Breast Implant Exchange – Part 2

In Part 1, I discussed how breast implants aren’t forever, and it’s best to be proactive about exchanging implants. But what if there is an unanticipated problem such as a capsular contracture that requires surgery? I’ll discuss two topics – capsular contracture and implant “leakage”, both of which require implant exchange.

A contracture is a hardening of the body’s natural scar capsule that it forms around any implant. Most breast capsules go unnoticed because they are thin and supple, but if they thicken or calcify, they can cause hardening of the breasts, distortion, and even pain. Thankfully capsule contracture is much less common these days, because of better techniques and antibiotic irrigation at the time of surgery, sub pectoral placement, as well as better implant material.

A capsular contracture needs to be treated with surgery. If you’ve read of treating capsular contracture with medications such as Singulair, it doesn’t work on established contractures, and it probably does little or nothing to prevent repeat capsular contracture. So, the treatment is surgery. The capsule is partially or completely removed, the implants are exchanged for new implants, and often a new pocket will be made for the new implants – typically moving the implant pocket from submammary to subpectoral.

What about “leakage”? I put that in quotes, because nowadays, the silicone gel implants are of a more cohesive quality, and the gel inside doesn’t really “leak”. Think of a gummy bear, but softer. Old gels however, did leak, and I still exchange old implants that have leaked, having gel either within the capsule (intracapsular), or outside the capsule (extracapsular). An extracapsular leak can cause problems, because getting all of that old gel out from the surrounding tissues is nearly impossible, and doing so can cause contour deformities on the chest. Also, the gel can migrate to lymph nodes under the arm, creating palpable nodes that then prompt a work-up (biopsy) to rule to breast cancer. (By the way, patients with breast implants do NOT have a higher risk for breast cancer, in fact the opposite is true, but that’s a topic for another time). If you have old gel implants, especially if anything even remotely suggestive of an implant leak is seen on a mammogram, you should get them exchanged as soon as you can.

When the FDA re-approved gel implants for cosmetic use in 2006, it suggested periodic (3 years, then every 2 years) MRI scans to look at the integrity of the implant shell. However, because of the expense of MRI scans, and the low incidence of early implant shell failure, and the less-than-perfect ability of even an MRI to detect all shell problems, this recommendation has been criticized. At a roundtable discussion with FDA representatives at the recent meeting I attended of the American Society of Plastic Surgeons, there was much discussion of better ways of follow-up, so I suspect that recommendation to be changed at some point.

Unfortunately, someone who has had a capsular contracture is at a higher risk of having another, but using some of the surgical techniques I’ve described will help minimize the risk. For the rare patient who has had repeat problems with contracture, using ADM (acellular dermal matrix) products to replace the lower portion of the breast implant capsule seems to be effective in breaking the cycle of contracture.

Most of what I’ve discussed relates to silicone gel-filled implants. Capsular contracture is slightly less common with saline implants. Leakage with saline implants is never a mystery – the saline leaks, and is absorbed by the body and the implant is obviously deflated. It can happen quickly, or over a period of a couple weeks or more for a very small leak. Because the deflated capsule will start to contract upon itself, it is important to replace it (and usually the opposite implant as well, depending on its age), as soon as possible, ideally within two weeks.

Douglas J. Mackenzie, M.D., F.A.C.S., Pacific Plastic Surgery, Santa Barbara, California

Douglas J. Mackenzie, MD

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