Breast contour is one of the defining features of a woman’s body. Breast size is not important to every woman, but some individuals feel that small breasts not only limit their fashion choices, but can cause dissatisfaction with body image. Women who choose breast implants to enlarge their breasts do so to improve their self image. Some feel dissatisfied because their breasts never developed to a size that meets their expectations. Others want to bring balance to a breast that is somewhat smaller than the other. Often, women want the procedure to restore their natural breast volume, which may have decreased as a result of pregnancy, weight loss or aging.

Breast augmentation enlarges a woman’s breasts through the surgical placement of breast implants. In general, it is a cosmetic procedure strictly performed to fulfill a woman’s personal desire for fuller breasts or to restore breast volume lost after weight reduction or pregnancy. Implants may also be used, however, for reconstructive purposes to restore a breast that is lost due to mastectomy, injury or for other reasons. In any case, breast implants allow women the choice of a fuller, natural appearing breast and a more balanced figure.

Women with breast cancer say that breast reconstruction with implants after mastectomy has helped their recovery by restoring a more natural appearance and a sense of wholeness. Whether it is performed immediately following mastectomy or at a later time, breast reconstruction can dramatically improve a woman’s appearance, self-confidence and overall quality of life.

The decision to have implants is a very personal one – each woman must decide for herself if the benefits of implants will achieve her goals and that the risks and potential complications are acceptable.

In 2000, the Institute of Medicine published its finding on the safety of silicone gel breast implants. This highly regarded scientific panel concluded that silicone gel implants do not increase the risk of autoimmune diseases such as lupus or cancer, as has been suggested in legal claims filed against silicone implant manufacturers. Instead, the Institute found that localized problems that may occur in the area of the breast implant were the primary concern.

Every surgical procedure has potential complications, such as infection, bleeding and scarring. Additionally, there are some potential complications that are specific to breast implants. It is important for women considering breast implant surgery to understand these potential problems and put them in perspective before making the decision to have surgery using silicone gel implants.

This article is designed to provide information about the risks and benefits of surgery using silicone gel implants.  Financial considerations of correcting problems that may occur and insurance issues are presented as well. Finally, for those women who decide that silicone implants are right for them, information about selecting a specific size or type of implant is provided.

Before reviewing this information, it is worth describing the silicone gel implant and explaining the differences between a silicone gel-filled and a saline-filled breast implant, which is an alternative to the silicone gel implant. The outer shell of both silicone and saline implants is made of a solid silicone material. Solid silicone is widely used in implantable medical devices. In contrast, silicone gel implants are filled with silicone gel, which is a semi-solid. Saline-filled implants are filled with the same kind of salt water that is used in I.V. fluids.

Surface of the implant. - The surface of a breast implant may be smooth or textured (multiple fine bumps on the surface). There is some evidence that textured implants have a lower incidence of tight scar formation around them. However, because a textured implant adheres to the surrounding tissue, it may cause visible rippling (wrinkling) in the skin. This can occur if there is not adequate soft tissue between the implant and the skin’s surface on top of it to prevent wrinkling of the implant from being transferred to wrinkling in the skin. A textured implant generally requires a larger incision due to the increased difficulty of sliding the implant through the surgical opening.

Position - Implants may be placed either beneath the breast tissue or on top of the pectoralis muscle (subglandular) or partially beneath the pectoralis major muscle (submuscular). There are advantages and disadvantages of each placement. Generally, placement of an implant beneath the muscle gives an extra layer of muscle coverage and may give less interference with mammographic examination of the breasts. Placement of the implant on top of the muscle in a patient with adequate breast soft tissue to cover the implant may be carried out under local anesthesia, if desired. Generally, this placement has less postoperative discomfort and a quicker return to activities. Placement beneath the pectoralis muscle usually requires more anesthetic and higher costs.

Incisions - A silicone gel implant is commonly inserted through an incision in the inframammary fold (crease under the breast) or just above it. This incision may vary from 3-6 cm in length. An implant may also be inserted through an incision around the pink portion of the nipple/areola complex (a peri-areolar incision). This incision is hidden to some extent by the color change at the edge of the areola. The incision at or above the inframammary fold is often hidden by the slight droop of the breast and is not seen unless an observer is looking up under the breast. Implants can also be inserted through an incision in the armpit (axilla) but this is more difficult. There is some evidence that more difficult insertions may cause damage to the implant.

