Subglandular breast augmentation with cohesive gel implants

Breast augmentation / breast enlargement

Breast augmentation is a common consideration for women who have always had small breasts, or who have lost breast volume after breast feeding or weight loss.

The great majority of people I see request a fairly natural appearance that is in keeping with their overall figure and proportions. When done appropriately it can give a significant boost to womens self confidence and quality of life.

Dr Davis is very experienced at breast augmentation surgery. He gives advice to help women decide if this is an appropriate procedure and will help guide them with many decisions including about volume and shape.

Frequently asked questions

General questions

Mr Davis does Breast augmentation for a fixed cost. The typical total cost is $12,500 for everything including follow up for the first year after surgery. For the current fixed cost please either email us or phone us on 0800 268 526..

The quoted cost for surgery covers everything including anaesthetist fees, theatre fees, consumables, the implants, staying overnight in hospital after surgery, any additional consultations after the first consultation and all the follow up for dressings and checks in the first year after surgery. This cost includes GST.

Examples of Mr Davis’ work can be seen at www.breast-surgery.co.nz.
Specific examples of anatomic variations may also be shown during a consultation where appropriate.

I only use the highest quality breast implants. They are made in the UK with strict manufacturing conditions. The implants meet ISO 13485 requirements for Class III sterile medical devices.

The implants are filled with a medical grade silicone gel. The gel is a semi-solid like the surface of a cut jellybean. Some US surgeons refer to these  as “gummy bear” implants. Older silicone implants contained a liquid that could leak out if the implant broke. Silicone particles can still “bleed” across the silicone outer shell. There is no known medical effect of this happening.

Although modern breast implants are thought to be very safe, complications can still occur as detailed below . The implants I use have a lifetime guarantee from the manufacturer for rupture and severe grades of capsular contracture.

After surgery I will give you the warranty information along with the implants details including serial number.

I am aware that some Kiwis having overseas surgery have lower quality implants used without the same guarantees.

There is no minimum age for surgery. You must be fully matured physically with no ongoing breast development occurring but more importantly, you need to be psychologically mature enough to make important decisions about your body. This age is different for everyone. Discussion with sensible family members and friends can help ensure the appropriateness of surgery.

I do all breast augmentation surgery under general anaesthetic. Although it is possible to do the surgery under local anaesthetic with deep sedation I do not do this as there is more risk to the sterility of the operating site, including from the patients own breath.  Contamination of the implants with a minor amount of microorganisms may increase the risk of capsular contracture (see below).

In Australia there have been several cardiac arrests caused by cosmetic surgeons (not Plastic Surgeons) doing breast augmentation surgery under local anaesthetic and overdosing the patient with anaesthetic because they were still sore during surgery.

All implants will wear out at some point.  It was previously recommended that breast implants were changed every 10 years.

Modern implants are referred to as 5th generation and do not need to be replaced unless there is a problem. If there is no concern they could be potentially left alone for the lifetime of the patient.

However all implants become more brittle with age and will deteriorate over time. Even if the implants do not need replacing, patients may want a different size or a lift  in future. The implants I use  have a lifetime guarantee from the manufacturer for rupture and severe contracture.

In future it is likely that other options for breast augmentation will be available. They may use tissue engineering and rely less on the use of foreign bodies.

The link between textured implants and a rare type of lymphoma (ALCL) is being extensively investigated. Further information about ALCL is discussed below under risks and complications.

During 2019, one textured implant brand (Allergan) was recalled. Theses Allergan implants have never been used by Mr Davis. These implants are highly textured and have been associated with about three-quarters of all worldwide cases of ALCL.

Mr Davis has used the much less textured Nagor implants which have a much lower association with ALCL but the nonetheless as a precaution we changed over to using smooth surface implants only during July 2019 which have no known risk of ALCL. There is no advice from any medical authority at present that suggests women who have previously had textured implants should have them removed prophylactically for ALCL. Some of the most up-to-date information as it comes to hand about textured implants is on the Australian TGA website.

