Risks and Complications in Breast Augmentation

from plastic surgery

As with all surgery, certain risks are inherent in breast augmentation. Read this section carefully, as your decisions hinge on your understanding of the risks. An in-depth discussion with your plastic surgeon is also essential to understanding these potential problems.

Capsular Contracture

Scar tissue forms around all implanted materials as a natural part of healing. Scar tissue around a breast implant is not troublesome, unless it tightens. An abnormally tight scar is known as a capsular contracture. It may cause the breast to feel firm, unnatural, or even painful. Capsular contractures mav occur at anv time, but tend to occur in two waves: earlv and late.

Early Capsular Contracture

Capsular contractures that occur within the first year of surgery are known as "early." Most of these are thought to be due to a present on everyone's skin and usually causes no problems. Staph, epi., as it is called, is generally benign unless it is in association with a prosthetic implant, such as an artificial joint, heart valve, pacemaker, or breast implant. Because it is so benign, it does not cause the classic signs of infection: redness, swelling, and fevers. Instead it remains dormant around the implant until it incites the surrounding scar tissue to tighten and contract.

Late Capsular Contracture

Capsular contractures that occur years after surgery are known as "late." These are frequently related to silicone gel implant ruptures, and they occur when the scar tissue around the implant becomes irritated or inflamed in response to silicone gel that has extruded through the implant shell. Saline implants are less likely to cause a late capsular contracture, because saline is absorbed by the body if the implant leaks and does not trigger an inflammatory response. Silicone, however, might cause an inflammatory response if the implant ruptures.

Risk and Prevention

Numerous studies have been published with capsular contracture rates varying between 10 and 50 percent. Perhaps the most meaningful way to interpret these apparently discrepant values is to consider that the risk of severe capsular contracture is close to 10 percent and the risk of mild capsular contracture may be as high as 50 percent. Efforts to prevent capsular contracture include meticulous sterile technique during surgery and implant displacement exercises following surgery. Displacement exercises are thought to stretch surrounding scar tissue, thereby reducing the rate of capsular contracture. Do not begin this until your surgeon advises you to do so.

Treatment

Treatment involves surgical removal of the scar tissue, or capsulectomy, and placement of a new implant. The implant might also be moved to a different plane (i.e., above or below the pectoralis muscle). If you have a moderate or severe capsular contracture, you may choose to undergo this operation. Realize, however, that capsular contracture may recur, as additional surgery is not guaranteed to solve your problem. Therefore, if your contracture is mild, as many are, you might choose to avoid surgery and simply live with it.

Interference with Mammography

Breast implants interfere with the ability of a mammogram to evaluate all breast tissue. Because one in nine women in the United States will develop breast cancer in her lifetime, mammographic screening for early diagnosis is important. The presence of a breast implant may, therefore, delay the diagnosis of breast cancer. A special mammogram method called the Ecklund technique is designed for women with breast implants, and all mammography facilities in the United States are required to offer it.

Implant Displacement

Implants can displace from their original position due to gravity, capsular contracture, muscle pull, the forces of healing, or the weight of the implant.

Interestingly, the nipple will point the direction opposite from where the implant has displaced. For example, if the implant moves upward, the nipple will appear to point downward (Figure 7-2a). Significant displacement can compromise the natural appearance of your breasts and can require an operation to recenter the implant. Due to the forces of gravity, it is much easier to fix an implant that has displaced upward or medially than an implant that has displaced downward or laterally. Efforts to raise low implants are particularly confounded when the implant is very large. Hence, a larger implant that has displaced downward is much more difficult to fix than a small implant that has displaced downward or a large implant that has displaced upward.

Implant Deflation and Rupture

Saline and silicone gel implants both have a shell made of solid silicone. By nature, this shell is soft and pliable, but it may also tear. When a saline implant shell tears, it is called a deflation, because the enclosed saline leaks out and is absorbed by the body, resulting in marked shrinkage of the breast. A rupture occurs when a silicone gel implant shell tears. The enclosed silicone gel might extrude to varying degrees, but the breast does not change in size.

Risk

The risk of saline implant deflation is about 1 percent per implant per year. Silicone gel implant rupture rate is about 3 percent during the first four years, which makes them roughly equivalent to the saline deflation rate during that time frame. Rates thereafter have not vet been determined, but studies are underway.

Treatment

Saline deflations require surgery for placement of a new implant. Silicone ruptures require replacement in addition to capsulectomy, which is the surgical removal of the surrounding scar tissue.

Rippling and Wrinkling

In a saline implant, the liquid moves freely within the shell and can cause small waves like those seen on the surface of a pond. These waves can be transmitted to the skin, causing the breast to ripple on its inner and upper sides. Rippling gives the breast an unnatural appearance. Thin women are particularly prone to rippling because they have less soft tissue covering their implants.

Wrinkling is the term plastic surgeons tend to use to describe an unnatural scalloping appearance that can occur on the side of the breast or underneath it. Again, thin women and those with saline implants are more prone to this. Be aware that the terms riffling and wrinkling can be confusing, as some plastic surgeons use them interchangeably.

Sloshing

Because saline has the consistency of water, it may slosh when you move. If so, sloshing usually is only perceived by the woman with the implants. It might be loud or distracting to the woman, but others generally do not hear it. Silicone, because it is more viscous, does not slosh.

Regardless of whether a woman chooses silicone or saline, she may have temporary sloshing within the first few weeks of surgery, but the reason for this is different. As a response to healing after surgery, the human body typically fills the space around the implant with clear liquid called serous fluid, which may slosh. As the body heals, it reabsorbs the serous fluid, and in the process, sloshing resolves.

Infection

Infection, which can occur after any operation, is devastating when it follows breast augmentation. It might require hospitalization, intravenous antibiotics, and removal of the implant. Months (in some cases years) afterward, a new implant can be placed. During that time, your breast asymmetry will be awkward. You will be markedly uncomfortable physically, emotionally, psychologically, and sexually. Fortunately, the risk of infection is less than 1 percent.

Sensory Changes

Your nipple or breast skin might lose sensation partially or completely following augmentation. As the nerve that conducts sensation to the nipple is typically small and thin, surgeons often do not see it during surgery. As such, it might be stretched, cut, or inadvertently cauterized. If stretched, sensation usually returns. If cut, sensation usually does not return. If cauterized, or burned, the likelihood of sensory return depends upon the extent of cautery.

The risk of permanent nipple numbness is about 15 percent. If loss of nipple sensation is unacceptable to you, you should carefully reconsider this operation. Another option is to ask your surgeon to avoid cautery near the nerve and to use only finger dissection, which confers a lower rate of nipple numbness.

The opposite problem, increased nipple sensation, is also possible and can be very aggravating. If it occurs, it usually resolves within a few weeks.

Breast augmentation does not usually affect nipple erection, which is preserved even if sensation is lost.

Hematoma

A hematoma is a blood collection that can accumulate next to the implant after surgery. Most hematomas appear either within a day of implant placement or about three weeks later. They usually require an additional operation for removal, as untreated hematomas are painful and increase the likelihood of capsular contracture and infection. The overall risk of hematoma is less than 2 percent, but it is higher in those who take aspirin or ibuprofen and in those who return to a physically demanding occupation or resume exercise too soon.