300000 US women undergo breast augmentation surgery each year and making it extremely likely that clinicians will encounter women who have breast implants In addition approximately tive ID: 938256
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CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 , 300,000 US women undergo breast augmentation surgery each year, and making it extremely likely that clinicians will encounter women who have breast implants. In addition, approximately tive surgery after mastectomy, of whom more than 88,000 (81%) receive implants (2016 This review discusses the evolution of reconstructive breast surgery, as the principles are similar. EVOLUTION OF IMPLANTSReports of breast augmentation surgery, also known as augmentation mammoplasty, date successfully transplanted from a patients back a patients breast marked the rst implant- By 1954, attempts aps, adipose tissue, and even omentum were Alloplastic materials gained popular-(Te on), and other synthetics. Adverse re-were plentiful: local tissue reactions, distor- REVIEW ABSTRACT Women receive breast implants for both aesthetic and reconstructive reasons. This brief review discusses the evolution of and complications related to breast implants, as well as key considerations with regard to aesthetic Nearly 300,000 breast augmentation surgeries are per-formed annually, making this the second most common Today, silicone gel implants dominate the world market, and in the United States, approximately 60% of implants ller.breast augmentation, typically presenting within the rst postoperative year and with increasing risk over time. It occurs with both silicone and saline breast implants.disease incidence. However, the risk of associated ana-consultation, and con rmed cases should be reported to a national registry. DEMETRIUS M. COOMBS, MD Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, RITWIK GROVER, MD Department of Plastic Surgery,Dermatology and Plastic Surgery Institute, Cleveland Clinic ALEXANDRE PRASSINOS, MD Surgery, Department of Surgey,Yale School of Medicine, New Haven, CT RAFFI GURUNLUOGLU, MD, PhD Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, Clev
eland Clinic; Profes-sor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 BREAST AUGMENTATION SURGERY n, rub-ber, petroleum jelly, and lique ed silicone. Outcomes were not good, and many patients ultimately needed mastectomy. The rst modern breast prosthesis was cantly.From silicone to saline, and back again rst silicone gel implants, introduced in This is a foreign body reaction in which pathologic Attempts to minimize this In atable implants lled with sterile saline However, as they became increasingly popular, de By the late 1980s, the thinner-shelled gen-Food and Drug Administration (FDA) placed While silicone implants were prohibited in the United States, development continued ed after several meta-analyses failed to reveal any Today, silicone gel implants dominate the In the United States, approxi- ller, and trends are similar in Europe. Table 1 summarizes the evolution of silicone Ta- lists the advantages and disadvantages of Currently, 3 companies (Allergan, Mentor, implants and implant-associated products TABLE 1 Silicone breast implants by generation First generation (1960s)ShellThick, smooth, silicone elastomer in 2 pieces with along the chest wallFillerSilicone gel, moderate viscosity ShapeAnatomic or teardrop ComplicationsHigh capsular contracture rate (approached 100% Second generation (1970s)ShellThinner, smooth, seamless, no Dacron patchesFillerSilicone gel, thinner and less viscousShapeRoundComplicationsRupture (nearly 60%), diffusion or bleeding of Third generation (1980s)ShellThicker, multilayer silicone elastomer, no Dacron FillerSilicone gel with larger particles, increased cross-linking, more viscous and thickFourth and fth generation (1990s to present) llerShell ing to strict criteria by American Society for TestingMethodology and US Food and Drug Administration ShapeAnatomic (teardrop) a During this period subpectoral i
