Since the introduction of silicone gel prosthesis in 1962 (2), breast augmentation has become the most commonly performed operation in cosmetic surgery in Europe, mainly in women under 35. Through breast augmentation, it is possible to change the shape and size of a breast that is too small or to correct a breast asymmetry by improving the harmony of the body and one’s sense of self-esteem. The female breast has been synonymous with femininity and hence a lot of focus has been given to the aesthetics of the organ. The ideal size and shape vary, depending upon the build of the individual and the cultural characteristics. Many a time, breast development does not take place adequately. As a result, women with smaller than normal breasts feel that they have a disproportionate figure and therefore seek correction through surgery. It is, therefore, important that the surgeon also takes into consideration the patient’s desires, when planning an augmentation surgery. Breast augmentation can have significant positive influence on the body image.

However, all surgery has risks and for breast augmentation surgery there are general surgical risks and implant-related risks and it is important to note that while textured anatomical implants carry risks, the same is true for smooth round implants which are more prone to capsular contractures and bottom-out (i.e. they slide down the wall).

Despite the evolution of breast implant technology and surgical techniques, the common complications observed remain the same. Capsular contracture continues to be the most prevalent postoperative complication followed by implant rupture (1). The etiology of capsular contracture is unknown; however, its development is believed to be a multifactorial fibrotic process (4). Implant rupture is also a significant complication with many potential causes and often few clinical symptoms, with an incidence rate believed to be linked to implant age (5). As such, continuous monitoring is essential to ensure patient safety following implantation. Currently, the FDA recommend women with silicone breast implants to undergo magnetic resonance imaging (MRI) at 3 years postimplantation and every 2 years thereafter to detect implant rupture. Despite a reduction in the incidence of rupture due to the advancements in silicone gel stability, performance of the silicone elastomer shell, and improvements in surgical technique, the risks remain significantly high for women undergoing breast augmentation and reconstruction. The risk often differs between breast augmentation and reconstruction, with an increased risk regularly reported for reconstructive patients (3). The following is a list of local complications and adverse outcomes that occur in at least 1 percent of breast implant patients at any time. You may need non-surgical treatments or additional surgeries to treat any of these, and you should discuss any complication and necessary treatment with your doctor. These complications are taken by Food & Drug Admninistration website, listed alphabetically:

  • Asymmetry: The breasts are uneven in appearence in terms of size, shape or breast level
  • Breast Pain: Pain in the nipple or breast area
  • Breast tissue atrophy: Thinning and shrinking of the skin
  • Calcification/Calcium deposits: Hard lumps under the skin around the implant. These can be mistaken for cancer during mammography, resulting in additional surgery
  • Capsular contracture: Tightening of the tissue capsule around an implant, resulting in firmness or hardening of the breast and squeezing of the implant if severe
  • Chest wall deformity: Chest wall or underlying rib cage appears deformed
  • Deflation: Leakage of the saltwater (saline) solution from a saline-filled breast implant, often due to a valve leak or a tear or cut in the implant shell (rupture), with partial or complete collapse of the implant
  • Delayed wound healing: Incision site fails to heal normally or takes longer to heal
  • Extrusion: The skin breaks down and the implant appears through the skin
  • Hematoma: Collection of blood near the surgical site. May cause swelling, bruising and pain. Hematomas usually occur soon after surgery, but can occur any time there is injury to the breast. The body may absorb small hematomas, but large ones may require medical intervention, such as surgical draining
  • Iatrogenic injury/Damage: Injury or damage to tissue or implant as a result of implant surgery
  • Infection, including toxic shock syndrome: Occurs when wounds are contaminated with microorganisms, such as bacteria of fungi. Most infections resulting from surgery appear within a few days to a week, but infection is possible any time after surgery. If an infection does not respond to antibiotics, the implant may need to be removed
  • Infiammation/Irritation: Response by the body to an infection or injury. Demonstrated by redness, swelling, warmth, pain and/or loss of function
  • Lymphedema: Swollen or enlarged lymph nodes
  • Malposition/Displacement: The implant is not in the correct position in the breast. This can happen during surgery or afterwards if the implant moves or shifts from its original location. Shifting can be caused by factors such as gravity, trauma or capsular contracture
  • Necrosis: Dead skin or tissue around the breast. Necrosis can be caused by infection, use of steroids in the surgical breast pocket, smoking, chemotherapy/radiation and excessive heat or cold therapy
  • Nipple/Breast Sensation Changes: An increase or decrease in the feeling in the nipple and/or breast. Can vary in degree and may be temporary or permanent. May affect sexual response or breast feeding
  • Palpability: The implant can be felt through the skin
  • Ptosis: Breast sagging that is usually the result of normal aging, pregnancy or weight loss
  • Redness/Bruising: Bleeding at the time of surgery can cause the skin to change color. This is an expected symptom due to surgery, and is likely temporary
  • Rupture: A tear or hole in the implant’s outer shell
  • Seroma: Collection of fluid around the implant. May cause swelling, pain and bruising. The body may absorb small seromas. Large ones will require a surgical drain
  • Skin Rash: A rash on or around the breast
  • Unsatisfactory Style/Size: Patient or doctor is not satisfied with the overall look based on the style or size of the implant used
  • Visibility: The implant can be seen through the skin
  • Wrinkling/Rippling: Wrinkling of the implant that can be felt or seen through the skin

