Breast Implants: Common Questions and Answers

 

Am Fam Physician. 2021 Nov ;104(5):500-508.

  Patient information: See related handout on breast implants, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Breast implants are used for a wide range of cosmetic and reconstructive purposes. In addition to breast augmentation, implants can be used for postmastectomy breast reconstruction, correction of congenital breast anomalies, breast or chest wall deformities, and male-to-female top surgery. Breast implants may confer significant benefits to patients, but several factors are important to consider preoperatively, including the impact on mammography, future lactation, and potential long-term implant complications (e.g., infection, capsular contracture, rupture, and the need for revision, replacement, or removal). A fundamental understanding of implant monitoring is also paramount to implant use. Patients with silicone breast implants should undergo routine screening for implant rupture with magnetic resonance imaging or ultrasonography completed five to six years postoperatively and then every two to three years thereafter. With the exception of complications, there are no formal recommendations regarding the timing of breast implant removal or exchange. Women with unilateral breast swelling should be evaluated with ultrasonography for an effusion that might indicate breast implant–associated anaplastic large cell lymphoma. There are no specific breast cancer screening recommendations for patients with breast implants, but special mammographic views are indicated to enhance accuracy. Although these discussions are a routine component of consultation and postoperative follow-up for plastic surgeons performing these procedures, family physicians should have a working knowledge of implant indications, characteristics, and complications to better counsel their patients, to ensure appropriate screening, and to coordinate care after surgery.

Breast implants are used for cosmetic and reconstructive purposes. Implant placement for primary breast augmentation is the most common cosmetic surgical procedure in the United States, with more than 313,000 procedures performed in 2018.1 Breast implants also play an important role in reconstructive procedures for breast hypoplasia,2 congenital breast anomalies,3 male-to-female top surgery,4 and postmastectomy breast reconstruction. Rates of breast reconstruction after mastectomy have increased since the passage of the Women's Health and Cancer Rights Act in 1998, which mandates insurance coverage for all stages of postmastectomy reconstruction.5 It also includes coverage of symmetry procedures for the contralateral breast in the case of a unilateral mastectomy.5 Implant-based breast reconstruction is more common than tissue-based (autologous) reconstruction, which commonly uses abdominal tissue for breast reconstruction, for patients who have undergone mastectomy.6 Operative techniques for breast implant placement can have important implications when assessing and examining patients. Notably, implants can be placed above the pectoralis major muscle, where they are more easily palpable, or below the pectoralis major muscle, where features such as implant rupture may be more difficult to discern on examination. Postmastectomy reconstruction improves patient-reported outcomes in psychosocial well-being, sexual well-being, and overall chest satisfaction.7

WHAT'S NEW ON THIS TOPIC

Breast Implants

In September 2020, the U.S. Food and Drug Administration released new guidance about labeling of breast implants to improve risk communication:

A boxed warning denotes risks such as breast implant–associated anaplastic large cell lymphoma and potential need for additional operations

A patient decision checklist should be provided to document discussion of alternatives to breast implants, risks of breast implant surgery, breast implant–associated anaplastic large cell lymphoma, systemic symptoms, and considerations for a successful breast implant candidate

Chemical materials contained in implants should be described

Silicone rupture screening guidelines

All patients should be given an implant device card

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Screen patients with silicone breast implants for implant rupture with magnetic resonance imaging or ultrasonography five to six years postoperatively and then every two to three years thereafter.20

C

Expert opinion and consensus guideline from the U.S. Food and Drug Administration in the absence of clinical trials

Suspect breast implant–associated ALCL in patients with textured silicone breast implants and late onset (eight to 10 years) seroma.27

C

Review of literature on cases of breast implant–associated ALCL

Patients with breast implants should receive additional radiologic displacement views during routine mammographic screening.38

B

Case series demonstrating improved image quality and breast tissue visualization using displacement views

Educate patients that breast implants are associated with a reduced

The Authors

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SARINA SCHRAGER, MD, MS, is a professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Madison....

