Breast Implant Complications and Revision

Dr. Mackenzie is experienced in fixing breast problems related to leaking or ruptured breast implants, capsular contracture, and aging implants. It is amazing how many women with breast implants are under the impression that their implants will last forever. They won’t. Years ago, perhaps some naive plastic surgeons told their patients that breast implantation is a one-time operation. Perhaps some simply implied it, and perhaps some patients were told the truth but ignored it. Regardless, nowadays, no ethical plastic surgeon will tell or imply to their patients that breast augmentation is a one-time operation.

Given enough time, the chance of having additional surgery on the breasts because of the implants is 100%. The good news is, the rupture rate of modern breast implants is low, and the capsular contracture rate is much lower than in the past, so it’s easier to consider revisionary surgery as something that can be planned for before a problem arises.

When considering breast augmentation, patients need to consider the future ramifications of the surgery. In other words, patients need to be financially and mentally prepared for the day when they will have additional surgery on their breasts. Despite the fact that the warranties from the implant companies are better than ever, future surgery will have an impact on your time and finances.  A rare cancer has been associated with some implants, please see our webpage on BIA-ALCL.

Implant Leakage

For ease of understanding, I tell my patients to consider a one to two percent per year rate of implant failure (the different implant failure rates between silicone and saline breast implants, or between manufacturers is pretty negligible). So in other words, about one in a hundred to one in fifty will have an implant rupture or “leakage” the first year. Low, but not zero. Add it up over several years, and you get the idea. I tell my patients, as a general admonition, to consider changing their breast implants out prophylactically between 10 and 15 years. I’ve seen implants in for 20, 30, even 40 years without rupture, but this is unusual and I would not recommend it. Often, when re-operating on someone with longstanding implants and no suspicion of leakage, one or both implants, are, in fact, leaking.

“Leaking” requires some explanation. First of all, “leaking” implies silicone gel implants, as saline implants that leak are pretty obvious – the breast deflates, the body absorbs the saline, and the implant obviously needs to be replaced. But with silicone gel implants, there is a difference between the implants of years ago, and the modern implants we use now.

Older breast implants had a more oily, sticky silicone. Silicone is a molecular polymer of many repeating units, and the older silicone gels had a high fraction of short-chain silicone polymers. In fact, some of the very shortest silicone polymers could leak through the shell of the implant even without a tear or rupture of the implant. When we do take out old ruptured implants, it is often difficult to get all of this sticky silicone out. When it has leaked beyond the breast’s scar capsule, it is considered an “extra-capsular” rupture and it is often impossible to get all the silicone out of the surrounding tissues. Lumps called silicone granulomas can form and removing these can cause contour deformities. This is why anyone with a known or suspected silicone breast implant rupture, particularly of an older style implant, should get them removed or replaced without delay.

Modern silicone gel breast implants have a more “cohesive” or “form-stable” gel, which means longer silicone polymers, and more cross-linking of the silicone molecules. This gives the gel more of a “jello” or “gummy bear” consistency and feel.  Perhaps you’ve seen the photos or videos of an implant cut in half – it holds its shape, and the gel tends to return back to its normal shape, even when squeezed.  An old gel implant cut in half would result in a big mess. When a modern gel implant does “fail” with a tear in the implant shell, the gel is more likely keep its shape, and doesn’t “leak” out like the old gels did.

Despite the advantages of these modern gel implants, there is an FDA recommendation to get a non-contrast MRI scan of the implants at three years and then every two years thereafter, to look at the integrity of the implant shell. I suspect the FDA may back off on these recommendations at some point, or allow substitution of high resolution ultrasound instead, but for now, that is the recommendation for follow up of silicone gel implants.

Capsular Contracture

Capsular contracture can occur months or years after breast implantation and requires surgery for all but the most mild contracture. The body walls off any implanted object with a scar capsule, and the same goes for breast implants. As long as this capsule stays thin and soft, it causes no problem and goes unnoticed. If it thickens or calcifies, it can “harden” the breast, distort the breast, and even cause pain. Usually this is a gradual process over months.

Often there is no known cause, but certainly some things will lead to a higher risk of getting a capsular contracture. These include the rare complications of bleeding, hematoma, or infection after the initial surgery. Whether or not massage or non-surgical methods can prevent or treat capsular contracture is controversial. Once established, surgery is needed to remove all or part of the capsule, replace the implants, and possibly place the new implants in a different plane of dissection. Occasionally acellular dermal matrix (ADM) is used which may help prevent capsular contracture, especially in recurrent cases. There is also the option of not replacing the implants at all.

Pocket revision

Sometimes the pocket within which the implant lies is too big, allowing the implant to move around too much, especially out to the side. This may also cause the implant to flip, which can distort the shape.

A procedure called a capsulorrhaphy places internal stitches to tighten the capsule and move the implant. A capsulotomy opens part of the capsule if the implant needs an adjustment of position or hasn’t dropped into a natural position as expected. Both procedures can be used together if necessary to adjust the shape of the pocket and position of the implant.

An implant malposition should be distinguished from a capsular contracture. If the implant remains high and never drops, it may look like a capsular contracture, but is usually simply a high implant, and a only capsulotomy is indicated. An implant that was once in proper position but has changed (usually going up and getting firm) is likely a capsular contracture and needs a more involved capsulectomy (see Capsular Contracture section above).

Symmastia

Also spelled synmastia and commonly known as “uniboob” this is when the two implants or their pockets meet in the middle. This difficult problem often needs a combination of surgical techniques to fix, and smaller implants may be recommended as well. Internal stitches, internal flaps, acellular dermal matrix (ADM), and prolonged external compression with a special bra may all be used to fix symmastia.

The preceding highlights some more common issues related to breast implant complications and indications for revision, but is certainly not exhaustive. If you have problems with your breast appearance, or have concerns about older implants, call Pacific Plastic Surgery in Santa Barbara today to schedule an appointment with Dr. Douglas Mackenzie.

Breast Implant Illness

I have a page on breast implant removal and en bloc capsulectomy, please see it HERE.

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