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This is an updated version of the article that appeared in print. Updated: November 4, 2021

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

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

This clinical content conforms to AAFP criteria for CME.

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

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 CExpert 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 CReview of literature on cases of breast implant–associated ALCL
Patients with breast implants should receive additional radiologic displacement views during routine mammographic screening.38 BCase series demonstrating improved image quality and breast tissue visualization using displacement views
Educate patients that breast implants are associated with a reduced rate of exclusive breastfeeding, but it is still possible and encouraged.39 BMeta-analysis of cohort and cross-sectional studies demonstrating decreased rates of exclusive breastfeeding in patients with augmentation

What Are the Key Characteristics of Breast Implants?

Several variables relating to the breast implant and operative technique can affect the outcome of a cosmetic or reconstructive procedure. These variables (Table 1) include the location of the operative incision, implant fill type (silicone vs. saline), and surface texture (smooth vs. textured).

Implant variables
Fill type
Silicone: commonly chosen by patients because of its more natural feel; it carries risk of silicone leakage into breast parenchyma with rupture
Saline: less natural feel; saline is safely absorbed in cases of rupture
Size
 Implants range, on average, from 150 to 800 mL
Outer shell texture
Smooth: slightly higher rates of capsular contracture
Textured: lower rates of capsular contracture, although currently not in use because of association with breast implant–associated anaplastic large cell lymphoma
Procedure variables
Incision placement (Figure 1)
 Transaxillary
 Periareolar
 Inframammary
 Transumbilical
Implant pocket
Prepectoral (above pectoralis major muscle): more common in augmentation, reduces postoperative pain, avoids implant displacement with contraction of pectoralis muscle (animation deformity)
Submuscular (below pectoralis major muscle): more common in reconstruction, provides better implant coverage after mastectomy (reduces infection, implant exposure), reduces visible implant rippling, carries risk of animation deformity

EVIDENCE SUMMARY

Decisions regarding implant characteristics are based on patient preference and surgeon experience. Operative decisions, including incision type and whether the implant is placed above (prepectoral pocket) or below the pectoralis muscle (submuscular pocket; Figure 1), are dependent on the indication for the procedure, anatomy, surgeon, and patient preference. A recent meta-analysis demonstrated that for breast augmentation, the periareolar approach—although cosmetically favorable—is associated with higher rates of capsular contracture, defined as thickening and hardening of scar tissue around the implant, than transaxillary or inframammary incisions.8

Silicone implants are more commonly used than saline in augmentation and postmastectomy reconstruction.9 Implants with a textured outer shell (referred to as textured implants) became popular secondary to reduced rates of capsular contracture compared with those with a smooth outer shell; however, they are currently not in use because of association with breast implant–associated anaplastic large cell lymphoma (ALCL).10

What Are the Acute Complications Associated with Breast Implants?

Most acute complications following breast augmentation or implant-based reconstruction are managed immediately by the surgical team (e.g., hematoma), but some may arise outside of the immediate perioperative period and present to the family physician. The most acute and time-sensitive complications include hematomas and an implant or tissue expander infection.

EVIDENCE SUMMARY

Rates of acute infection range from 1% to 2.5% for cosmetic procedures.11 Risk factors for infection in patients with breast implants include obesity, diabetes mellitus, smoking, mastectomy skin-flap necrosis, lymph node dissection, and radiation therapy.12 Acute infections generally present within the first four weeks after breast implant or tissue expander placement with unilateral breast pain, redness, swelling, and warmth. Constitutional symptoms may also be present. Infection severity can range from superficial cellulitis to abscess formation and sepsis. The most common source of infection is from gram-positive bacteria.11 Management of superficial infections may be initiated by the primary care physician with oral antibiotics; the plastic surgeon should be contacted for discussion and follow-up evaluation. More severe infection warrants admission for intravenous antibiotics and, in some cases, surgical washout with removal of the expander or implant. Prompt referral to the operating surgeon for management of antibiotics and possible implant removal is recommended for patients. The rate of implant salvage for infected breast implants used for reconstructive purposes is approximately 58%,13 and for augmentation it approaches 90% with medical management and/or washout in the operating room.14,15

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