it is very difficult for me to defend the choice of having costly MRI scans in such an asymptomatic breast. I personally have seen a patient who presented with MRI “confirmed” ruptures of both silicone gel implants and the operation revealed two absolutely normal and intact implants. If I were advising my own family member I would advise her to only consider an MRI scan in the event that there was something abnormal with her breasts. If everything was perfectly normal, I still might consider a prophylactic or investigative MRI at nine and a half years or so, shortly before the 10 year warrantee expires. This is a choice for each individual to make and I certainly do not discourage patients from getting MRI scans as recommended by the FDA. I do however have concerns about the cost and the relatively low yield for the study, particularly since it has been shown that silicone does not cause any disease. Current data show that in ten years, the failure rate following primary breast augmentation for these implants is less than 6%. Routine mammography is still necessary to screen for breast cancer.
The above information summarizes what we consider to be the most commonly encountered risks of breast augmentation surgery. It is not an exhaustive list of all of the risks of this procedure. Although most of these are either minor or relatively infrequent, they do occur from time to time and everyone must accept these risks and give their informed consent in order to proceed with surgery.
Gregory J Stagnone, M.D., P.A.