Breast Implants: To Be or Not to Be….

I have been in the business of Plastic Surgery for over 20 years if you include training prior to private practice. During that time, I witnessed many evolutions of breast implants. When I was in my residency from 2001-2003, saline implants were our only option as a moratorium on silicone implants had been leveled by the FDA in 1992 with concern for the instability of the devices over time. Silicone implants had been on the market since 1963 when they were taken away; saline implants were predictable, stable, and easy to insert through small incisions and the patients were pleased in general with their results.

I moved to Fort Worth in 2004 to set up shop and start my private practice. What was to have been a career in Craniofacial Surgery after a Fellowship in that specialty in Dallas from 2003-2004 quickly evolved into a breast and body, ‘Plastic Surgery from a Female Perspective’ lifestyle. I treasure this and feel certain I found the niche I was meant to be in. Breast augmentation and all related to that became my bread and butter very quickly but even then, only saline implants. Until 2006…

I recall the reps coming to the office to present the newest wares: modern, cohesive, FDA-approved silicone gel breast implants! This was the closest thing I can imagine to discovering electricity back in the day. What is this sorcery, I asked? This device feels like liquid but in fact is a form stable gel. Are they safe? Are they really ‘back’? Yes, they were and yes they are.

I drank the Kool-Aid, so to speak, after the obligatory period of research and the training the manufacturers required to order and place the implants. At the time, there were really just two manufacturers, Allergan and Mentor. The market has since expanded to include Sientra and some other smaller players but suffices it to say, silicone implants have been vetted, the FDA has signed off on their utilization for breast augmentation and breast reconstruction, and, in the opinion of myself and most others, they are here to stay. Or are they?

In 2019, concern for a very rare lymphoma related to the textured surface of implants came to mainstream media. Breast implant-associated Anaplastic Large Cell Lymphoma (BIA-ALCL) was first discovered in 1997. As of June 2022 according to the American Society of Plastic Surgery, 389 cases, both suspected and confirmed, have been reported in the US and 1216 cases worldwide. This is not breast cancer but rather a very rare lymphoma that arises in the capsule around the implant, a natural reaction to a foreign body that is effectively what an implant is. The intent of this blog is not to dive deeper into this diagnosis but suffice it to say that it is very rare and very treatable with the removal of the implants and all of the capsule surrounding the implant. Despite this knowledge, it is my opinion that this news has prompted many who already had breast implants without any clinical concerns to have them removed. Further, many patients pursuing aesthetic revision of their breasts for a myriad of reasons…after childbearing and breastfeeding, after weight loss, the genetic tendency toward deflated breasts in healthy, younger patients…have been spooked by this news and wish to consider either removal of existing implants or options to rejuvenate their breasts without the addition of an implant.

Learn more about BIA-ALCL

Let’s take a deeper dive:

Imagine a patient who has had breast implants for years, is very pleased with their breasts, and doesn’t necessarily WANT their implants removed but is anxious about this rare diagnosis. My opinion on the longevity of implants is that if it ain’t broke, don’t fix it. For saline implants, the longest warranty offered by manufacturers is 10 years. This had led to the fallacy that all implants must be replaced at the 10-year mark. This is not true. For a saline implant that is intact and soft at 10, 12 or 20 years-whatever the case may be-my advice is to leave well enough alone. Remember the old adage ‘the enemy of good…’ A saline implant is obvious when it has deflated. Consider this a social emergency more than a surgical emergency; once the replacement size has been determined, removal and replacement in the operating room is a straightforward procedure in the majority of cases.