I am frequently contacted by patients who have had breast implant surgery with other surgeons. I am happy to see anyone who has concerns about their breast implants. Some patients have been concerned about a possible rupture, the implants going hard (capsular contracture) or “Breast implant illness” which I have discussed below under risks and complications.

With age body proportions can change. The original implants may be too big or too small or simply no longer needed.

Sometimes there will be a concern about the position of the implants and I have seen implants that are too close together (synmastia), too far apart or at different heights.

Sometimes removal of the outer capsule will be recommended (capsulectomy -discussed below). This will be the case if there is a rupture or capsular contracture.

A lift may also be required especially of the implant was large and the skin has been stretched. Further information about lifts is under the mastopexy section.

Alternatives

There are several alternatives to breast implants:

1. Prosthesis or padded bra

A prosthesis may be placed inside the bra or a padded or push-up bra worn.

2. Brava system

Tissue expansion using the Brava system has some success. This is a suction cup system attached over the breasts. Over many months some minor increase in size is possible. This is rarely used by surgeons now and is mentioned largely for historical interest.

3. Fat grafting (lipofilling)

Fat grafting is also known as lipofilling. This is a technique I use a lot in the face for patients with reconstructive defects and is used in some cases of breast reconstruction after cancer surgery where there is a small localised defect.

The advantages are that your own body tissue is used.  There are no concerns about foreign material. The disadvantages are:

a. Limited change in cup size. At the ISAPS meeting in Geneva in 2012, the world experts presenting this technique had an average volume change of just 140cc.

b. Cost. The extended time taken for surgery to harvest and then prepare the fat significantly increase the cost.

c. Unpredictability of fat graft survival. Perhaps two-thirds of the fat survives and this cannot be known for several months after surgery. A second procedure is commonly needed (with more cost).

d. Donor site. Most patients I see simply don’t have enough fat for the size they want to be and would risk rippling and dimpling of the donor site (usually the hips and abdomen)

e. Future weight changes. The transplanted fat can also increase or decrease in size with weight changes at the donor site.

The potential cancer causing effects of transplanting fat into the breast gland are still not fully known.

 

4. Tissue reconstruction

Breast volume can be increased using flaps, including microvascular flaps and is one of the options following mastectomy.

5. Tissue engineering

I believe that in the future we will be inserting a biodegradable membrane that has the shape of the implant and it will fill with the patients own natural tissues.

 

 

PIP implants were widely discussed in the New Zealand media several years ago. They were manufactured in France and subsequently discovered to be filled with an industrial grade of silicone gel. Medical grade silicone is made to a very high standard so that it is free of impurities. Industrial grade silicone used in the implants was normally used for instance for ball bearings and mattress foam.

PIP implants were noted to have a much higher rupture rate and to create quite a local inflammatory reaction when they broke. These implants were used widely in Europe and the UK. About 20 were used in NZ. Thousands of women were required to undergo surgery to have their implants removed. The implant maker was imprisoned.

I have not used PIP implants. I have removed 5 sets of PIP implants that were inserted overseas.

For frequently asked questions and further information about these implants, please see the NZ Medsafe and Australian TGA links below.

Polyurethane implants have been used for many years. They went out of favour for a time because one of the breakdown products, toluenediamine (TDA) was thought to cause breast cancer. More recent research suggests this is highly unlikely.

South American surgeons who have performed many thousands of implants have recently shown that they had a lower than expected capsular contracture rate.

Some surgeons suggest that as the polyurethane is broken down, the silicone shell is all that is left and this just delays the onset of capsular contracture.

Because my own capsular contracture rate is very low, I don’t see any advantage to changing the implants I currently use and would prefer to see longer follow up studies from other groups first to confirm their safety. I may consider their use in future if there is a demonstrated advantage over my current practice.

Some New Zealand women choose to go overseas for their breast surgery.

The main advantages are the lower cost of surgery and the possibility of a “holiday” at the same time.

In many cases this surgery probably goes well. Unfortunately I see a steady stream of less than ideal outcomes.

As a surgeon the main concerns I have is the inadequate and rushed preoperative consultation many women describe, the use of inappropriately large implants with little patient choice in the process, the pressure to proceed with surgery even if there are doubts and the lack of back up after surgery if something goes wrong. Even the most experienced surgeon will have complications.