mplant placement gained popularity, decreasing capsular contracture rates.b Restricted from US market temporarily in 1992; textured surfaces were introduced during this period in an effort to decrease capsular contracture.c Greater quality control during manufacturing; wider variety of implant shapes and surface texturing available. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 COOMBS AND COLLEAGUESAnother company, Motiva, makes an im-Australia, and the device is currently under- Pending nal ap-barrier layer, improved silicone gel ller, 3-D cation transponders that can transmit data about the implant wirelessly.Surface (textured vs smooth)around the prosthesis. Additionally, texturing rst textured implants were covered The capsular contraction rate has been Form-stable vs uid-formSilicone is a polymer. The physical properties An early report of breast surgery TABLE 2 Advantages and disadvantages of silicone and saline breast implants AdvantagesDisadvantagesConsistency with palpation mimics dense, Quicker adjustment to alterationsExposure to silicone in the event of rupture, implants), including cost of recommended lled with saline to desired event of rupture, and rupture is immediately ation) lling leads to increased rmness, lling results in rippling and a higher risk Consistency with palpation mimics water (as environment (eg, feels cold after swimming) CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 BREAST AUGMENTATION SURGERY In form-stable implants, the silicone cient chain length and cross- but they require slightly larger incisions. ller with shorter chain length, less cross-link- uidity. llers, the properties of sili-length and cross-linking within the polymer. Table 1 exible yet rubbery character. Silicone elasto-Implant shape (round vs anatomic)The shape of an implant is determined by the gel distribution inside of it. To understand gel derstand the gel-shell ratio. This ratio increases ller increases,
and it rep- ller to the shell and a preserved implant shape at rest. The gel-shell ratio varies among manufac- ller may be more No anatomically shaped implant is manu-However, in the United States, 95% of pa- PATIENT ASSESSMENTBefore breast augmentation surgery, the sur-the patients desires and expectations, as well as what the patients anatomy allows. An ter illustrate what to expect postoperatively. Psychosocial factorsOne must consider the patients psychology, motivations for surgery, and emotional stability. Here, we look for underlying body dysmorphic disorder; excessive or unusual encouragement to undergo the procedure by a spouse, friends, or others; a history of other aesthetic procedures; u-encing the desire to undergo this surgery. patients height, weight, and overall body implants. A reliable method for determining the appropriate implant must include the cur-elasticity, soft-tissue thickness, and overall body habitus. Ultimately, the most important considerations include breast base diameter, Filler type, followed by shape (round or anatomically shaped), anterior-posterior pro- le, and shell type (smooth or textured) are Preoperative sizing can involve placing method is particularly effective in minimizing A computerized implant selection pro-implant based on a clinicians measurements. the patients psychology, for surgery, Figure 1. tomically shaped; right, smooth and round. Note the slop-would be oriented inferiorly in the patient to simulate a native breast shape. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 COOMBS AND COLLEAGUESTraditionally, plastic surgeons place breast but beneath the glandular breast Advantages of submuscular placement A popular modi cation of submuscular and the pectoralis major fascia. This dual - Figure 2. Breast augmentation CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 BREAST AUGMENTATION SURGERY Implant rupturein most cases, Table 3 highlights important consider- AN
TIBIOTICSof antibiotic before surgery, a practice that However, the t of routine postoperative use of anti-breast augmentation surgery. PERIOPERATIVE PERIODAt our institution, breast augmentation sur-is, however, according to surgeon preference, POSTOPERATIVE PERIODIn the immediate postoperative period, pa- Depending on the patients situation, recovery, and heal- Additional instructions are surgeon-specif-ic. However, the patient is instructed to avoid bathing, swimming, immersion in water, and pair healing of an inferior incision; instead, Showering is allowed the next day or the second day after surgery, and of course there is no driving while on narcotics. Additionally, Patients are typically seen in clinic 1 week