Breast Enlargement / Breast Implant Surgery

RISKS SPECIFIC TO BREAST IMPLANT SURGERY

Capsular Contracture

What it is:

• Capsular Contracture is the most common complication of breast augmentation surgery.
• The result of capsular contracture is breast firmness. As the body heals after the placement of breast implants, it is normal to form a coating or lining of scar tissue (the 'capsule') around the implant, which strengthens and shrinks over the first three months post-surgery. In most cases, the pocket containing the implant remains open and roomy, allowing the implant to sit and move normally. In some people, however, this normal capsule will tighten and squeeze the implant. This makes the breast feel very hard and can distort its appearance to take on a 'ball-like' look.
• This can occur at any time, but seems to be more common in the first six months after surgery.
• It may occur on one or both sides, or not at all. The degree or severity of tightening might also be different on one side compared to the other.
• Although both breasts never match exactly, varying degrees of capsular contracture may mean that differences between the two breasts may be more noticeable. This is sometimes able to be corrected, but may not be possible.

Possible Causes of Capsular Contracture (these are still very unclear, but the following are thought to put patients at higher risk):

• Infection or transient germ (bacterial) contamination. This could be a result of invasive dental cleaning or dental procedures, urinary tract infections, a previous history of mastitis, wound infection, Streptococcal throat infection, to name a few. At Brisbane Cosmetic Clinic, it is our policy to prescribe antibiotics for the first week post-op to minimise the chances of infection.
• Seroma: a collection of fluid that sometimes occurs following surgery. This is normal when in small amounts. The body normally produces fluid when it has been injured and is now healing. It only becomes a problem if you make a large collection of fluid. This fluid is able to be easily drained and may require drainage a number of times before it settles and heals normally.
• Hematoma: a collection of blood or large bruises around the healing breast implant pocket. This can cause an inflammatory reaction. Very rarely is this a problem, but if a large bruise occurs and there is a collection of blood larger than the size of the implant, then this may need drainage, which will require another visit to operating theatre.
• Smoking decreases the oxygen levels in the blood, which results in delayed healing, and possibly an inflammatory reaction. Brisbane Cosmetic Clinic recommends that, at the very least, you should not smoke for two weeks prior to, and one month after surgery.

Levels of Capsular Contracture (The Baker Grading System identifies four grades of Capsular Contraction):

• Baker Grade 1: Anyone with breast implants will have this level, since there is always capsule formation around an implant. The breast is normally soft, and looks natural.
• Baker Grade 2: The breast is a little firm, but appears natural.
• Baker Grade 3: The breast is firm and is beginning to appear distorted in shape.
• Baker Grade 4: The breast is hard, and has become quite distorted in shape. Pain or discomfort may be associated with this level of Capsular Contracture.

Treatment of Capsular Contracture

• Medical Treatment
  
  
• Consult your doctor immediately you notice any firming of your breast. Intervention at this stage could slow or even halt the progress of Capsular Contracture. In particular, investigations for the presence of low-grade infection, signs of trauma, integrity of the implant are of special importance. At this stage, medical treatment is possible, often with a successful outcome.
• Accolate, a drug used in the treatment of Asthma, is the newest treatment for Capsular Contracture. It is used due to its anti-inflammatory properties. It is a leukotriene receptor inhibitor. Leukotrienes are a group of chemical compounds that occur naturally in white blood cells. They are able to produce allergic and inflammatory reactions. The drug inhibits this process and is said to work best on early contractures, but may even reverse existing capsules. If the capsule is well formed, it can take several months to treat it successfully. If Dr Konrat believes you may be at significant risk of Capsular Contracture, she may advise preventative treatment using this drug. She will be able to discuss this with you if it is relevant, quoting encouraging research results
• At Brisbane Cosmetic Clinic, we encourage our patients to assist the healing process by adopting a diet with a high nutrient density and in addition, to take nutritional supplements such as anti-oxidants, Vitamins C and E, Omega Fatty Acids, Zinc and Selenium for at least two weeks prior to surgery.
• We also recommend Infrared Crystalite therapy every second day of the first post-operative week to help reduce swelling, regulate inflammation and facilitate healing.
• Surgical Treatment: Open Capsulotomy
  
• This is the most successful treatment for Capsular Contracture.
• The doctor opens the existing pocket, removes the implant and 'scores' or cuts the scar tissue, in order to release the capsule's hold on the implant. The scar tissue is not removed. If you choose to have another implant placed, your body will form a new capsule around the breast implant. You will be advised to undergo treatment with the drug Accolate to reduce the risk of Capsular Contracture occurring again.
• A general anesthetic or Twilight anesthetic is required for this procedure

Calcification

• Calcium deposits can form in the scar tissue surrounding the implant and may cause pain and firmness.
• It is possible that calcifications may interfere with mammography, as these deposits need to be differentiated from calcium deposits that are a sign of breast cancer.