SARAH M. LYON, MD, is a resident in the Division of Plastic Surgery at the University of Wisconsin School of Medicine and Public Health.

SAMUEL O. POORE, MD, PhD, is an associate professor in the Division of Plastic Surgery at the University of Wisconsin School of Medicine and Public Health.

Address correspondence to Sarina Schrager, MD, MS, University of Wisconsin, 1100 Delaplaine Ct., Madison, WI 53715 (email: sbschrag@wisc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. American Society of Plastic Surgeons. 2018 national plastic surgery statistics. 2018. Accessed November 1, 2020. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf...

2. van Aalst JA, Phillips JD, Sadove AM. Pediatric chest wall and breast deformities. Plast Reconstr Surg. 2009;124(1 suppl):38e–49e.

3. Manzano Surroca M, Parri F, Tarrado X. Poland sequence: retrospective analysis of 66 cases. Ann Plast Surg. 2019;82(5):499–511.

4. Miller TJ, Wilson SC, Massie JP, et al. Breast augmentation in male-to-female transgender patients: technical considerations and outcomes. JPRAS Open. 2019;21:63–74.

5. Centers for Medicare and Medicaid Services. Women's Health and Cancer Rights Act (WHCRA). Updated April 13, 2020. Accessed April 17, 2020. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet

6. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15–23.

7. Pirro O, Mestak O, Vindigni V, et al. Comparison of patient-reported outcomes after implant versus autologous tissue breast reconstruction using the BREAST-Q. Plast Reconstr Surg Glob Open. 2017;5(1):e1217.

8. Li S, Chen L, Liu W, et al. Capsular contracture rate after breast augmentation with periareolar versus other two (inframammary and transaxillary) incisions: a meta-analysis. Aesthetic Plast Surg. 2018;42(1):32–37.

9. American Society of Plastic Surgeons. Plastic surgery statistics. Updated April 27, 2021. Accessed June 30, 2021. https://www.plasticsurgery.org/news/plastic-surgery-statistics

10. Largent J, Oefelein M, Kaplan HM. Risk of lymphoma in women with breast implants: analysis of clinical studies. Eur J Cancer Prev. 2012;21(3):274–280.

11. Lalani T. Breast implant infections: an update. Infect Dis Clin North Am. 2018;32(4):877–884.

12. Ooi AS, Song DH. Reducing infection risk in implant-based breast-reconstruction surgery: challenges and solutions. Breast Cancer (Dove Med Press). 2016;8:161–172.

13. Song JH, Kim YS, Jung BK, et al. Salvage of infected breast implants. Arch Plast Surg. 2017;44(6):516–522.

14. Spear SL, Seruya M. Management of the infected or exposed breast prosthesis: a single surgeon's 15-year experience with 69 patients. Plast Reconstr Surg. 2010; 125(4):1074–1084.

15. Khan UD. Breast augmentation, antibiotic prophylaxis, and infection: comparative analysis of 1,628 primary augmentation mammoplasties assessing the role and efficacy of antibiotics prophylaxis duration. Aesthetic Plast Surg. 2010;34(1):42–47.

16. Bachour Y, Bargon CA, de Blok CJM, et al. Risk factors for developing capsular contracture in women after breast implant surgery: a systematic review of the literature. J Plast Reconstr Aesthet Surg. 2018;71(9):e29–e48.

17. Spear SL, Murphy DK; Allergan Silicone Breast Implant U.S. Core Clinical Study Group. Natrelle round silicone breast implants: core study results at 10 years. Plast Reconstr Surg. 2014;133(6):1354–1361.

18. Walker PS, Walls B, Murphy DK. Natrelle saline-filled breast implants: a prospective 10-year study. Aesthet Surg J. 2009;29(1):19–25.

19. Ryu AJ, Glazebrook KN, Samreen N, et al. Spectrum of chronic complications related to silicone leakage and migration. Am J Med. 2018;131(11):1383–1386.