Cases I have been involved with have had inferior quality implants or no knowledge of the device used. I have seen cases of over oversized implants, stretch marks, infection requiring implant removal and I am aware of deaths due to a pneumothorax (punctured lung).

The New Zealand public hospital system will remove infected implants but will not replace them even if patient supplies the implants. This has caused considerable angst for some patients.

In New Zealand patients can check the training and qualifications of their surgeon and take their time selecting the appropriate person after seeing them for a consultation to ensure they can trust them. If something goes wrong, redress can occur through ACC, the NZ Medical Council, the Health & Disability Commissioner, disputes tribunal and court system. This cannot happen with overseas surgery.

Your options

There is no perfect breast implant size for any individual and for each patient I will generally give them a range of  sizes based on their chest measurements with my recommendations about what is most suitable  for their situation. Final size choice is a joint decision between surgeon and patient.

Breast augmentation surgery is not just about increasing size. Shape is equally important and this involves assessing the breast base and tissue type. I estimate the volume needed to be added by inserting trial implants within a surgical bra and wearing a tight top. The colour of the top can affect the apparent size of the implants and dark tops disguise the shape changes more than lighter colours.

It is important to assess overall physique including the hips, waist, shoulders and the projection of the buttocks and stomach. Some people have recommended using rice inside a bag as another method of assessing volume.

For most people there will be a range of implant sizes that may be chosen that their tissue type will accept and the exact size can be a personal choice depending on the look wanted. Many of my patients trial the various implant ranges discussed in their own time after the initial consultation to be sure about everything. They may have specific items in their wardrobe they want to check these with.

Most of my patients prefer a natural look. They would like other people not to be able to tell they have breast implants including when they are undressed. Some prefer a slightly fuller look that is not entirely natural.

Most patients are about a C-cup or D-Cup after surgery depending on personal choice. Some patients who are very athletic are better with a B-cup as this looks more natural with their physique and the implant weight is less of a restriction during extreme competitions or when running marathons.

The exact cup size is not absolutely critical. I think the overall proportions when that person is viewed from a distance are more important. For instance someone with narrow hips and shoulders needs to be cautious about overly large breasts compared to someone of the same height who does have wider hips and shoulders.

Cup size can change over time for instance if the patient loses or puts on weight. It will also depend on which part of the body the weight is lost from of added to.

The smaller the implant, the more natural the look. At some point increasing the implant size will no longer look natural. Many people I see do not want other people to know that they have breast implants.

Large implants can give the optical illusion that the person is overweight, or may give a “matronly” look depending on their physique.

Large implants stretch the breast tissue and will accelerate the natural drop that occurs in all breasts with gravity. It is more difficult to do physical exercises.

Future corrective surgery is much more likely. If the implants are removed one day, the stretched breast envelope will be more droopy and may need lifting which creates new scars.

There are several possible incisions for inserting breast implants. I almost always use a scar in the fold beneath the breast (inframammary fold). This incision is relatively hidden and tends to leave a fine scar with time. This scar gives the best access to view the implant cavity and is easier if the implants ever need adjustment in the future.
The scar is about 4cm long for implants up to 260 cc and 4.5-5cm long for implants over 320cc.

I do not use the periareolar incision which may leave a more noticeable scar, will cut breast ducts and may affect breast feeding, is more likely to affect nipple sensation and may lead to a higher capsular contracture rate because of bacteria within the ducts.

I also do not usually use the axillary (armpit) incision which can only be used for implants being placed beneath the pectoralis muscle. The visualization of the lower part of the pocket is more difficult and muscle fibre release and control of bleeding can be more difficult with this approach. The scar may be visible when wearing sleeveless dresses.

I place about 2/3rds of implants under the muscle layer. The main reasons for putting implants beneath the muscle are to disguise the upper medial pole of the implant and give better soft tissue coverage over the implant. If a soft semi-filled implant is used and there is adequate soft tissue coverage, placement under the muscle may not be necessary.