after surgery. The cost of surgery may be $5,000 to cantly from center Figure 3. row are 7 months after breast augmentation surgery with 350-cc smooth, round silicone CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 COOMBS AND COLLEAGUEStransgender surgery. The patient is typically IMPLANT LONGEVITY AND RUPTURE Unfortunately, the existence of multiple implant manufacturers, numerous implant generations, and poorly standardized screening protocols and reporting systems make the true cult to assess with- Damage from surgical instrumentation dur- Other causes include under Leakage of silicone gel ller may be con- ned to the periprosthetic capsule (intracap-capsular ruptures progressed extracapsularly, Implant rupture occurs silently in most sudden asymmetry, rmness, pronounced cap-sular contracture, contour irregularity, or pain. Aside from physical examination, compre-ultrasonography, mammography, computed tomography, and magnetic resonance imaging Reoperation rates for primary breast surgery approach 20% TABLE 3 Considerations in incision location LocationAdvantagesDisadvantagesInframammaryExcellent visualization of both the Periareolar Excellent exposure of the implant pocket cit to lower breast pole Potentially higher rat
e of capsular contractureTransaxillary cult route to place silicone implantsTransumbilicalRemote incision, may be obscured by CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 BREAST AUGMENTATION SURGERY(MRI). Of these, MRI is the method of choice, city exceeding 90% Classic ating implant shell, or the teardrop sign ndings on ul- Mammography effectively detects free ; however, it cannot detect rupture Current FDA recommendations to detect Many plastic Of note, capsular contracture im- If implant rupture is con rmed, the current placed depending on the patients preference. plants; however, in the event of extracapsular Reoperation rates for primary breast aug-tients lifetimethe highest rate of all aes- CAPSULAR CONTRACTURE typically pre- rst postoperative year, It occurs with both silicone and saline breast implants. In some studies, the incidence exceeded rst 2 years after surgery, and near- Other studies found rates The etiology is not well understood and is A meta-analysis from 17,000 implants cantly higher when an implant was and that although textur-with smooth implants, the effect was modest With regard to in- The leading theory is that contamination lm formation. Subclini- Textured implants induce a greater in ing in a thicker capsule; however, contracture Interestingly, lower rates with later-generation, cohesive-gel, form-sta- Although more research is needed, sili- Irrigating the breast pocket intraoperatively lin, and gentamicin) before placing the implant Treatments for capsular contracture in-clude pocket modi cations such as capsulot-subglandular, the replacement is placed in the proceduredecreases ratesand seroma CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 COOMBS AND COLLEAGUES t from implant ADDITIONAL COMPLICATIONS Irrigation during the implantation proce- Some surgeons also choose to irrigate the Additionally, many prefer using a sterile de- Infection is less common with cosmetic rec
onstruction, likely because of healthier, mastectomy. Seroma is thought to be a consequence of texturing. Though poorly understood, an asso- After primary breast augmentation, 10- Malposition of the implant over time is cient of friction compared Visible skin rippling may be a consequence of texturing and also of thin body habitus, eg, in patients with a body mass index less than Large implants and extensive lateral dis- Ultimately, the 10-year incidence of sec- Additional cos- BREAST CANCER AND DETECTIONor survival. However, more patients with im- Breast implants may actually facilitate conservation therapy. AUTOIMMUNE DISEASES fth-generation silicone breast implants with In various clinical studies in mastectomy Addi-tionally, in meta-analyses of data from more One study noted no increase in autoantibodies in patients with Patients with with regard to breast cancer detection, tumor burden, recurrence, CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 BREAST AUGMENTATION SURGERY Studies have also demonstrated that in during the perinatal period is comparable with Another study, examining cant difference in silicon levels (used as