EVERYTHING YOU EVER WANTED TO KNOW ABOUT BREAST IMPLANTS

Is it just a man thing or do women have the same thoughts? I really don’t know, but it’s probably not a question people ask out loud. Instead, it’s something you wonder to yourself, privately, and unless you have inside knowledge, may not ever know. But, really,  it’s not something you should notice or think about in the first place. What am I talking about? The title of this article should give you a clue without me actually saying it. 

In the past 30 years, millions of women have had cosmetic breast surgery. In fact, the most common operation plastic surgeons perform is one of the various procedures to enlarge or reconstruct a woman’s breasts. To accomplish that end, breast implants of several varieties were devised. They are, then, surgically inserted within a pocket formed in the breast. This operation gives a woman her “figure” back, as well as her self-esteem. In 2018, alone, 313,000 patients had breast implant surgery. However, the subject has been plagued with controversy for decades, and has thus seen many changes and restrictions.

As I just mentioned, the major reason breast implant surgery is done is to improve the external appearance of small-breasted women or women who are unhappy with their current less-than-full-bodied figure. This is called breast augmentation, or augmentation mammoplasty. The other more serious reason for implant surgery is to reconstruct a breast(s) surgically removed for cancer or breasts that are deformed from birth or mis-shapened for some other reason. This is called post-mastectomy reconstruction. It often requires more than a single procedure.

Breast implants are silicone rubber sacs filled with either silicone gel or saline (salt water). Silicone implants are used more often than saline because they feel more like natural breast tissue and are ideal for augmentation and reconstruction. Implants were first used for breast augmentation in 1964 and because silicone implants gave a fuller, more normal textured feel to the breast, they became the implant of choice. Unfortunately, the Dow Corning corporation, the inventor of silicone implants, failed to use a substance in the inner surface of the implant that was impervious to silicone. So, over time, silicone-filled implants contracted, became odd-shaped, and leaked. Silicone leaking into the area surrounding the implant causes a severe inflammatory reaction of human tissue. This caused quite a problem, and resulted in very unhappy and disfigured patients who filed a total of 200,000 lawsuits. 

In 1992, the FDA banned silicone breast implants and Dow Corning broke up into several subsidiaries. This left saline implants as the only option. (There are also “gummy bear” implants filled with a thicker gel that provide a firmer feel and maintain their shape better.) If saline implants leak, which they occasionally do, the saline is absorbed into the tissue without any inflammatory reaction, and the implant “deflates,” ie. flattens. This looks funny, but it doesn’t harm the patient.

Implants also come with smooth or textured surfaces. Smooth-surfaced implants slide around  within the pocket into which they are placed. They don’t stick to the breast tissue and move around. Textured implants have a “rough” surface that sticks to the pocket, and in time become fixed to the surrounding tissues and don’t move. They do have the tendency to contract, or shrink, leading to dimpling or indentations in the breast. 

The rupture of any breast implant is a problem, but especially for silicone implants. A silicone  rupture causes a local inflammatory reaction. A saline rupture causes a flat, deflated breast. In any case, the implant needs removal and replacement—another big surgery! “Silent rupture” occurs as often as 50% of the time in implants 20 years old or older. To correct the leakage problem, polyurethane was used to form the inner layer of the implant, and capsular contraction and leakage was nearly eliminated. Polyurethane-surface silicone implants have, however, induced sarcomas, a form of cancer, in rats, but this association has not been reported in humans.

“There has never been any publication showing an increased risk of breast cancer in women with implants (whether silicone or polyurethane)….If statistical data are to be believed, evidence points to the contrary in that the incidence of breast cancer is lower in women with breast implants.”

There are no specific recommendations for breast cancer screening in women with implants. But women with silicone implants are advised to be screened for rupture with MRI, or ultrasound, 5-6 years after surgery, then every two years after. These imaging methods are more sensitive for detecting leaks and lesions that may be obscured by the implant. Long term implant complications (rupture, leakage, revision, replacement, removal) increase in frequency over time, and lactation can be affected significantly.

Improved, safer silicone implants were re-introduced in 2006, but other controversies continue. Many countries have banned implants that contain polyurethane in the surface layers because of breast-implant-associated anaplastic large cell lymphoma—BIA-ALCL. When one breast swells for unknown reasons, ultrasound should be done to look for signs of the disorder. Textured implants seem to be the culprit. Since textured implants were introduced, the global incidence of BIA-ALCL has increased, but the reason is unknown. BIA-ALCL has occurred in smooth surface implants, too, but is far less common. Of the 733 reported cases, only 28 occurred in smooth-surface implants. The  manufacturer, Allergan, voluntarily recalled all textured implants in 2019, and the FDA has issued a “black box” warning for future implant use, but has not recommended removing those already implanted. 

The average lifespan of a breast implant varies. The FDA policy states that breast implants are not a lifelong device and that they may rupture or leak at any time. One surgeon’s average time to removal was 7.5 years for saline and 4.9 years for smooth silicone implants. For implants removed for rupture, the mean time was 8.4 years for saline and 8.1 years for smooth silicone gel implants. So having implants removed and replaced happens more often than I ever realized.  

Implants and breast cancer have long been a concern of physicians. But many studies have shown breast implants are NOT associated with an increased risk of breast cancer incidence or death, and those unfortunate patients who do develop breast cancer “do not experience delayed detection or poorer post-breast cancer survival.” 

Contraction of the implant capsule is the biggest problem and is yet to be solved. Texturing was one solution, but with the development of anaplastic large cell lymphoma, ALCL, it is obviously not the answer. Thousands of women are still having augmentations and reconstructions every year so the desire for a more attractive appearance and the concern about breast cancer outweigh any potential implant-related problems. 

Dr. G’s Opinion: I’m not a woman so I don’t have the emotion or perspective of the feminine mind, but I would ponder long and hard about having breast implant surgery. Not because I saw bad things occur from the surgery, itself, but because I would never be satisfied with how I look. Expectations for this surgery are high, and unless your surgeon is an artistic master, your outcome may not be as good as you hoped. No surgeon can make you Bo Derek, but your hope is he/she will. When that doesn’t happen, your disappointment makes you second-guess decisions made about the procedure, and you’ll never be happy. 

However, a woman’s perspective is entirely different, and I may be mis-judging the situation. Breast implant surgery may be the one thing a woman does for herself that makes her life better in her eyes, and she thinks in the eyes of others, as well.

References: https://www.plastic surgery.org/cosmetic-procedures/breast-augmentation/implants.

Van Zele D, Heymans O. Breast Implants: A Review Acta Chir Belg 2004 Apr;104(2):158-165.

Deapen, D. Breast implants and breast cancer: a review of incidence, detection, mortality, and survival. Plast Reconstr Surg 2007 Dec;120(7 suppl 1):70S-80S.

Schrager S, Lyon SM, Poore SO. Breast Implants: Common questions and answers. Am Fam Phys 2021 Nov;104(5):500-509.

Perry D, Frame JD. The history and development of breast implants. Ann Roy Coll Surg Engl 2020;102:478-482.