There is some evidence than under the muscle gives a lower capsular contracture rate and also makes future mammograms easier.

This decision is based on a careful assessment of the overlying soft tissue, the shape of the chest cage, dimensions of the implant, possible future weight changes and the person’s occupation.

Considerations for placement under the muscle are that the initial recovery could be more uncomfortable and when the muscle contracts the implant may move upwards and change shape. A very loose overlying skin envelope may not be filled if the implant is beneath a relatively tight muscle.

If a capsular contracture does occur, it is in a deeper plane and less visible.
Submuscular placement does not affect the rate of “drop” of the implant over time because the lower pole is not held up by muscle.

If you have “droopy” breasts, a breast lift (mastopexy) can be done at the same time if appropriate.

Inserting a breast implant creates a small of degree of breast lift.

With minor degrees of droop, implant insertion alone is all that is required. In severe cases an implant alone will not give sufficient lift. This is especially the case when there is a lot of excess skin or the nipple is already sitting in a very low position.

There is a grey area in between where the decision to do a lift will depend on the nature of the breast tissues and the size of the implant inserted. If a large enough implant is inserted, most cases of drooping could be corrected however the implant size required may be inappropriately large in many cases.

On occasions a decision will be made to insert and implant and see what happens and then perform a lift only if absolutely necessary 6 months later. Although a breast lift creates additional scars, for most people this is outweighed by the improvement in shape.

This is discussed in further detail under the mastopexy section. If you are uncertain if a lift will be required, I am happy to look at photographs to give an opinion about whether this is likely.

Saline breast implants were more common in the past. Previously there was concern that silicone gel may irritate body tissues. This is why saline implants were developed.  However saline breast implants still had a silicone outer shell touching the body tissues. Saline breast implants deflate if ruptured. Water cannot be compressed so saline breast implants feel harder.

Many studies have now confirmed the safety of silicone gel filled implants. Medical grade silicone doesn’t not irritate body tissues and there is no evidence that it is harmful. The same medical grade silicone is used in intravenous cannulas, neonatal feeding tubes, breathing tubes, chemotherapy catheters, tendon rods etc. Silicone gel also gives breasts a more natural “feel”.

Silicone gel implants were banned in the US by the FDA from 1992-2006 while more information was gathered. During this time surgeons in New Zealand, Australia and the UK continued to use silicone implants.  Now most US surgeons would now only use silicone gel filled implants because of their superior feel and well proven safety profile.

Anatomic (tear drop shaped) implants all have a textured surface. As only smooth surface implants are used I no longer use anatomic implants.

All round implants now used have a smooth surface. A range of profiles (projections) are available to suit specific situations.

When anatomic implants were available I only used them in about 10% of cases anyway. Low profile round implants take on an anatomic shape when they are upright and look very natural with the additional benefit of having more upper pole fullness and less of a droopy appearance than anatomic implants sometimes give.

Anatomic implants were  more expensive and any rotation was potentially a problem.

Body builders and body sculptors tend to have very little subcutaneous fatty tissue to disguise breast implants. I see more body sculptors than body builders requesting breast implants.

 It can be counterproductive to insert the implant beneath the pectoralis muscles as some of the lower muscle fibres need to be divided and they are often very thick in the lower part of the muscle. Body sculptors may prefer a higher profile lool in the upper pole because of the way they re scored during competitions. For this reason I may place the implant over the muscle even though this risks it being more easily felt.

The plane in which the implant is placed (above or below the muscle) varies cases by case depending on individual preferences.

During surgery

There are a number of complications that can occur after surgery. These will be explained during the consultation and in written information given to you. Most are explained in more detail below.

Most potential complications or adverse outcomes can be improved by further surgery. In the case of breast augmentation this includes haematoma, ripples, poor position, implant rotation, implant rupture, capsular contracture and incorrect size. If the complication was caused by a technical error on my part I would fund the total cost of revision surgery. If this is not the case, for instance a capsular contracture, then I would not charge a surgical fee if the complication occurred within five years of surgery however the patient would have to fund the cost of the hospital and anaesthetic fees.