20. U.S. Food and Drug Administration. Saline, silicone gel, and alternative breast implants: guidance for industry and FDA staff; September 2020. Updated September 28, 2020. Accessed June 30, 2021. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/saline-silicone-gel-and-alternative-breast-implants

21. Van Slyke AC, Carr M, Carr NJ. Not all breast implants are equal: a 13-year review of implant longevity and reasons for explantation. Plast Reconstr Surg. 2018;142(3):281e–289e.

22. U.S. Food and Drug Administration. Breast implants—certain labeling recommendations to improve patient communication: guidance for industry and Food and Drug Administration staff; September 2020. Updated September 28, 2020. Accessed June 2, 2021. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/breast-implants-certain-labeling-recommendations-improve-patient-communication

23. U.S. Food and Drug Administration. Medical device reports of breast implant-associated anaplastic large cell lymphoma. Updated August 20, 2020. Accessed October 27, 2020. https://www.fda.gov/medical-devices/breast-implants/medical-device-reports-breast-implant-associated-anaplastic-large-cell-lymphoma

24. Doren EL, Miranda RN, Selber JC, et al. U.S. epidemiology of breast implant-associated anaplastic large cell lymphoma. Plast Reconstr Surg. 2017;139(5):1042–1050.

25. U.S. Food & Drug Administration. Breast implant associated-anaplastic large cell lymphoma (BIA-ALCL)— letter to health care providers; February 6, 2019. Updated July 24, 2019. Accessed June 2, 2021. https://www.fda.gov/medical-devices/letters-health-care-providers/breast-implant-associated-anaplastic-large-cell-lymphoma-bia-alcl-letter-health-care-providers

26. Lazzeri D, Agostini T, Giannotti G, et al. Null-type anaplastic lymphoma kinase-negative anaplastic large cell lymphoma arising in a silicone breast implant capsule. Plast Reconstr Surg. 2011;127(6):159e–162e.

27. Leberfinger AN, Behar BJ, Williams NC, et al. Breast implant-associated anaplastic large cell lymphoma: a systematic review. JAMA Surg. 2017;152(12):1161–1168.

28. Clemens MW, Medeiros LJ, Butler CE, et al. Complete surgical excision is essential for the management of patients with breast implant-associated anaplastic large-cell lymphoma [published correction appears in J Clin Oncol. 2016;34(8):888]. J Clin Oncol. 2016;34(2):160–168.

29. Miranda RN, Aladily TN, Prince HM, et al. Breast implant-associated anaplastic large-cell lymphoma. J Clin Oncol. 2014;32(2):114–120.

30. Alcalá R, Llombart B, Lavernia J, et al. Skin involvement as the first manifestation of breast implant-associated anaplastic large cell lymphoma. J Cutan Pathol. 2016;43(7):602–608.

31. Taylor KO, Webster HR, Prince HM. Anaplastic large cell lymphoma and breast implants: five Australian cases. Plast Reconstr Surg. 2012;129(4):610e–617e.

32. Adrada BE, Miranda RN, Rauch GM, et al. Breast implant-associated anaplastic large cell lymphoma: sensitivity, specificity, and findings of imaging studies in 44 patients. Breast Cancer Res Treat. 2014;147(1):1–14.

33. U.S. Food and Drug Administration. Allergan recalls Natrelle biocell textured breast implants due to risk of BIA-ALCL cancer. Updated September 12, 2019. Accessed April 17, 2020. https://www.fda.gov/medical-devices/medical-device-recalls/allergan-recalls-natrelle-biocell-textured-breast-implants-due-risk-bia-alcl-cancer

34. U.S. Food and Drug Administration. Questions and answers about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Updated October 23, 2019. Accessed April 5, 2020. https://www.fda.gov/medical-devices/breast-implants/questions-and-answers-about-breast-implant-associated-anaplastic-large-cell-lymphoma-bia-alcl

35. U.S. Food and Drug Administration. Statement on the agency's continued efforts to protect women's health and enhance safety information available to patients considering breast implants. Updated October 23, 2019. Accessed April 17, 2020. https://www.fda.gov/news-events/press-announcements/statement-agencys-continued-efforts-protect-womens-health-and-enhance-safety-information-available

36. Siu AL. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement [published correction appears in Ann Intern Med. 2016;164(6):448]. Ann Intern Med. 2016;164(4):279–296.

