Breast Augmentation

Epidemiology

Incidence: 313,000 Breast Augmentation procedures per year in U.S. (2018)
1. Most Common U.S. cosmetic surgical procedure

Indications
Breast Implant

Cosmetic Breast Augmentation
Postmastectomy Breast Reconstruction
1. Implants are more common than tissue implantation (e.g. TRAM Flap)
Congenital Breast anomaly correction
Breast hypoplasia
Male to Female Transition Surgery ("Top" Surgery)

Types
Implant

Implant Fill Types
1. Silicone
  1. Preferred by patients for its more natural feel
  2. Implant rupture risks leakage of silicone into the Breast parenchyma with associated complications
  3. FDA recommends MRI or Ultrasound at 5-6 years post-implant and then every 2-3 years
  4. Mean implant lifespan 4.9 years (removed for rupture, contracture, pain, malrotation, rippling)
2. Saline
  1. Safely reabsorbed in case of rupture
  2. Mean implant lifespan 7.5 years (removed for rupture, contracture, pain, malrotation, rippling)
Implant Size
1. Volume ranges from 150 to 800 ml
Implant Outer Shell Texture
1. Smooth
  1. Risk of capsular contracture
2. Textured
  1. Designed to reduce the risk of capsular contracture as seen with smooth implants
  2. Association with anaplastic large cell Lymphoma has resulted in discontinued textured implants in U.S.
    1. All textured implants recalled by manufacturer (Allergan) in 2019

Types
Procedure

Incision Location
1. Transaxillary
2. Periareolar
  1. Increased risk of capsular contracture
    1. Li (2018) Aesthetic Plast Surg 42(1): 32-7 [PubMed]
3. Inframammary
4. Transumbilical
Implant Pocket Location
1. Prepectoral Implant
  1. Implanted superficial to the pectoralis major Muscle
  2. More comon in Breast Augmentation
  3. Less postoperative pain than submuscular Implant
  4. Risk of implant rippling visible below skin
2. Submuscular Implant
  1. Implanted deep to the pectoralis major Muscle
  2. Preferred in Breast Augmentation after Mastectomy
  3. Implant is better covered by Muscle with less risk of infection, exposure
  4. Implant may displace (supralateral) with pectoralis Muscle Contraction (animation deformity)
  5. Implant rupture may be more difficult to detect than prepectoral implant

Management
Post-Operative

Home Measures
1. Displacement massage starting day 3 to 5 after surgery
Return to Work
1. Normal activities may be resumed at 1-2 weeks
2. Avoid strenuous activity for 3-4 weeks

Adverse Effects

Breast Cancer Screening Precautions
1. Mammogram Test Sensitivity may be reduced with implants (despite the displacement views)
2. Breast Implant rupture is uncommon with Mammogram, but may occur
  1. Brown (2004) J Womens Health 13(4): 371-8 [PubMed]
Breast Feeding Precautions
1. Breast Augmentation may significantly reduce ability to Breast feed
2. Roberts (2015) Med J Aust 202(6): 324-8 [PubMed]
3. Cheng (2018) J Hum Lact 34(3): 424-32 [PubMed]
4. Bompy (2019) Ann Plast Surg 82(1): 11-4 [PubMed]