Risks Related to Silicone:

Gel-filed Implants

Silicone Bleed and Implant Rupture

Some silicone gel may diffuse or "bleed" through the shell of an intact implant into the scar tissue or capsule that surrounds the implant. Rupture of an implant may be related to the length of time it has been in the body. All breast implants, like other medical devices, fail over time and need to be removed or replaced. Rupture may also be related to force or trauma, such as a blow to the chest in an auto accident.

If an implant ruptures, the silicone gel may be contained within the scar capsule that has formed around the implant. Removal or replacement of the implant may be necessary due to the potential for local complications to occur, particularly if the scar capsule has been broken and the gel has migrated outside of the capsule. If it is necessary to remove the scar capsule, as well the implant, this involves additional surgery and there will be charges for the operating facility, anesthesia, and pathology. Costs will vary depending on what needs to be done. Total costs may be as much as or more than the original surgery, and there also may be a surgeon’s charge. Insurance plans may not cover the removal of an implant, and almost certainly will not cover replacement with another implant. Be sure to discuss these potential additional costs with your doctor when you are considering surgery.

Capsular Contracture - What is it and what causes it?

In the simplest terms, a capsular contracture is breast firmness. As your body heals after the placement of breast implants, it forms a coating or lining of scar tissue around the implant. Over time, the scar capsule may contract or tighten excessively, much like squeezing a soft balloon, causing a change in breast shape and/or discomfort. The appearance of the breast may appear artificially round and/or feel unnaturally firm to the touch. There are four grades of capsular contracture: Baker Grades I - IV. The Baker grading is as follows:

Grade I -the breast is normally soft and looks natural
Grade II - the breast is a little firm but looks normal
Grade III - the breast feels firmer than normal and looks somewhat abnormal (change in shape)
Grade IV - the breast is hard, may be painful and clearly looks abnormal (greater distortion)

Capsular contracture may occur on one side, both sides or not at all. The degree or severity of tightening may also be different on one side compared to the other. Although both breasts never match exactly, if any of these deformities occur, differences in the two breasts may be more noticeable and may not be correctable.

Can capsular contracture be corrected?

In severe cases, the disfigurement or discomfort resulting from capsular contracture may require surgery to remove the scar tissue around the implant and/or implant replacement. Capsular contracture may recur after surgical procedures to correct this condition. In some cases, the contracture may not be correctable and implant removal may be necessary.

Closed capsulotomy is a non-surgical technique that has been used to treat contractures. It involves forcefully squeezing the breast to tear the scar capsule around the breast implant. This technique is not recommended due to concerns about implant rupture, localized bleeding, and the manufacturer’s product warranty.

How often does capsular contracture occur?

Excessive firmness of the breasts can occur soon after surgery or years later. The occurrence of bothersome capsular contracture is not predictable, however, the chance of it happening increases with time.

Calcification

Calcium deposits can form in the scar tissue surrounding the implant and may cause pain and firmness. The calcifications may interfere with mammography. These deposits must be differentiated from calcium deposits that are a sign of breast cancer. Should this occur, the additional surgery which may be necessary to remove and examine calcifications may cause damage to the implant.

Implant Extrusion

If the skin or breast tissue covering the implant is very thin and/or if there is a problem with healing, the implant may break through the skin and become exposed. This will require removal of the implant. Surgery needed to correct this can result in unacceptable scarring or breast tissue loss.

Risks of Larger Implants

Many surgeons agree that a larger breast implant may result in higher risks. Some of these risks may include decreased nipple sensation, abnormal nipple position (too high or too low), displacement of the breast shape medially or laterally (too close together or too far apart), excessive ptosis (droop) over time, internal scarring # capsule contracture, and skin changes such as thinning with the extreme of skin loss and an exposed implant requiring implant removal. Implant size is a personal decision for a woman, and there are a number of factors to consider in arriving at a decision. Factors to consider include tissue thickness, breast volume, nipple sensation, familial traits of large or droopy breasts, and anatomy with size from infra-mammary fold to nipple and chest width.

Wound Healing Problems or Tissue Necrosis

Some patients experience delayed healing, and for others the incision site may not heal well. It may open from injury or infection or after the chest has been treated with radiation. This can result in an unattractive scar. If the implant is exposed, further surgery will be required.