The decision to remove and/or replace silicone implants is slightly more complicated but not much. The modern implants are a stable gel and therefore could be ruptured in the pocket without external knowledge of such. Because of this, when the FDA allowed silicone implants to return to the public, a recommendation for imaging surveillance to confirm the implant is indeed intact was made. This is an ultrasound or an MRI and should be considered routinely throughout the lifespan of a silicone implant. I see my implant patients once a year forever and it is my job to remind the patient that it is time for surveillance….you need not worry about this yourself. Most Plastic Surgeons now have ultrasound capabilities in their offices making surveillance even easier. The tricky part can be if the silicone implant is completely ruptured and not contained in the shell. There are tools to remove this in the operating room but suffice it to say, messy and not as straight forward as saline removal but that’s a story for another day.

The most common sequelae of breast implants is capsular contracture with an incidence estimated between 10 and 15% of all breast implant patients. Capsular contracture is a relatively poorly understood phenomenon even after decades of breast implants and millions of patients but primarily thought related to a specific bacteria in the breast pocket. There have been more publications regarding how to minimize the risk of this development but nothing to date definitive or ‘curative’, so to speak. Capsular contracture, or in layman’s terms excessive scar tissue around the implant, can be a function of exposure to silicone in the capsule related to a rupture. The modern silicone implants are fabricated from a gel and designed to hold their shape. If and when the implant ruptures, and all implants do eventually rupture as a fact of life, the silicone exposed from the implant shell can cause irritation and scarring in the body’s capsule, hence capsular contracture. If capsular contracture develops, that capsule should be removed and the replacement implant, if desired, placed in another new tissue plane otherwise the new device would have the same appearance within the scarred tissue shell as the old one.

There are many other ‘what ifs’ with breast implants, not unlike the list of ‘what ifs’ that are related to every other procedure in the Plastic Surgery world. Implant malposition, or failure of a sufficient capsule to form to secure the implant in the desired location, infection, pain…or just desire to have the device removed and go ‘au naturel’, whatever that may look like for any given patient.

There is another piece of the puzzle that is as tricky to navigate as BIA-ALCL. BIA-ALCL is very real and very rare. Breast implant illness (BII) is a complex of symptoms that patients believe is related to the presence of breast implants but regretfully, no science has supported this concern. In 2022, two very solid research papers were published by esteemed Board Certified Plastic Surgeons that refuted the belief that capsules around implants of patients that believe they have BII are any different that patients that do not have concerns for this diagnosis. If a patient comes to me with interest in implant removal because they believe the presence of the devices is causing joint pain, memory loss, brain fog, thinning hair….I can certainly take those implants out. I cannot, however, make any guarantees that symptoms will change once the implants are removed and given the modern data, there is no indication to remove all of the capsules around those implants, quite unlike what is indicated for BIA-ALCL. Many patients have suffered injuries in the operating room from surgeons that elected to remove the often very thin and clinically normal capsules surrounding the implants in these patients that could have been avoided with simple implant removal and a window without the devices to see if symptoms do indeed improve. No harm, no foul….if you like what you see without them and feel better, you’re done. If you don’t like what you see without the devices whether or not you feel better, consider replacing them. This blog not intended to debate BII but it must be mentioned as this is a common presentation in today’s world for patients wishing implants removed or perhaps seeking options to make their breasts look the way they would like without the addition of an implant.

Fat grafting must be addressed here as literally, everyone asks about it.

This sounds amazing, right? Do some liposuction to fix one area and use that fat to build up the shape and volume of the breast without an implant, perhaps with the addition of a breast lift. Fat grafting is a workhorse of breast reconstruction: patients that have had breast tissue removed for cancer and reconstructed with either an implant or their own tissues as a flap, often have contour deformities (rippling of the implant, visible edges of the device under thinner tissues for example) that are easily corrected by placing fat under the skin over the area of concern. Yes, surgeons have used fat to augment the entire breast but that process in my opinion is neither practical nor sustainable. Grafted fat is living tissue that we are asking to live somewhere else in the body. To survive, the fat cells must establish a blood supply in the grafted area (breast, face, buttocks for most common examples). All of those fat cells are not going to survive and the reported rates of resorption range from 30 to 80%. I most commonly cite 50ish% loss of grafted fat volume. So imagine you’re using this to build up breast volume: it would take a repeated series of procedures to keep adding fat after each round once the tissues have stabilized and I don’t think this a very financially responsible or reasonable alternative to implants. Just my opinion.