Complications
General

General
1. Longterm complications typically occur within 8 years of implant
2. Complications requiring repeat surgery in 24%
3. Higher Incidence of complication post Mastectomy
4. Lower complication Incidence with Breast enhancement
Breast Pain
1. Shooting pain, burning and general discomfort is common following surgery
2. Treat with Oral Analgesics (Acetaminophen, Ibuprofen)
Bleeding or Hematoma (first 24 hours)
1. Presents with painful, unilateral Breast swelling
2. Contact plastic surgeon who performed the original procedure
3. Patient may need to return to the operating room (Hematoma removal, stop bleeding)
Wound Seroma
1. Persistent fluid pocket at surgical site
2. Drainage pf persistent seroma under Ultrasound by plastic surgery or by Intervention Radiology
Implant rejection
1. Presents with a sudden firmness at the implant
Chest Trauma to Breast Implant
1. Evaluate for other chest injuries
2. Breast Implant evaluation (confirming intact) is by non-emergent MRI
Capsular contracture
1. Scar tissue hardening around the Breast Implant
  1. Results in implant becoming palpable and visible, and in some cases distorted and painful
2. Most common complication following Breast Implant (approximately 20% risk in 10 years)
3. Higher risk with periareolar incision and with Breast Reconstruction
4. Lower risk with textured implant outer shell (but not available due to risk of Lymphoma)
Deformity
1. Implant asymmetry, malposition, rippling
2. Implant may displace wih pectoralis Muscle Contraction (animation deformity) with submuscular placement
  1. Distorts Breast skin and nipple
Silicone Breast Implant Illness
1. No obvious consistent link between Rheumatologic Conditions and silicone implants
  1. Janowsky (2000) N Engl J Med 342(11): 781-90 [PubMed]
2. Possible association with autoimmune Dysautonomia triggered by silicone in some cases
  1. Halpert (2021) J Autoimmun 120:102631 [PubMed]
Breast Implant Removal Indications
1. Implant Rupture
2. Capsular Contracture
3. Silicone Breast Implant illness type symptoms
4. Breast Implant associated ALCL
5. Wound Infection (washout alone or with implant removal)

Complications
Anaplastic large cell Lymphoma (Breast Implant associated ALCL, esp. textured implants)

Presents as peri-implant effusion at 8-11 years after implant
1. Rarely presents with Breast Mass, fever or Night Sweats
2. Lymphoma that may originally appear similar to Cellulitis
3. Axillary adenopathy in up to one third of patients
As of 2020, FDA has issued a black box warning, and has found 733 cases of implant-associated ALCL
1. Incidence: 1 in 30,000
2. Most common with textured implants
Evaluation
1. Breast MRI (82% Test Sensitivity) or Breast Ultrasound (84% Test Sensitivity)
2. Fine needle aspirate by surgery is diagnostic (CD30, cell morphology, T Cell Flow Cytometry)
Management
1. ALCL remains confined to Breast in most cases, and has a 90% five year survival
2. Treatment with surgical excision and Chemotherapy

Complications
Implant Rupture

Results in content leakage into surrounding tissue
Requires routine surgical removal or replacement
Mean time of rupture ~8 years from implant
Saline implant rupture leaks into adjacent Breast tissue and is reabsorbed; decrease in Breast size obvious
Silicone implants maintain their shape and size after rupture
1. Silicone slowly extravasates into the surrounding capsule (intracapsular rupture)
2. Silicone may extravasate further into the Breast parenchyma (extracapsular rupture)
  1. Interferes with mamography
  2. Silicone moves into regional Lymph Nodes
  3. Silicone Granulomas may form (may be confused with breast Nodules)
3. FDA recommends MRI or Ultrasound at 5-6 years post-implant and then every 2-3 years

Complications
Wound Infection

Incidence 1 to 2.5%, typically presenting within the first 4 weeks after Breast Implant
Risk Factors: Early Infection
1. Diabetes Mellitus
2. Tobacco Abuse
3. Mastectomy skin-flap necrosis
4. Lymph Node dissection
Risk Factors: Late Infection (>30 days after implant)
1. Reconstruction after Mastectomy
2. Radiation Therapy
3. Increased Body Mass Index
4. Hematogenous risks of implant seeding
  1. Sepsis or bacteremia
  2. Dental work
  3. Chronic Foot Ulcer
Signs
1. Unilateral Breast Pain
2. Warmth
3. Swelling
4. Erythema
  1. Erythema is normal (not infected) at incision site if <1-2 cm from incision
Management
1. Urgent Consultation with plastic surgery in all patients
2. Antibiotics intravenous or oral depending on severity
3. Breast Implant may need to be removed and the cavity washed out
  1. Implant salvage 58% in Breast Reconstruction cases
  2. Implant salvage 90% in Breast Augmentation with Antibiotics and possible surgical wash-out
  3. No implant replacement until after at least 6 months if removed

References

Claudius and LoTempio in Herbert (2018) EM:Rap 18(10): 17-8
Gabriel (1997) N Engl J Med 336:677-82 [PubMed]
Schrager (2021) Am Fam Physician 104(5): 500-8 [PubMed]