Common Complications of Breast Enhancement
Complications after breast augmentation are not uncommon. They can occur in women with either silicone gel– or saline-filled implants; conflicting incidence rates for capsular contracture (the most common local complication3,4) have been reported following insertion of silicone gel–filled implants, compared with saline implants.5,6 It has been noted, however, that prospective data comparing the two implant types are lacking in the literature.7
Complications can be categorized as either local or systemic. In addition to capsular contracture, local complications (which are more common) include implant rupture or deflation, and implant rippling or wrinkling.
Systemic complications may include anaplastic large-cell lymphoma, a rare but serious complication that is currently under study for its potential association with breast implants8 (see third article in this series, “Anaplastic Large-Cell Lymphoma”9-14). Other systemic sequelae include autoimmune disorders, connective tissue disease, and fibrositis/fibromyalgia conditions; these conditions can only be addressed in an article of greater scope.
In 2006, breast implant manufacturers were mandated to conduct postapproval studies regarding the devices’ safety15 (see fourth article in this series, “History of Breast Implant Regulation,”2,15-20). Findings from these studies can facilitate primary care providers’ management of patients who have augmented breasts.
Capsular Contracture
Capsular contracture occurs with frequencies ranging from 1.9% to 2.3%.8 As a result of the immune response to any foreign body, collagen fibers form and weave around the prosthetic device once it is implanted. For reasons not completely understood, these fibers can begin to tighten over time. As the capsule continues to tighten and harden, the implant is then compressed, resulting in breast pain and deformity.
The degree of capsular contracture is categorized according to Baker’s classification system regarding implant position and breast firmness postaugmentation.2,21 A Baker’s grade I designation implies that the modified breast is soft and looks normal. Grade II describes a breast that is slightly firm upon exam but looks completely normal. In grade III, the breast is firm and has taken on an abnormal appearance. In grade IV, the breast looks abnormal and is firm on examination, with the patient describing significant pain.
Some researchers believe that capsular contracture develops because of a subclinical bacterial infection, while others suggest that silicone leakage may be the cause.6,22,23 A patient who is diagnosed with a hematoma during the postoperative period is at increased risk for capsular contracture, and one who has been treated previously for capsular contracture has a significant risk for recurrence.2,24
Capsular contracture is usually treated surgically by a capsulectomy or a capsulotomy. Currently, the preferred procedure is an open capsulectomy to remove the implant, surgically excise the entire capsule, and replace the implant.4
Implant Deflation, Rupture
Most ruptures of implants (whether they are used cosmetically or for reconstruction) occur between 10 and 15 years after implantation.3,25 Incidence of implant removal by 10 years postsurgery ranges from 21% to 32% for silicone gel–filled implants, depending on the specific implant model.17
Saline implant deflation is relatively easy to detect because it presents with a rapid decrease in breast size on the affected side. Ruptures of silicone gel–filled implants, by contrast, can go undetected for years—hence the term silent rupture applied in this circumstance.3 If a rupture is detected, the faulty breast implant is removed and returned to the manufacturer for investigation.
If surgical instrumentation leads to a puncture during saline gel–filled implant surgery, it is usually noticed immediately. A silicone gel–filled implant can also be punctured during the implantation procedure, often with no obvious signs of the rupture.
Rupture of a silicone gel–filled implant may be intracapsular or extracapsular. In intracapsular ruptures, the contents of the implant remain within the capsule that has formed around the implant. Extracapsular ruptures involve migration of the silicone material outside the capsule.3 Current-generation silicone implants are increasingly biodurable, thereby reducing the risk for silicone migration.26,27
MRI is currently considered the study of choice to detect silent rupture of a silicone gel–filled implant.28 As primary care providers should be aware, the FDA recommends that women with silicone gel–filled implants undergo MRI screening three years after implantation and every two years thereafter to assess the implants’ integrity.17 This applies to all age-groups and does not replace screening mammography requirements for breast cancer.
While mammography is ideal for detecting extracapsular silicone implant ruptures, it fails to detect intracapsular implant rupture consistently.29 Breast ultrasound cannot effectively detect ruptures in the posterior portion of the implant and cannot evaluate the chest wall. Thus, MRI, with its high spatial resolution and marked contrast between implants and natural breast tissue, is considered most effective in detecting either intracapsular or extracapsular ruptures.3,28,29
Despite earlier reports that implant rupture could prompt an immunologic reaction, giving rise to autoimmune or related diseases, subsequent studies reveal “no association between silicone gel–filled breast implants and connective tissue disease, breast cancer, or reproductive problems.”17 Apart from a relatively low risk for silicone migration, implant rupture has been deemed relatively harmless.30
Implant Wrinkling, Folding
Implant wrinkling visible to the naked eye can mar the aesthetic appearance of an augmented breast. In some cases, the wrinkled implant may be detected only by palpation. Causes of wrinkling include:
• Thin skin and insufficient natural breast tissue, especially in the lower outer pole
• Subglandular placement of the implant, which allows less coverage over the implant than submuscular placement; and
• Use of saline-filled or textured-surface implants.
Because saline has a lower viscosity than silicone, it may allow lower-pole expansion and settling—and hence, wrinkling. Insufficient filling in saline implants may contribute to the problem, in addition to palpable shell folding, palpable shifts of filler material, sloshing, and other compromised aesthetic results.3,31
In rare cases, wrinkling over thin skin can cause implant extrusion. Additionally, the friction created as the shell rubs against itself can cause implant deflation or even rupture due to the development of a “hot spot.”
Options to address implant wrinkling are to replace saline-filled implants with silicone gel–filled implants or to revise placement of the implant from the subglandular to the submuscular location. Use of acellular dermal matrix can help reinforce existing breast tissue, especially when placed in the lower pole of the affected breast.32,33