Tissue breakdown, or necrosis, is the development of dead tissue around the implant. It will delay wound healing, may cause wound infection and may require surgical correction and/or implant removal. Tissue breakdown has been reported following the use of steroid drugs, chemotherapy, radiation to breast tissue, smoking, and excessive heat or cold therapy. In some cases, it may occur without any known cause.

Visible Skin Wrinkling and Rippling

Visible rippling can result when an implant pulls on the overlying tissues or when the natural folds in the implant are visible through the skin.

Change in Nipple and Skin Sensation

Some change in nipple sensation is not unusual right after surgery. After several months, most patients have normal sensation. Occasionally, partial or permanent loss of nipple and skin sensation or hypersensitivity may occur in one or both breasts. Changes in sensation may affect sexual response or the ability to breast feed a baby.

Chest Wall Deformity

In rare cases, the chest wall or underlying rib cage may appear deformed upon removal of implants. Chest wall deformity has been reported following the use of tissue expanders and breast implants. The consequence of chest wall deformity is of unknown significance, but is not believed to produce any known health consequences.

Malposition

A breast implant may rotate or shift position after initial placement. This may cause discomfort and/or distortion in breast shape, and additional surgery may be necessary to correct this condition. Excessive sagging or stretching of the lower breast tissue may result in an implant that appears too low or causes the nipple to point excessively upwards. This is sometimes called "bottoming out." The implants can also shift toward the side, widening the apparent gap between the breasts. Contracture or tightening of the lower implant pocket may cause an upward displacement of the implant. This is more common when the chest or breast has been treated with radiation. Patients are advised to ask their surgeons about bra choices, as some bra styles may contribute to malposition of an implant(s) in the early postoperative period.

Asymmetry

Most women’s breasts have at least some asymmetry. Breast implants may improve size differences but may make nipple-areola angle and position more accentuated. There is no accurate way of measuring breast size so it is difficult to determine the difference in volume of an implant to correct size differences.

Surface Contamination of Implants

Skin oil, lint from surgical drapes, or talc may become deposited on the surface of the implant at the time of insertion. The consequence of this is unknown.

Breast Tissue Atrophy

Pressure from breast implants may cause the surrounding tissue to thin and shrink. This may also occur normally with aging. Thinning of tissues over the implant may result in its becoming more visible or palpable (able to be felt).

Toxic Shock Syndrome

In extremely rare instances, life-threatening infections, including toxic shock syndrome, can occur after breast implant surgery.

Infection

An infection following breast implant surgery is unusual, in the range of 0 - 4% in cosmetic augmentation, and 2 - 25% in breast reconstruction with an implant. It may appear shortly after surgery or at any time following the insertion of a breast implant. A low-level infection may be difficult to diagnose. Infection around a breast implant is more difficult to treat than an infection in normal body tissues. If an infection occurs, antibiotics are usually given, and if the infection does not respond to antibiotics, the implant may have to be removed. Depending on the circumstances, this can sometimes be handled in an office or outpatient facility but may require additional surgery and a general anesthetic.

Costs may be more than the original surgery. If the original implant operation was for cosmetic purposes, insurance plans often will not cover this. After the infection is treated, a new breast implant can usually be inserted several months later and additional costs will again be incurred.

Bleeding (Hematoma)

A hematoma is collection of blood that may occur around a breast implant following surgery. It occurs in 2 - 4% of breast implant procedures. Each woman’s experience may be different. In some cases, this is a simple matter that can be handled in the plastic surgeon’s office, but more frequently it will require a general anesthetic and additional surgery to remove the hematoma and stop the bleeding. The additional cost may be more or less than the original surgery. Frequently plastic surgeons will not charge for this additional surgery, but this is a question to ask your surgeon before breast implant procedure. If the original implant operation was for cosmetic purposes, insurance plans often will not cover this additional procedure.

A hematoma may contribute to capsular contracture, infection or other problems. Aspirin, other medications that may contain aspirin, and anti-inflammatory medications should not be taken for ten days before or after surgery, as their use may increase the risk of bleeding. Your surgeon may also not want you to take non-prescription "herbs" or dietary supplements prior to surgery, as these may increase the risk of surgical bleeding.

After a few weeks, the risk of an early problem with bleeding is low. However, a hematoma can occur at any time following an injury to the breast. If one or both breasts seem to quickly increase in size, this may be caused by a hematoma. This rapid swelling is often associated with increased bruising and discomfort.