There’s also the rare risk of anaplastic large cell lymphoma (ALCL). It’s a newly recognized, rare form of blood cell cancer that’s been associated with long-term presence of breast implants, most commonly textured silicone implants. At this time, there have been 414 reported cases worldwide that the FDA is tracking. Based upon these reports, the estimated risk of getting ALCL associated with breast implants is between 1 in 3800 and 1 in 30,000 patients (U.S. Food & Drug Administration).

Another important factor to consider is breastfeeding after breast surgeries. Research is limited. However, most mothers who have had breast or nipple surgery are able to produce some milk, but not all of these mothers will be able to produce a full milk supply for their infants. Having a full milk supply is not necessary for a successful breastfeeding experience because it is possible to supplement in a way that supports breastfeeding (Centers for Disease Control and Prevention). A french study encountered the fact that few patients in childbearing age ask for information about breastfeeding before undergoing surgery, but surgeons do not systematically give such information either. The impact of surgery on breastfeeding depends on the type of intervention and the surgical technique. Even though breastfeeding is possible, the mean period of breastfeeding after surgery is shorter and the most frequent difficulty encountered is lactation insufficiency, even more after reduction mammaplasty, periareolar incision, and nipple hypoesthesia after surgery (7).

Others studies focused on the psychological issues associated with breast augmentation. The results of seven epidemiologic studies which have identified a relationship between cosmetic breast augmentation and suicide shown the suicide rate among women with cosmetic breast implants is two to three times the expected rate. The literature in this area should be used to guide the psychosocial assessment and management of cosmetic breast augmentation patients. There currently is little evidence to support a recommendation that all women who present for cosmetic breast augmentation be required to undergo a psychiatric evaluation before surgery. Given the relationship between breast implants and suicide, however, it is recommended that women with a history of psychopathology who present for breast augmentation, or those who are suspected by the plastic surgeon of having some form of psychopathologic abnormality, should undergo a mental health consultation before surgery (6).

In conclusion, it is recommended to find a certified plastic surgeon. Read their patient reviews, and check out before and after photos of past patients. Aside from reviews and qualifications, be sure you’re comfortable with your surgeon and confident in their abilities.

Bibliography

  1. Adams WP. Capsular contracture: What is it? What causes it? How can it be prevented and managed? Clin Plast Surg. 2009;36(1):119-126.
  2. Cronin TD, Gerow FJ. Transactions of the Third International Congress of Plastic and Reconstructive Surgery. Amsterdam: Excerpta Medica; 1964. Augmentation mammaplasty: A new “natural feel” prosthesis.
  3. Duteille F, Perrot P, Bacheley MH, Stewart S. Eight-Year Safety Data for Round and Anatomical Silicone Gel Breast Implants. Aesthet Surg J. 2018 Feb 17;38(2):151-161. doi: 10.1093/asj/sjx117. PMID: 29040345.
  4. Haedon H, Kasem A, Mokbel K. Capsular contracture after breast augmentation: an update for clinical practice. Arch Plast Surg. 2015;42(5):532-543.
  5. Hillard C, Fowler JD, Barta R, Cunningham B. Silicone breast implant rupture: a review. Gland Surg. 2017;6(2):163-168.
  6. Sarwer DB. The psychological aspects of cosmetic breast augmentation. Plast Reconstr Surg. 2007 Dec;120(7 Suppl 1):110S-117S. doi: 10.1097/01.prs.0000286591.05612.72. PMID: 18090820.
  7. Tran PL, Houdjati H, Barau G, Boukerrou M. Allaitement après chirurgie mammaire : information des patientes [Breastfeeding after breast surgery: patient information]. Gynecol Obstet Fertil. 2014 Apr;42(4):205-9. French. doi: 10.1016/j.gyobfe.2014.01.003. Epub 2014 Mar 29. PMID: 24685643.

Sitography

  1. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/breast-surgery.html
  2. https://www.fda.gov/medical-devices/breast-implants/questions-and-answers-about-breast-implant-associated-anaplastic-large-cell-lymphoma-bia-alcl
  3. https://www.fda.gov/medical-devices/breast-implants/risks-and-complications-breast-implants
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825138/