a proxy for silicone) cantly higher in cows milk and store- BREAST IMPLANT-ASSOCIATED ANAPLASTIC LARGE-CELL LYMPHOMAlymphoma (BIA-ALCL) is a subtype of T-cell or, more rarely, palpable disease in the axilla. rarely, constitutional symptoms. BIA-ALCL brous periprosthetic Of note, there is no documented case in- but it may be fth-generation textured implants.this association is currently under study. The absolute risk of BIA-ALCL was re- as 1 in 35,000 by in a 2015 US study. In comparison, breast The diagnosis is con rmed by ultraso- ne-needle aspiration uid and subsequent immunohis- rmation, imaging is inef- Treatment involves implant removal and total capsulectomy, with samples sent for pa- Of In cases of advanced or recurrent ALCL, diagnosed late or inappropriately, the Nation- An-ecdotally, at our institut
ion, we have recently vant therapy. The mechanism of this malignancy is cur- National societies advise plastic surgeons rmed cases to Large Cell Lymphoma Etiology and Epidemi- ARE PATIENTS HAPPIER AFTERWARD?breast augmentation surgery, patients note improvement in body image, and satisfaction dence and body image. An evalu- Patientsreport high satisfaction afterward CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 NUMBER 2 FEBRUARY 2019 COOMBS AND COLLEAGUESBREAST-Q Augmentation Questionnaire Although epidemiologic studies have re-those whom the surgeon deems it necessary. Several high-quality studies have demon-improve after breast augmentation surgery. Inter-estingly, a recent study reported that patients pexy (breast-lifting) surgery. ne our tween psychosocial factors before and after sur-gery in patients seeking and undergoing breast 1. Derby BM, Codner MA. Textured silicone breast implant use in primary augmentation: core data update and review. Plast Reconstr Surg 2015; 2. Maxwell GP, Gabriel A. Breast implant design. Gland Surg 2017; 3. Gabriel A, Maxwell GP. The evolution of breast implants. Clin Plast 4. American Society of Plastic Surgeons. Procedural statistics trends 1992 2012. www.plasticsurgery.org/documents/News/Statistics/2012/ 5. American Society of Plastic Surgeons. Plastic surgery statistics report 2016. www.plasticsurgery.org/documents/News/Statistics/2016/plastic- 6. Henderson PW, Nash D, Laskowski M, Grant RT. Objective comparison of commercially available breast implant devices. Aesthetic Plast Surg 7. Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg 8. Spear SL, Jespersen MR. Breast implants: saline or silicone? Aesthet 9. Cronin TD, Gerow FJ. Augmentation mammaplasty: a new natural feel prosthesis. In: Transactions of the Third International Conference of Plastic Surgery: October 13 18, 1963, Washington, DC. 10. Maxwell GP, Gabriel A 11. Hillard C, Fowler JD, Barta R, Cunningham Bture: a review. Gland Surg 2017; 6(2):163 16
8. doi:10.21037/gs.2016.09.12 12. Derby BM, Codner MA. Textured silicone breast implant use in primary augmentation: core data update and review. Plast Reconstr Surg 2015; 13. Tugwell P, Wells G, Peterson J, et al. Do silicone breast implants cause rheumatologic disorders? A systematic review for a court-appointed national science panel. Arthritis Rheum 2001; 44(11):2477 2484. 14. Alpert BS, Lalonde DH 15. Hidalgo DA, Spector JA. Breast augmentation. Plast Reconstr Surg 16. ClinicalTrialsgov. Study of the safety and effectiveness of Motiva Implants®. https://clinicaltrials.gov/ct2/show/NCT03579901. Accessed 17. Establishment Labsmotiva/innovation-for-enhanced-safety/. Accessed January 17, 2019. 18. Sforza M, Zaccheddu R, Alleruzzo A, et altion of experience with silksurface and velvetsurface Motiva silicone breast implants: a single-center experience with 5813 consecutive breast augmentation cases. Aesthet Surg J 2018; 38(suppl 2):S62 S73. 19. Huemer GM, Wenny R, Aitzetmüller MM, Duscher Dmix round silksurface silicone breast implants: outcome analysis of 100 primary breast augmentations over 3 years and technical consider- 20. Lista F, Ahmad Jplasty. Plast Reconstr Surg 2013; 132(6):1684 1696. 21. Namnoum JD, Largent J, Kaplan HM, Oefelein MG, Brown MH ed by surgical 22. Handel N, Garcia ME, Wixtrom R. Breast implant rupture: causes, incidence, clinical impact, and management. Plast Reconstr Surg 2013; 23. Hölmich LR, Friis S, Fryzek JP, et al. Incidence of silicone breast implant 24. Mccarthy CM, Pusic AL, Disa JJ, Cordeiro PG, Cody HS 3rd, Mehrara BBreast cancer in the previously augmented breast. Plast Reconstr Surg 25. Egeberg A, Sørensen JA. The impact of breast implant location on the risk of capsular contraction. Ann Plast Surg 2016; 77(2):255 259. doi:10.1097/SAP.0000000000000227 26. Wickman Mtion: a three-year follow-up. Plast Reconstr Surg 1995; 95(4):712 718. 27. Kjøller K, Hölmich LR, Jacobsen PH, et altion of local complications after cosmetic breast implant surg