So I briefly mentioned breast reconstruction, having clearly focused primarily on cosmetic augmentation here. Implant-based breast reconstruction after a mastectomy is the most common technique utilized with only about 19% of all patients opting for tissue-based reconstruction without implants. I am a breast cancer survivor and I have silicone breast implants. I selected this as my preferred technique for reconstruction after a double mastectomy. I cannot imagine a stronger endorsement for the safety of breast implants than a female Plastic Surgeon who had breast cancer opting for this technique. Because of this statistic, I am focusing on cosmetic procedures here and not reconstruction as I think options are severely limited without implants post-mastectomy. Good topic for another blog another day…

So what if a patient wants their breasts perkier, maybe slightly firmer, and not necessarily fuller?

A mastopexy is a skin bra: imagine you love what you see in your bra but you’re pretty unhappy once you take that bra off. A mastopexy recreates that lift internally through a series of techniques far beyond the scope of this read. I feel that I have already pushed the envelope with this read now on page 3 having just been typing for about 30 minutes. I do have a lot to say…whew! The biggest limitation of a breast lift is developing upper pole fullness in the breast…a job that an implant does very well. I have been toying with different techniques trying to create the perfect breast lift for shape, contour, lift…and upper pole fullness. I think I am finally on to something pretty great.

The technique of a breast lift, or a breast reduction for that matter, is to reposition the nipple to the desired, corrected level then arrange or remove what’s left to shape the breast as optimally as possible. So many patients believe that the nipple is routinely removed during these procedures and attached at the completion. This is not true. The incision seen around the nipple-areolar complex (the NAC) is from insetting it into the elevated, desired position. If it were removed completely, there would be no sensation and the blood supply may or may not result in the grafted nipple surviving. One of the principles of a breast lift is to maintain the predominant blood supply to the central breast and the NAC. That blood supply is either inferior or superiorly based, either or. Once the blood supply has been determined, the design of the operating surrounds that outlined the amount of tissue, tissue is removed as indicated and the breast is reshaped. But what if a patient wanted a lift, and had reasonable breast volume just in the wrong place? Keep everything including both blood supplies and shape the living daylights out of the tissue to create a breast mound that looks like an implant, without an implant. Is this a perfect solution or right for everyone? Of course not. But for a patient that the tissues lend themselves to shaping a nice breast, it is a great alternative to an implant. What if the final result is not exactly what was imagined? Too small? Not enough upper pole fullness? Then add an implant at any time. My patients that are candidates for this feel empowered by the opportunity to make a decision for themselves, potentially avoid a device that will by definition require revisions and replacements down the road, and very possibly accomplish their aesthetic goals in a single stage.

So there you have it…

My two cents…more like 20 bucks….on the ins and outs of breast implants, what they do well, what they can lead to, and how they can potentially be avoided to accomplish the same or a very similar cosmetic objective with the patient’s own tissues creatively restructured. My list of satisfied patients using this technique is growing and I am eager to build this list so perhaps if this is something you have been considering and there is anything possibly left to say after this lengthy oration, give us a call and we’ll make a decision together. I have to go do a breast reduction now on a lovely lady that absolutely does NOT need an implant to accomplish what she wishes to see.

Here's up to it!

EBM

Dr. Emily B. McLaughlin is a double-board-certified plastic surgeon located in Fort Worth, Texas. In her practice, onsite surgery center, and med spa, she performs mommy makeovers, breast augmentation, tummy tuck, eyelid surgery, liposuction, laser skin resurfacing, Emsculpt muscle building, and more. Dr. McLaughlin serves Fort Worth and surrounding areas including Aledo, Arlington, Dallas, Grapevine, & Southlake.

Breast Implants: To Be or Not to Be….