Seroma

Fluid may accumulate around the implant following surgery, trauma or vigorous exercise and additional treatment may be necessary to drain the fluid accumulation. A seroma may contribute to infection, capsular contracture, or other problems. If one or both breasts seems to increase in size over time or if it seems that there is fluid around the implant, this may indicate a seroma. The cost of treating the seroma may be more than the original surgery.

Scars

All surgery results in scarring – it is nature’s way of healing - and the quality of a scar may vary quite a bit from one person to another. Healing is an individual patient’s response to surgery and it is often not within the control of the surgeon. Most scars following breast augmentation are pale thin lines.

They may, however, become red, firm and elevated. Scars such as this are called "hypertrophic." They usually fade with time, but may leave more visible permanent scarring.

Another type of scar, which occurs in some surgical patients, is called a keloid. This is an enlarged scar that does not fade or flatten with time. Scar revision may be desired and this additional surgery can result in additional costs.

Immediate Breast Reconstruction Surgery (implant/tissue expander breast reconstruction performed at the time of mastectomy)

Patients who choose immediate breast reconstruction at the time of mastectomy must consider the risks and uncertain outcomes from the mastectomy operation. These include the surgical complications related to the mastectomy, possible need for additional surgery to remove residual breast cancer discovered at the time of the mastectomy, possible need for additional breast cancer treatments (radiation and chemotherapy), and local recurrence of breast cancer. All of these could adversely affect the outcome of immediate breast reconstruction procedures.

Risks of Anesthesia

There are three types of anesthesia used during surgery, all of which carry some level of risk.

Local Anesthetic: The lowest level of risk is a local anesthetic, which involves minimal I.V. sedation with injection of local anesthetic in the area beneath the breasts. Some patients have an allergic reaction to the local anesthetic or experience a rapid heart beat due to the epinephrine that is used to reduce bleeding. There may be some discomfort intermittently throughout the procedure with a local anesthetic. Local anesthesia is generally less expensive than other anesthetics.

I .V. Sedation: A second method of anesthesia is I.V. sedation (intravenous medications delivered without a tube in the throat). This carries risks of respiratory distress, reactions to the medications or medication overdose. It is recommended that a professional trained in the use of I.V. sedation be available to monitor and administer the medications. The cost for this type of anesthesia is generally higher due to the cost of the medication and personnel to administer them.

General Anesthesia: A third option is general anesthesia in which a patient is asleep during the surgical procedure. The risks of general anesthesia are the same as those of a general anesthetic used for other operations and can involve respiratory problems, blood clots in the legs, etc. As a rule, the risk is low because women having implant surgery are generally in good health. The expense of general anesthesia is higher because of the anesthesia professional needed and the equipment and medications used.

Pneumothorax: During injection of local anesthetic the needle may enter the chest and injure the lung causing it to collapse. A chest tube may need to be inserted and the patient observed in the hospital with added costs.

Pain

Pain may persist or develop after breast implant surgery. A large number of women without implants have breast pain at least once a month. Some women who did not have pain prior to surgery may have persistent pain after surgery. These pain symptoms are unpredictable and in some patients no cause can be found.

Cancer

At this time there is no scientific evidence that silicone gel-filled breast implants increase the risk of cancer in women, however, this possibility cannot be completely ruled out. The follow-up time of completed studies of women with implants has not been long enough to be fully conclusive. Only the future will determine the significance of this potential risk.

Risk to Offspring

The presence of a breast implant will have no effect on your ability to become pregnant, deliver a baby, or even breastfeed. Breast implants have not been shown to have an effect on children or future offspring.

Risk of Breast Feeding

Breast implant surgery should not prevent you from following any desire you may have to breast feed. Be aware that the surgical approach used for implant placement may influence breast feeding as the option of placing the scar around the nipple area could, theoretically, interfere with the breast ducts. While this is uncommon and theoretical, discuss the options with your surgeon and be sure to indicate any interest in breast feeding in the future. Although there have been rare reports of tiny amounts of the element silicon (a derivative of silicone) seen in breast milk from lactating women, there have been no health risks identified with this finding.

Mammography

Women who have breast implants should have mammograms at a certified mammography center. Be sure to inform the personnel of your breast implants. The presence of a breast implant may make screening mammography more difficult. Implants can partially block the ability to see all areas of the breast during a mammogram, and as a result may possibly hide disease. To maximize the results from the breast tissue that can be seen, additional mammography views will be taken.