Changes in Nipple and Skin Sensation

• Some change in nipple sensation immediately after surgery is not unusual.
• After several months, most patients have normal or near 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 feed a baby.

Risks Associated with Larger Implants

Many doctors agree that a larger breast implant may carry an increased risk of complications. Some of these risks 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 (Capsular Contracture)
• Skin changes such as thinning, the extreme situation being skin loss and exposed implant requiring implant removal.
• Please refer back to Implant Size in the section entitled All About Cohesive Silicone Gel Breast Implants.

Wound Healing Problems or Tissue Necrosis

• Tissue Necrosis, or tissue breakdown, 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.
• Some patients experience delayed healing, either of the surgical pocket in which the implant is placed, or of the incision itself, which may open from injury or infection. This can result in an unattractive scar or breast tissue loss.
• If the implant is exposed, further surgery will be required.
• Tissue Necrosis or tissue breakdown has been reported following the use of steroid drugs, chemotherapy, radiation to breast tissue, smoking and excessive heat or cold therapy. Occasionally, it can occur without any identifiable cause but this is very rare.

Visible Skin Wrinkling and Rippling

• This can occur when an implant pulls on the overlying tissues, or when the natural folds in the implant are visible through the skin due to certain movements.
• Choosing the correct implant for your particular body characteristics can significantly reduce the risk of visible rippling. Dr Konrat will provide very specific advice for your needs.

Implant Extrusion

• This is an exceedingly rare complication.
• If the skin or the breast tissue covering the implant is very thin and/or there is a problem with healing, the implant may break through the skin and become exposed.
• This will require the removal of the implant, as surgery to correct this condition can result in unacceptable scarring or breast tissue loss.

Chest Wall Deformity

• This is an extremely rare complication.
• 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 in conjunction with breast implants.
• The consequence of chest wall deformity is of unknown significance, but is not believed to produce any known health consequences.

Malposition

• Occasionally 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 required 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.

Asymmetry

• Most women's breasts have at least some asymmetry. Significant asymmetry can be addressed by using implants of slightly different sizes.
• It is important to be aware that this can result in an improvement in size difference, but could accentuate differences in nipple-areola angle and position.
• There is no way of accurately measuring breast size, apart from visually, so it is difficult to determine the difference in volume of an implant to correct size differences.

'Snoopy' Effect

• This phenomenon most often occurs when breast implants are placed underneath the pectoralis muscle.
• It may not be noticeable in the first months or even years after surgery, but as the breast tissue and overlying skin stretches, for example, with pregnancy, breast-feeding or weight gain, the natural breast tissue can tend to fall over the underlying implant.
• The effect can be magnified by placement of the breast implants under the muscle in women who already have a sposis or an element of sag or droop.
• The implant remains firmly placed beneath the muscle, while the breast tissue and overlying skin fall further with age.
• This can only be corrected by removing the implants and replacing them sub-glandularly (between the muscle and the breast tissue).

Infection

• Infection following breast surgery is very unusual and statistically unlikely. If, however, it does occur, it is taken very seriously indeed as infection around a breast implant is more difficult to treat than in normal body tissues. For this reason, Dr Konrat believes in taking a strongly preventative attitude to infection. Her directives regarding pre-operation health, and the post-operative course of antibiotics are designed to minimize still further the likelihood of any infection.
• If, however, a diagnosis of a whole breast pocket infection is made, it is rare that further antibiotics alone will resolve the situation. If the infection does not respond to antibiotics, the implants may have to be removed. In this situation, the patient will need to remain on antibiotics for up to three months to ensure complete resolution of the initial infection. Once the infection is completely cleared up, new breast implants can usually be inserted several months later. Additional costs will be incurred in this situation.

