The Breakdown on Implants

Breast augmentation is the most often performed plastic surgery in the United States. This surgery is for women seeking a larger breast volume. It can be performed with a breast lift if the breast skin laxity is pronounced and the nipples are pointing downwards or starting to sag. Options for augmentation include implants (silicone or saline) or fat transfer. I perform these surgeries using general anesthesia in the operating room.

Silicone- and saline-filled breast implants are equally common and have distinct benefits, risks, and cost profiles. They can be inserted under the breast gland or under the pectoralis major muscle. There is a slightly high risk of capsular contracture and visibility with a subglandular placement. An animation deformity (or lateral motion of the implant with arm use) can be seen with a submuscular placement, but this option can give a better upper pole slope and camouflage the implant in thin-tissued patients. Mammograms may be more complicated with implants in place, as they may require more additional views. Recovery with either option is very quick, 2-3 days with minimal pain; however, there is a lifting and upper body exercise restriction in place for 2-4 weeks.

Saline implants are a silicone shell filled with sterile salt water. They are inserted into your breast pocket empty and filled to a desired volume. They are available to women 18 and older. Although rupture rates remain low, when they do, the salt water spills into your breast pocket and will be absorbed by your body without any issues. You will notice this fairly soon as the breast will deflate. There may be an increased chance of rippling with a saline-filled implant based on the thickness of your breast skin and type of implant selected. Saline implants do require clinical assessments for scarring or issues, but do not have to be exchanged at any defined time period.

Silicone implants are filled with a silicone gel and have various levels of cohesiveness or firmness. You may have heard of a gummy bear implant, which is a level 4/5 cohesiveness and firm. If the implant ruptures, the gel does not spill out into the tissues as readily. Silicone implants have a more natural feel and less incidence of rippling. These are available to women 22 and older. The FDA recommends evaluation by a plastic surgeon 5 years after implant placement and every 2-3 years thereafter with imaging to observe for silent rupture. These implants should be changed every 10 years because the risk of rupture steadily increases after this time period.

The risks of implants include capsular contracture, or scarring around the implant that can cause distortion or deformity and sometimes pain. Breast pain, infection, and changes in nipple sensation can also occur. Implant rupture is rare but can occur.

You may have heard of a type of cancer associated with breast implants—Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA ALCL). Implants with textured and polyurethane outer shells seem to have the high risk of this, although this is rare. It is not breast cancer. We typically no longer use this type of implant. For those implants placed 5-10 years ago, symptoms include late swelling or seroma, pain, and asymmetry.

20% of women will have to have their implants removed within 8-10 years of placement for various reasons. These are NOT considered lifetime devices and deserve clinical evaluations routinely with your plastic surgeon.

According to the FDA, “The FDA has not detected any association between silicone gel filled breast implants and connective tissue disease, breast cancer, or reproductive problems.”

Breast Implant Illness (BII) describes symptoms such as fatigue, memory loss, rash, “brain fog,” and joint pain that may be associated with breast implants. BII is poorly understood and research on this topic has not shown any link to implants; however, the research is still ongoing. The recommendation by the American Society of Plastic Surgeons is to undergo a thorough rheumatologic workup and remove the implants.

If you are hesitant about implants, fat transfer or fat augmentation of the breast is a natural way to increase breast volume. This is distinctly different from implant augmentation as the filling occurs more in the middle and lower portions of the breast delivering a tear dropped shape. If you are seeking a distinct upper pole fullness, this is best achieved with an implant, and we can discuss this further with pictures during our clinic visit. The donor sites for fat harvest are carefully selected during our visit, as we would never want to deliver a poor cosmetic result to the donor site to achieve a more aesthetic breast. Typical donor sites include the abdomen (as long as skin laxity is not an issue), lower back, flank, arms, or inner thigh. The fat is harvested very carefully at a low pressure to preserve viability, then is gently re-injected into the breast tissue. Typical quantities of transfer include 30-400 milliliters of fat, depending on the desired outcome. We can increase breast size by a half or 1 cup with 1 session. Multiple sessions may be required if additional volume is desired. Typically 60% of the fat cells transferred will survive and the final breast size can be seen at 3 months post surgery. These fat cells will grow if you gain weight, shrink if you lose weight, and will be with you for a lifetime! Risks can include fat oil cysts, difficulty with mammogram interpretation, pain, contour deformity, asymmetry, and donor site complication. Recovery is quick, namely 2-3 days. You would be required to wear a compression garment for up to a month and may require lymphatic massage sessions. You can resume upper body exercise 1-2 weeks after surgery.