Breast compression, which is part of the mammogram procedure, presents a risk of rupture of the scar around the implant or rupture of the implant itself. This is rare. When it does occur, it is usually related to having a very firm internal scar, called a capsule, around the implant. This risk, however, should not keep you from obtaining a mammogram when your physician indicates this is appropriate.

Implant Size Selection Preoperatively

Breast size is important and should be a focus of discussion with your surgeon. Many women believe they will be too large after surgery and therefore direct their surgeon to choose a smaller size than what they really desired. You will likely become more comfortable with your new breast shape after surgery and some women have wished they had opted for a larger size. On the other hand, some women are unrealistic and desire a larger implant than fits their body.

It may be difficult to visualize your ultimate breast size and shape before surgery. There are many ways to evaluate size, such as using a larger bra with padding to help you with your comfort level. Bra sizes are not uniform and one brand’s C cup may equal another’s D cup in fit and size. Breast implant manufacturers have improved the shape of implants over time, and it may be better to not only consider size, but also the width of your chest and the desired projection. A wider implant may provide more cleavage, but less fullness of the breast. A higher profile implant will provide more projection and fullness but have less width and cleavage. Once you determine the shape and overall size that you are seeking, talk with your surgeon about which implant(s) will get you as close to that shape as possible. There are some limits to size. Factors such as body frame and the distance from the infra-mammary fold to the nipple will influence what size will provide a natural appearance to the breast. Many surgeons believe a short distance from the bottom fold to the nipple will prevent use of a very large implant, resulting in distortion of the nipple position (too low), or if the fold is released and a large implant used, the nipple may rise to a high distorted position.

Your body’s size and characteristics, along with your desire for a specific shape and size, will usually dictate what is possible. You should be aware that after implant surgery one woman’s breasts will be different than another’s even though the same implant size and shape was used. Also be aware that each woman’s body is different, and before and after photos of women who have had breast implant surgery, often shown on Web sites, do not apply to you.

Dissatisfaction with Size

Discussion with your surgeon before the surgery about your goals for breast size and shape are very important. After surgery, a silicone gel breast implant cannot be adjusted. If you wish to have a different size implant(s), this will mean a second operation and additional costs. You should reach an agreement with your surgeon before surgery as to realistic choices. You should understand that the female breast will change over time, and your breasts will sag and droop with age and lose some volume over time. Pregnancy and breast feeding may influence this as well as weight gain or loss. Additionally, you should understand that the breast size that you desire and the implants that you choose today may be not be the same as what you might choose at a different stage of your life. In the future you may need a change of implant and breast shaping to achieve your desired result at that time.

Breast Deformity After Implant Removal

If breasts implants are removed for any reason, the appearance of the breasts may not be desirable or pleasing following surgery. Older patients and those with large implants may have more cosmetic deformity if they choose not to replace them or to undergo additional reconstructive surgery. Typical problems include asymmetry, drooping, dimpling or puckering of the breast skin.

Replacement

If you decide after surgery that your implants are too large or too small after the swelling has resolved, you may decide you want to have the implants replaced with a larger or smaller size. The cost of replacement, including the surgical facility fee and anesthesia, will be similar to that of the original surgery. Additionally, the surgeon may charge a fee. Be sure to ask your surgeon about such charges.

Breast and Nipple Piercing Procedures

Women with breast implants seeking to undergo body piercing procedures to the breast region must consider the possibility that an infection could develop anytime following this procedure. Should an infection occur, it is possible that it could spread to the breast implant space. Treatment including antibiotics, possible removal of the implant, or additional surgery may be necessary and additional costs will be incurred. A breast infection or an infection with the presence of a breast implant is harder to treat than an infection in normal body tissues. If an infection does not respond to anti biotics, the breast implant may have to be removed.

The Women’s Health Rights and Cancer Act of 1998 requires health plans that cover mastectomy to cover breast reconstruction after mastectomy and surgery on the other breast to help achieve symmetry, if necessary. Breast reconstruction with either tissue expanders or implants is a multi-staged process to create a breast mound, place a permanent implant, and surgically create a nipple and areola, if desired. Additional surgery to revise or improve the results of the breast reconstruction and/or replace implants may not be covered by your health insurance plan. Review your health insurance plan’s subscriber information or contact your plan about their coverage policies. Patients who choose to have breast reconstruction need to understand the potential for future surgery to maintain the quality of their breast reconstruction(s).

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