Bleeding (Hematoma)

• Hematoma is a collection of blood that may occur around a breast implant following surgery. It occurs in 2-4% of breast implant procedures. It will usually require a general ansthetic and additional surgery to remove the hmatoma and stop the bleeding. Commonly a Day Surgery fee and an Anesthetists fee will be charged, but there are no further surgical fees charged. Dr Konrat does not charge a surgical fee for revision surgery to correct an immediate post-operative complication.
• Hematoma may contribute to capsular contracture, infection or other problem.
• Aspirin and most other anti-inflammatory medications should not be taken for ten days before and after surgery, as their use may increase the risk of bleeding. Dr Konrat also prefers that you do not take any non-prescription herbal remedies 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, hmatoma can occur at any time following an injury to the breast. If one or both breasts seem to increase in size quickly, this may be caused by hmatoma. This rapid swelling is often associated with bruising and discomfort.

Seroma

• Seroma is the accumulation of fluid, in this case, around the implant, following surgery, trauma or vigorous exercise. 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 increase in size over time, or if it seems that there is fluid around the implant, this may indicate a seroma, and you should consult your doctor.

Pain

• A significant number of women without implants experience breast pain at least once per month.
• Pain may develop or persist after breast implant surgery. 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

Studies to date consistently conclude that breast implants are not associated with increased rates of breast cancer. There is, of course, ongoing research in this area, as these studies require many years of follow-up time to be fully conclusive. Women with breast implants should follow the same breast-screening guidelines as women without implants.

Mammography

• Women with breast implants should have mammograms at a certified mammography centre. You should inform the personnel that you have breast implants.
• The presence of breast implants may make screening mammography more difficult as implants can partially block the ability to see all areas of the breast during a mammogram, thus possibly hiding disease.
• To ensure the most complete result from the mammogram, 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, although this is rare. When it does occur, it is usually related to having a very firm internal scar, or capsule, around the implant. However, this risk should not keep you from obtaining a mammogram when your doctor indicates this is appropriate.
• Ultrasound of the breast may be performed to aid in screening for breast cancer.

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.

Risk of Breastfeeding

• Breast implants should not prevent you from breast-feeding.
• Choice of incision location could have an effect on your ability to breast-feed: an incision around the nipple could, theoretically, interfere with the breast ducts. While this is not necessarily the case, if you believe you may wish to breast-feed in the future, you should mention this to Dr Konrat when planning your surgery.

Breast and Nipple Piercing Procedures

• If you are thinking of having any body piercing to your breast region after having breast implants, you should consider the possibility that an infection could develop any time following this procedure.
• If an infection does occur, it is possible it could spread to the breast implant pocket.
• If this occurs, treatment, including antibiotics, possible removal of the implant or other surgery may be necessary. In this case, additional costs would be incurred.
• A breast infection with the presence of an implant is harder to treat than an infection in normal body tissues. If an infection does not respond to antibiotics, the breast implant may need to be removed.

GENERAL RISKS OF SURGERY

Because surgery is such a vital part of modern medicine, there is a tendency to forget that there are risks associated with every type of surgery. While these risks are small, every person undergoing surgery should be aware of the risks.

Wounds

All internal and external wounds need time to heal after surgery. Sutures or stitches and other material are used to hold wounds closed while they heal.

Infections

Despite taking precautions, infections can occur during and just after surgery. These may be general, such as pneumonia, or specific to breast surgery. Because of their generally good health, breast implant patients usually have a lower risk of developing general infections such as pneumonia.

Pulmonary Risks

• All surgery patients have a risk of forming a blood clot in the leg (deep vein thrombosis) that breaks off and gets stuck in the lung circulation (pulmonary embolism). This is minimized by the wearing of surgical 'stockings' during the surgery, and by getting the patient out of bed as soon as possible.
• You will also be encouraged to breathe deeply when you wake up from the anesthetic as this expands your lungs and helps ensure your blood oxygen levels are good.

Risks of Anesthesia

As a rule, these risks are very low in cosmetic surgery patients, because the patients are generally in good health. Dr Konrat will take a full medical history, will order a number of tests prior to surgery and will make lifestyle recommendations to ensure your health is optimal before the surgery. This will minimize any general risks.

Mental Health Disorders and Elective Surgery

• It is important that all patients seeking to undergo elective surgery have realistic expectations that focus on improvement rather than perfection.
• Complications or less than satisfactory results are sometimes unavoidable and may require additional surgery. This can be stressful.
• Please discuss openly with Dr Konrat in your consultation prior to surgery, any history of emotional depression or mental health disorders. If you are unsure whether a matter is relevant, please mention it anyway. Although many individuals may benefit psychologically from the results of elective cosmetic surgery, the effects on mental health can never be predicted and could possibly have a negative influence on emotional stability.