37. Oeffinger KC, Fontham ETH, Etzioni R, et al.; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society [published correction appears in JAMA. 2016;315(13):1406]. JAMA. 2015;314(15):1599–1614.

38. Eklund GW, Busby RC, Miller SH, et al. Improved imaging of the augmented breast. AJR Am J Roentgenol. 1988;151(3):469–473.

39. Miglioretti DL, Rutter CM, Geller BM, et al. Effect of breast augmentation on the accuracy of mammography and cancer characteristics. JAMA. 2004;291(4):442–450.

40. Brown SL, Todd JF, Luu H-MD. Breast implant adverse events during mammography: reports to the Food and Drug Administration. J Womens Health (Larchmt). 2004;13(4):371–378.

41. Roberts CL, Ampt AJ, Algert CS, et al. Reduced breast milk feeding subsequent to cosmetic breast augmentation surgery. Med J Aust. 2015;202(6):324–328.

42. Cheng F, Dai S, Wang C, et al. Do breast implants influence breastfeeding? A meta-analysis of comparative studies. J Hum Lact. 2018;34(3):424–432.

43. Bompy L, Gerenton B, Cristofari S, et al. Impact on breastfeeding according to implant features in breast augmentation: a multicentric retrospective study. Ann Plast Surg. 2019;82(1):11–14.

44. Michalopoulos K. The effects of breast augmentation surgery on future ability to lactate. Breast J. 2007;13(1):62–67.

45. Sinha I, Pusic AL, Wilkins EG, et al. Late surgical-site infection in immediate implant-based breast reconstruction. Plast Reconstr Surg. 2017;139(1):20–28.

46. Hunter JG, Padilla M, Cooper-Vastola S. Late Clostridium perfringens breast implant infection after dental treatment. Ann Plast Surg. 1996;36(3):309–312.

47. Chang J, Lee GW. Late hematogenous bacterial infections of breast implants: two case reports of unique bacterial infections. Ann Plast Surg. 2011;67(1):14–16.

48. Stoopler ET, Sia YW, Kuperstein AS. Do patients with solid organ transplants or breast implants require antibiotic prophylaxis before dental treatment? J Can Dent Assoc. 2012;78:c5.

49. Breastcancer.org. What is breast implant illness. Updated October 29, 2020. Accessed June 30, 2021. https://www.breastcancer.org/treatment/surgery/reconstruction/types/implants/special-report/breast-implant-illness

50. Institute of Medicine; Grigg M, Bondurant S, Ernster VL, et al., eds. Information for Women about the Safety of Silicone Breast Implants. National Academies Press; 2000.

51. Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 2000;342(11):781–790.

52. Institute of Medicine; Committee on the Safety of Silicone Breast Implants; Bondurant S, Ernster VL, Herdman R, eds. Safety of Silicone Breast Implants. National Academies Press; 1999.

53. Magnusson MR, Cooter RD, Rakhorst H, et al. Breast implant illness: a way forward. Plast Reconstr Surg. 2019;143(3S A Review of Breast Implant-Associated Anaplastic Large Cell Lymphoma):74S–81S.

54. Tang SYQ, Israel JS, Afifi AM. Breast implant illness: symptoms, patient concerns, and the power of social media. Plast Reconstr Surg. 2017;140(5):765e–766e.

55. Halpert G, Watad A, Tsur AM, et al. Autoimmune dysautonomia in women with silicone breast implants. J Autoimmun. 2021;120:102631.

56. U.S. Food and Drug Administration. Risks and complications of breast implants. Updated September 28, 2020. Accessed June 30, 2021. https://www.fda.gov/medical-devices/breast-implants/risks-and-complications-breast-implants

57. Tanna N, Calobrace MB, Clemens MW, et al. Not all breast explants are equal: contemporary strategies in breast explantation surgery. Plast Reconstr Surg. 2021;147(4):808–818.

 

 

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