The implants I use have a guarantee from the manufacturer for rupture and severe (grade 3 and 4) capsular contracture. They would supply a new set of implants but not fund the revision surgery.

After surgery

Patients stay the night after surgery and are checked by Mr Davis before discharge. Patients are given a detailed information sheet with his contact phone number.

Appropriate pain relief is given to take home.

Guidelines about lifting heavy weights, arm movements and driving will be given.

Dressings are removed the following week, or detailed instructions given if patients are removing their own dressings (especially those who live a long distance away).

I recommend wearing a soft stretchy sports bra after breast implant surgery. An example will be shown during the consultation. Advice about size will be given. These cost less than $10 from The Warehouse, Farmers or Postie Plus. You do not need one with a zip at the front. It is ok to lift your arm over your head after surgery.

You do not need to wear a bra immediately after surgery because of the way the breasts are taped, but it may be more comfortable.

Post surgical bras are available but I do not see any advantage for most patients and soft sports bras are usually more comfortable.

I recommend waiting at least 4-6 weeks before getting measured for a new bra. This allows time for any swelling to subside, the position to settle and the breast to soften.

I recommend caution with under-wire bras after surgery. These should be padded enough so the wire doesn’t leave imprints on your skin. The wire may thin the tissue over time and make the implant more easily felt many years later.

I  recommend pushing your breast implants from the outside towards the middle for 1 minute every day in the first few weeks after surgery. This helps to maintain the inner cavity especially if the chest wall muscle tends to pulls the implants outwards. The massage technique will be demonstrated. The easiest way is to sit forwards and use the side of your arms to push the implants towards the middle.

Although some surgeons recommend general massage of the implants after surgery I do not do this. I do not think it makes a difference to capsule development in most cases.

Sleep position after breast implants can take some adjusting for some people especially if you usually sleep on your front.

The first night is spent on your back and slightly elevated. After the first night you can also sleep on your side. Curling into a ball and hugging  a pillow is one option.

You should avoid sleeping on your front until about 3 weeks after surgery.  In the long term there is no restriction in sleeping position and you may sleep on your front if you wish. Your body weight will massage the implants in this position.

Most of my patients prefer a natural look. They prefer others not to be able to tell they have breast implants when undressed. Others prefer a fuller less natural look.

Most patients are between a C-D cup after surgery. Others prefer a larger cup size. Very athletic people may prefer a smaller size which looks more proportionate with their physique and the implant weight is less of a restriction during extreme competitions and when running.

The exact cup size is not absolutely critical. I believe the overall proportions are more important. Cup size can change over time especially if the patient loses or puts on weight.

Breast shape after surgery is strongly influenced by your breast shape before surgery.

The shape of your rib cage and the density of your  breast tissue is very important.

Your skin is also very important and excess skin may need to be removed to give the best shape.

The shape of the implant and whether it is placed above or below your muscle is less important.

A round implant will have a different upper pole shape to an anatomic (tear drop) shaped implant. A low profile round implant can look very natural. If your want an unnaturally full upper pole then a higher profile round implant will be needed.

Examples of before and after pictures are given on the gallery page. Please carefully note the pre-existing breast shape in each case

I usually place the incision in the fold beneath the breast (inframammary fold). This is relatively hidden and tends to leave a fine scar with time. This location is easier if the implants ever need adjustment in the future.

The scar is about 4cm long for implants up to 260 cc and 4.5-5cm long for implants over 320cc.

The periareolar incision (around the areola) may leave a more noticeable scar, will cut breast ducts and may affect breast feeding, is more likely to affect nipple sensation and may lead to a higher capsular contracture rate because of bacteria within the ducts.

The axillary (armpit) incision may be visible when wearing sleeveless dresses.

It is normal for an area of skin about the size of a 50 cent piece immediately above the incision to be very numb for a long time. Rarely there may be numbness of the nipple and areolar complex. Hypersensitivity is more common, about 1:10 cases. This can take many weeks to settle and slight hypersensitivity may be permanent in a small number of cases.

