Breast Augmentation Mammoplasty

Did you know there are a variety of breast implant options when you are seeking a breast augmentation mammoplasty? You have the choice between silicone or saline implants, and round or anatomically shaped.

Saline implants are often described as having a “water bed” feel.  Some even report a slight ripple effect that can be seen through the skin.  This can be remedied to an extent by using smooth surfaced, round implants that are overfilled (within manufacturer specifications) creating a firmer feel.  Should an implant rupture, it will deflate and the saline easily absorbed by the body.

Silicone implants have a lower incidence of rippling than saline implants thanks to the consistency of silicone gel.  They have a natural feel, designed to mimic breast tissue.  However, unlike saline implants, silicone implants will not be absorbed by the body and can cause issues with hardening of the breast or capsule contracture.

“Saline Breast Implant” if a saline implant rupture occurs, the saline will be absorbed harmlessly by the body.

Breast implants come in a range of shapes and sizes, meaning you can choose almost any size for your breasts.  This range of choice means you and your surgeon can together choose the best size for your body and desires.

Breast implants also come in different shapes – round and anatomical.

Round implants have the advantage that should they rotate in the breast pocket, the breast shape won’t be affected. Anatomically shaped or ‘tear drop’ shaped breast implants are designed to enhance the lower pole of the breast.  However, if an anatomical implant rotates in the breast pocket, breast shape is affected and it will need to be repositioned to restore the correct appearance.

You must remember that all surgery will result in scarring in one form or another. Breast Augmentation surgery is no different. Your level of scarring will depend on a variety of factors, including incision methods and genetic disposition to scarring.

Capsular contracture is graded clinically using the Baker classification.

Breast Implant Rupture

All breast implants have an outer shell that can potentially develop a tear or hole i.e. a rupture. The risk of implant rupture increases as the implant ages and 50% of implants will show signs of loss of integrity at 10 years after surgery.

Implant rupture are classified into intracapsular and extracapsular rupture.

Intracapsular rupture means the implant has ruptured inside the tissue capsule which the body has formed around the implant. Intracapsular rupture is usually asymptomatic, meaning the breast and implant looks and feels normal. It is usually diagnosed incidentally on an ultrasound performed for other reasons.

Extracapsular rupture means the silicone has broken through the tissue capsule which the body has formed around the implant, and silicone can spread into the breast tissue or surrounding muscle. Extracapsular rupture can also be asymptomatic (known as silent rupture), but may result in breast pain, lumps in the breast or armpit or a change in size and shape of the breast.
An intracapsular rupture will eventually progress into an extracapsular rupture, but the rate of progression is unpredictable.

Implant rupture can be detected on ultrasound, and confirmed by MRI.

Ruptured implants can interfere with breast screening. Silicone deposits in the breast tissue may mask an underlying breast cancer. Mammograms may worsen the implant rupture due to pressure applied to the implant.

Generally, it is recommended that ruptured implants be removed.

Implant Malposition

The implant may move from its original pocket resulting in various deformities. This includes the double-bubble deformity, where the implant drops below the inframammary fold.

Breast Implant Cancer (BIA-ALCL)

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare cancer of the immune system that occurs only in women with breast implants. It is not breast cancer, but rather a type of lymphoma that grows in the tissue capsule which the body has formed around the implant.

The risk of BIA-ALCL is estimated to be between 1 in 1000 and 1 in 10000, meaning 1 woman will be diagnosed with BIA-ALCL for every 1000 to 10000 women with breast implants.

All Australian cases have occurred in women with textured implants (and no cases in women with smooth implants as of January 2020). The risk of BIA-ALCL is significantly higher for “macro” textured (e.g. Silimed Polyurethane, Allergan Biocell) compared to “micro” textured (e.g. Mentor Siltex) implants. BIA-ALCL occurs with both saline and silicone implants. There is no difference in risk in women who have implants for breast augmentation or reconstruction.
The main symptoms of BIA-ALCL are persistent breast swelling or pain. It can also present as a lump in the breast or armpit. Most cases occur between 3 and 14 years after surgery.

The first line investigation is a breast ultrasound to assess for the presence of fluid. If fluid is present, a sample will be taken to look for cancerous cells. Fluid collections (seroma) is common after breast implants and most are not BIA-ALCL. Mammograms are not helpful for the diagnosis.
Most patients with BIA-ALCL are cured by complete removal of the intact capsule with the implant contained inside, a technique known as total intact capsulectomy (or en-bloc capsulectomy).

It is currently not recommended that breast implants be removed in women without any symptoms. This is because:

• BIA-ALCL is considered relatively rare
• BIA-ALCL has a high rate of cure once diagnosed
• Any surgery and anaesthetic has risks