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 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).

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