The risks

Smoking greatly increases the risk of surgery complications and has specific risks for breast implants. In particular the risk of a capsular contracture distorting the breast implant is more likely in the presence of smoking.I want my patients to have the best possible result so please don’t smoke!

A single cigarette will cause the small vessel in the skin to tighten (vasoconstriction) for about 50 minutes. This will affect wound healing. The chance of a hypertrophic scar, wound edge separation and infection is much more likely in active smokers.

Smoking decreases the elastin content of the skin. Over time it will have less elastic recoil. This is most noticeable in the face with visible wrinkles but also affects breast skin.

Atelectasis, or collapse of the small air spaces in the lung, is much more common after an anesthetic in smokers.

Ideally smoking should stop a minimum of 6 weeks before surgery and needs to permanently stop to maintain the best results and tissue tone over time.

There are a number of complications that can occur after surgery. These will be explained during the consultation and in written information given to you. Most are explained in more detail below.

Most potential complications or adverse outcomes can be improved by further surgery.In the case of breast augmentation this includes haematoma, ripples, poor position, implant rotation, implant rupture, capsular contracture and incorrect size.

If the complication was caused by a technical error on my part I would fund the total cost of revision surgery. If this is not the case, for instance a capsular contracture, then I would not charge a surgical fee if the complication occurred within 5 years of surgery however the patient would have to fund the cost of the hospital and anaesthetic fees.

The implants I use have a guarantee from the manufacturer for rupture and severe (grade 3 and 4) capsular contracture. They would supply a new set of implants but not fund the revision surgery.

Infections are rare after breast augmentation surgery. In severe cases the implant would need to be removed and replaced at a later stage. This risk is about 1 in every 500 cases. If this is the case the cost would be covered by ACC as a Treatment Injury.

In about 1% of cases there may be a minor skin infection for which I prescribe antibiotics as a precautionary measure for a few days.

The risk of haematoma, or bleeding in the surgery site is about 2% (1 in 50).

Haematomas typically occur between 8-12 hours after surgery. Initially the breasts are soft and symmetrical then one side will become very swollen. It may be quite uncomfortable as swelling progresses. If this happens you will need to be taken back to the operating theatre, the incision opened and the clot removed. Most people will still go home the next day as planned but this will depend on the timing of surgery. A late haematoma after patient discharge is very rare.

The cost of the further surgery is covered by ACC as a “Treatment Injury”. You do not have to pay additional costs.

Every foreign body inside the body (eg hip joint, heart valve, chemotherapy catheter, shrapnel, windscreen glass) is walled off by scar tissue.

In the case of a breast implant, this scar tissue is called a capsule. It is normal for every breast implant to be surrounded by a capsule.

In about 5% of cases, this capsule may tighten, a so-called capsular contracture. My own personal rate of capsular contracture is much lower, but because they may develop many years later, I do not yet know if my contracture rate may be as high as 5% a decade after surgery.

There are various grades of capsular contracture.

  • Grade I. The implant feels firmer than the other side
  • Grade II. The upper pole of the breast becomes more rounded
  • Grade III. The implants are quite distorted and misshapen
  • Grade IV. The implants are painful

I have several patients with Grades I and II contractures who have decided it is not worth intervening unless the contracture becomes worse. The implants I use have a guarantee from the manufacturer for Grades III and IV capsular contracture. They will supply a new set of implants.

It is thought that capsular contracture may be caused by a bacterial “slime” layer, a so-called “biofilm”. This is not an infection. Every time you brush your teeth, bacteria from the mouth can appear in the blood stream. This is called a bacteraemia. Bacteria from any source of infection or during major dental surgery could lodge on the implant capsule and cause a biofilm. It is recommended that a short course of antibiotics be taken if undergoing major dental surgery to decrease the risk of capsular contracture.

Modern implants are filled with highly cohesive memory gels that are more solid than liquid. Their consistency is a balance between maintaining shape and creating a “feel” similar to normal breast tissue. When the implants are upright, the gel will preferentially fill the lower pole of the implant giving a more anatomical shape. In under-filled implants this can cause a rippling of the overlying implant shell. I use nearly fully inflated implants to minimise this effect but it is still possible.