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z SM. Association of breast implants with anaplastic large-cell lymphoma. JAMA Oncol 2018; 4(3):341 342. 41. American Society of Plastic Surgeons. BIA-ALCL physician resources. www.plasticsurgery.org/for-medical-professionals/health-policy/bia- 42. The American Society for Aesthetic Plastic Surgery, Inc. Member FAQs: latest information on ALCL. www.surgery.org/sites/default/ les/Member-FAQs_1.pdf. Accessed January 17, 2019. 43. The American Society of Plastic Surgeons. BIA-ALCL resources: summary and quick facts. www.plasticsurgery.org/for-medical-professionals/health-policy/bia-alcl-summary-and-quick-facts. Accessed January 17, 44. National Comprehensive Cancer Network. T-cell lymphomas. www. 45. The Plastic Surgery Foundation PROFILE Registry. www.thepsf.org/ le. Accessed January 17, 2019. 46. Sarwer DBmentation. Plast Reconstr Surg 2007; 120(7 suppl 1):110S 117S. 47. Rohrich RJ, Adams WP, Potter JK. A review of psychological outcomes and suicide in aesthetic breast augmentation. Plast Reconstr Surg 48. Kalaaji A, Bjertness CB, Nordahl C, Olafsen K. Survey of breast implant patients: characteristics, depression rate, and quality of life. 49. Kalaaji A, Dreyer S, Brinkmann J, Maric I, Nordahl C, Olafsen Kmentation mastopexy: a comparative study. Aesthet Surg J 2018; : Raf Gurunluoglu, MD, PhD, Department of Plastic Surgery, Euclid Avenue, Cleveland, OH 44195; gurunlr@ccf.org Dear Doctor:As editors, wed like you to look into every issue, every the Cleveland Clinic Journal of Medicine. Wed like to know Heres our goal: Few How do you read the average issue? Heres our goal: Cover-to-coverWe put it in writingWe want to hear from you.Lyndhurst, Ohio 44124 FAX 4 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 86 € NUMBER 2 FEBRUARY 2019 BREAST AUGMENTATION SURGERYimplants: a systematic review. Plast Reconstr Surg 2006; 118(5):1224… Gurunluoglu R, Sacak B, Arton J Gurunluoglu R, Sha“ ghi M, Schwabegger A, Ninkovic Mary breast reconstruction with deepithelialized
free ” aps from the nance of breast volume. J Reconstr Microsurg 2005; 21(1):35…41. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstru Surg Moyer HR, Ghazi B, Saunders N, Losken A. Contamination in smooth technique in a cadaver model. Aesthet Surg J 2012; 32(2):194…199. Handel N. The effect of silicone implants on the diagnosis, prognosis, and treatment of breast cancer. Plast Reconstr Surg 2007; 120(7 suppl Kjøller K, Friis S, Lipworth L, Mclaughlin JK, Olsen JHoutcomes in offspring of mothers with cosmetic breast implants: a review. Plast Reconstr Surg 2007; 120(7 suppl 1):129S…134S. Semple JL. Breast-feeding and silicone implants. Plast Reconstr Surg de Boer M, van leeuwen FE, Hauptmann M, et al. Breast implants McCarthy CM, Horwitz SM. Association of breast implants with American Society of Plastic Surgeonswww.plasticsurgery.org/for-medical-professionals/health-policy/bia- The American Society for Aesthetic Plastic Surgery, Inc. Member FAQs: latest information on ALCL. www.surgery.org/sites/default/“Member-FAQs_1.pdf. Accessed January 17, 2019. The American Society of Plastic Surgeonsand quick facts. www.plasticsurgery.org/for-medical-professionals/health-policy/bia-alcl-summary-and-quick-facts. Accessed January 17, National Comprehensive Cancer Network. T-cell lymphomas. www. The Plastic Surgery Foundation PROFILE Registry. www.thepsf.org/research/registries/pro“ le. Accessed January 17, 2019.Sarwer DB Rohrich RJ, Adams WP, Potter JKand suicide in aesthetic breast augmentation. Plast Reconstr Surg Kalaaji A, Bjertness CB, Nordahl C, Olafsen K. Survey of breast Kalaaji A, Dreyer S, Brinkmann J, Maric I, Nordahl C, Olafsen Kmentation mastopexy: a comparative study. Aesthet Surg J 2018; : Raf“ Gurunluoglu, MD, PhD, Department of Plastic Surgery, Euclid Avenue, Cleveland, OH 44195; gurunlr@ccf.o