If the implants are overfilled, there will be an unnatural fullness of the upper pole of the breast in some cases.

Traction rippling is also possible and is more noticeable in very thin people with minimal fat overlying the implant. It may be able to be disguised by inserting fat grafts.

Rotation is not a concern with a round implant. It will not be detected if it occurs. Rotation of 20 degrees of an anatomical implant is noticeable but rotation is uncommon.

Minor asymmetry before surgery is common and normal. Asymmetry may occur if there is a pre-existing asymmetry of the breasts of the chest wall. It may become more pronounced as equal sized implants project forward. This would normally be detected during the examination and whilst trialing implant sizes. In significant cases of asymmetry, different sized implants may be used or a breast lift or breast reduction procedure performed on one side.

There is no known connection between breast implants and connective tissue disorders.

In the past this was unclear. In 1992 the US FDA banned the use of silicone breast implants until their safety could be verified. One implant manufacturer (Dow Corning) went out of business and was sued by past patients at the time.

Subsequently it has been conclusively shown that the use of medical grade silicone is safe, and it is used in many types of medical devices.

Muzzafar A. The Silicone gel-filled breast implant controversy: An update. Plast. Reconstr. Surg. 742: 109, 2002

 

There is no evidence that breast implants cause breast cancer. The rate of breast cancer may be slightly lower in women who have breast implants but this is probably because they tend to have less breast tissue than the general population.

Over 3000 women in LA were studied over 10 years. The rate of breast cancer in women with implants was slightly lower than expected.
Deapen D. Augmentation mammaplasty and breast cancer: A 5 year update of the Los Angeles study. J. Clinical Epidemiology 48:551, 1995.

In the largest study to date, about 11,000 women from Canada were followed. The incidence of breast cancer in women with breast implants was the same as the general population.
Bryant H. Breast implants and breast cancer: Reanalysis of a linkage study. New England Journal Medicine 332:1535, 1995.

Breast implants have been associated ALCL which is discussed below.

Anaplastic Large Cell Lymphoma (ALCL) is a rare type of lymphoma that can affect the fluid layer and capsule (scar layer) around a breast implant.

No cases of anaplastic large cell lymphoma have occurred with smooth surface implants. In 2019 I started to use smooth surface only implants to avoid any worry about this rare condition.

The risk with textured implants is thought to be about 1:5000. This means that for 5000 women with breast implants, 1 will develop ALCL and 4999 will not.

No country has recommended removal of textured surface implants. It is thought that this may cause  more harm than good.

The most common symptoms of ALCL are either sudden swelling of a breast (caused by a fluid collection) or a mass. If you develop either of these you should speak to you surgeon. Common causes of a delayed seroma (fluid collection) are infection or trauma, however suspicious swellings should receive a fine needle aspiration test. Lymphadenopathy (swollen armpit lymph nodes) are a less common sign.

Most people who have developed ALCL have been cured by total removal of the implant and the capsule layer around the implant. If there is a mass, chemotherapy may also be recommended. Although rare, fatal disease is possible.

The risk of 1:5000 (only if there is a textured implant) should be balanced against the lifetime risk of developing normal breast cancer which is about 1:7

The FDA website summarises available data as it comes to hand.

U.S. Food & Drug Administration

I am happy to see women who are concerned that they may have BII and work with them to determine whether surgery to remove their implants is appropriate for them.

Breast implant illness (BII) is a term that some women  use to refer to a wide range of symptoms that can develop in association with breast implants. Symptoms may include for instance; joint and muscle pain, chronic fatigue, memory and concentration problems, rashes and skin problems, anxiety and gut problems.

BII is not currently recognized as an official medical diagnosis. Whether it really exists as  a specific disease entity is controversial among doctors because the cluster of symptoms don’t fit into any other classic disease diagnosis.

Some women who have thought they have BII have found that surgery to remove the breast implants improves or completely resolves the BII symptoms. For other women it has made no difference presumably because their implants did not cause their symptoms. Some of these women went on to develop autoimmune diseases unrelated to their implants.

If implants are removed for BII, it is important to remove the outer scar layer (capsule) completely because this is likely to contain silicone microparticles and biofilm on the surface of the implants. Either  a total capsulectomy or en-bloc capsulectomy will remove the entire capsule. The capsule is then sent for laboratory testing.

It is recommended that new implants are not reinserted if the symptoms do resolve.

 

 

Going forward

Breast feeding is not affected by the way I do surgery. An inframammmary crease incision is used beneath the breast and implants are placed behind the breast gland. No breast ducts are cut.

Other ways of surgery can affect breast feeding. A periareolar incision cuts some breast ducts, has more of an effect on nipple sensation and increases the risk of capsular contracture.

During breast feeding, the breast gland can increase in size significantly. When it subsequently decreases in size, the breast may have a different shape and in some cases it may droop over the implant. In severe cases the patient may request a breast lift. This can be done without disturbing the implant although some people also request a size change at this time.

Approximately one in every 7 New Zealand women will develop breast cancer during their lifetime. Breast screening is recommended every 2 years for women once they reach age 45. Women who have a strong positive family history of breast cancer will start breast screening at an earlier age.

Mammograms image the breast tissue better than other types of xrays in most cases. Some women with very dense breast tissue may have ultrasound scans or MRI scans recommended by their breast surgeon.

A mammogram normally images about 93% of the breast gland. After breast augmentation this drops of to about 87% of the breast gland. However it appears that breast cancers are felt more easily in the presence of breast implants. Studies show that breast cancer is diagnosed at a similar stage in women both with and without breast implants and the prognosis is comparable.

Handel N. Breast Cancer diagnosis and prognosis in augmented women. Plastic & Reconstruction Surgery: 118; 587-93, 2006.

When performing mammography in women with implants, a displacement technique is used, the Eklund technique. In reviewing the safety of silicone implants the FDA had reported “the effectiveness of mammography to screen women with breast implants for cancer is generally similar to that of women without implants”

With older generation implants, it was recommended that patients see their surgeon every year for an implant check. Because modern generation implants have a much lower capsular contracture and rupture rate, this is not thought to be necessary.

It is recommended that a course of antibiotics be taken if undergoing major dental surgery. The bacteraemia associated with this surgery may theoretically increase the risk of a capsular contracture. In the same way patients with a prosthetic heart valve have antibiotics if undergoing similar dental work.

With any patient I have operated on, I have an open door policy if any problem arises in the future related to that surgery. Consultations in the first year after surgery are not charged for.

Breast implant removal can be done at any time in the future. There are several considerations.

If there is no implant complication, the implants could be removed under local anaesthetic using the inframammary crease incision.

If there is a capsular contracture or implant rupture then a capsulectomy is recommended. this will need a general anaesthetic.

A total capsulectomy removes the entire capsule. An en-bloc capulectomy removed the implant and capsule together. An en-bloc capsulectomy requires  a much longer incision and may not be possible where the capsule is stuck to ribs. A total capsulectomy may then be performed instead for safety reasons.

When implants are removed  there is may be more tissue stretch and drooping than if implants had never been placed. Whether or not a breast lift (mastopexy) will be needed will depend on the size of the implants, the amount of breast tissue present and quality of the breast tissues.

A capsulectomy is removal of the capsule layer that forms around a breast implant.

Many foreign bodies can left inside tissue including after trauma (windscreen glass, shrapnel etc) and surgery (contraceptive rods, pacemakers, joint replacements, tendon rods, heart valves, breast implants etc). Your body will seal off any foreign body by putting a scar layer around it. In the case of a breast implant, this layer of your own scar tissue is called a capsule and it lies directly against the implant.

If your breast implant is ruptured, or this scar layer becomes thick creating a capsular contracture, then removal of the capsule would be recommended at the time the breast implants is exchanged/ removed.

A total capsulectomy removes the entire capsule. An en-bloc capulectomy removed the implant and capsule together. An en-bloc capsulectomy requires  a much longer incision and may not be possible where the capsule is stuck to ribs. A total capsulectomy may then be performed instead for safety reasons.