A breast enlarger implant is a prosthesis used to enlarge the size of a woman's breasts (known as breast augmentation, breast enlargement, mammoplasty enlargement, augmentation mammoplasty or the common slang term boob job) for cosmetic reasons; to reconstruct the breast (e.g. after a mastectomy; or to correct genetic deformities), or as an aspect of male-to-female sex reassignment surgery. According to the American Society of Plastic Surgeons, breast augmentation is the most commonly performed cosmetic surgical procedure in the United States. In 2006, 329,000 breast augmentation procedures were performed in the U.S.

History

Implants have been used since 1895 to augment the size or shape of women's breasts. The earliest known implant was attempted by Vincenz Czerny, using a woman's own adipose tissue (from a lipoma, a benign growth, on her back). Gersuny tried paraffin injections in 1889, with disastrous results. Subsequently, in the early to mid-1900s, a number of other substances were tried, including ivory, glass balls, ground rubber, ox cartilage, Terylene wool, gutta-percha, Dicora, polyethylene chips, polyvinyl alcohol-formaldehyde polymer sponge (Ivalon), Ivalon in a polyethylene sac, polyether foam sponge (Etheron), polyethylene tape (Polystan) or strips wound into a ball, polyester (polyurethane foam sponge) Silastic rubber, and teflon-silicone prostheses. In recent history, various creams and medicaments have been used in attempts to increase bust size, and Berson in 1945 and Maliniac in 1950 performed a flap-based augmentation by rotating the patient's chest wall tissue into the breast enlarger to add volume. Various synthetics were used throughout the 1950s and 1960s, including silicone injections, which an estimated 50,000 women received. Development of silicone granulomas and hardening of the breasts were in some cases so severe that women needed to have mastectomies for treatment. Women sometimes seek medical treatment for complications up to 30 years after receiving this type of injection.

Indications

breast enlarger implants are used for: primary reconstruction (to replace breast tissue that has been removed due to cancer or trauma or that has failed to develop properly due to a severe breast abnormality) revision-reconstruction (revision surgery to correct or improve the result of an original breast reconstruction surgery) primary augmentation (to increase breast size for cosmetic reasons) revision-augmentation (revision surgery to correct or improve the result of an original breast augmentation surgery)

Patient characteristics

Patients seeking breast augmentation have been reported as being usually younger, healthier, from higher socio-economic status, and more often married with children than the population at large. Many of these patients have reported greater distress about their appearance in a variety of situations, and have endured teasing about their appearance. Studies have identified a pattern (shared by many cosmetic surgery procedures) that suggest women who undergo breast implantation are slightly more likely to have undergone psychotherapy, have low levels of self-esteem, and have higher prevalences of depression, suicide attempts, and mental illness (including body dysmorphia) as compared to the general population.

Post-operative surveys on mental health and quality of life issues have reported improvement on a number of dimensions including: physical health, physical appearance, social life, self confidence, self esteem, and sexual function. Longer term follow-up suggests these improvements may be transitory, with the exception of body esteem related to sexual attractiveness. Most patients report being satisfied long-term with their implants even when they have required re-operation for complications or aesthetic reasons.

Procedure

The surgical procedure for breast augmentation takes approximately one to two hours. Variations in the procedure include the incision type, implant material, and implant pocket placement.

Incision types Breast implants for augmentation may be placed via various types of incisions: Inframammary - an incision is placed below the breast in the infra-mammary fold (IMF). This incision is the most common approach and affords maximum access for precise dissection and placement of an implant. It is often the preferred technique for silicone gel implants due to the longer incisions required. This method can leave slightly more visible scars in smaller breasts which don't drape over the IMF. In addition, the scar may heal thicker. This technique has been refferred to as the "French lollipop", due to the distintive scarring.

Periareolar - an incision is placed along the areolar border. This incision provides an optimal approach when adjustments to the IMF position or mastopexy (breast lift) procedures are planned. The incision is generally placed around the inferior half, or the medial half of the areola's circumference. Silicone gel implants can be difficult to place via this incision due to the length of incision required (~ 5cm) for access. As the scars from this method occur on the edge of the areola, they are often less visible than scars from inframammary incisions in women with lighter areolar pigment. There is a higher incidence of capsular contracture with this technique.

Transaxillary - an incision is placed in the armpit and the dissection tunnels medially. This approach allows implants to be placed with no visible scars on the breast and is more likely to consistently achieve symmetry of the inferior implant position. Revisions of transaxillary-placed implants may require inframammary or periareolar incisions (but not always). Transaxillary procedures can be performed with or without an endoscope.

Transumbilical (TUBA) - a less common technique where an incision is placed in the navel and dissection tunnels superiorly. This approach enables implants to be placed with no visible scars on the breast, but makes appropriate dissection and implant placement more difficult. Transumbilical procedures may be performed bluntly or with an endoscope (tiny lighted camera) to assist dissection. This technique is not appropriate for placing silicone gel implants due to potential damage of the implant shell during blunt insertion. Transabdominoplasty (TABA) - procedure similar to TUBA, where the implants are tunneled up from the abdomen into bluntly dissected pockets while a patient is simultaneously undergoing an abdominoplasty procedure.

Types of implants Saline implants

Silicone gel-filled breast implants Saline-filled breast implants were first manufactured in France in 1964, introduced by Arion[15] with the goal of being surgically placed via smaller incisions. Current saline devices are manufactured with thicker, room temperature vulcanized (RTV) shells. These shells are made of silicone elastomer and the implants are filled with salt water after the implant is placed in the body. Since the implants are empty when they are surgically inserted, the scar is smaller than is necessary for silicone gel breast implants (which are filled with silicone before the surgery is performed). A single manufacturer (Poly Implant Prosthesis, France) produced a model of pre-filled saline implants which has been reported to have high failure rates in vivo.

Saline-filled implants were most common implant used in the United States during the 1990s due to restrictions that existed on silicone implants, but were rarely used in other countries. Good to excellent results may be obtained, but as compared to silicone gel implants, saline implants are more likely to cause cosmetic problems such as rippling, wrinkling, and to be noticeable to the eye or the touch. Particularly for women with very little breast tissue, or for post-mastectomy breast reconstruction, silicone gel implants are considered as superior. In patients with more breast tissue in whom submuscular implant placement is used, saline implants can look very similar to silicone gel.

Silicone gel implants

Thomas Cronin and Frank Gerow, two Houston, Texas, plastic surgeons, developed the first silicone breast prosthesis with the Dow Corning Corporation in 1961. The first woman was implanted in 1962. Silicone implants are generally described in terms of five generations which segregate common characteristics of manufacturing techniques. First generation

The Cronin-Gerow implants were made of a silicone rubber envelope (or sac), filled with a thick, viscous silicone gel with a Dacron patch on the posterior shell. They were firm and had an anatomic "teardrop" shape.

Second generation

In response to surgeons' requests for softer and more lifelike implants, breast implants were redesigned in the 1970s with thinner, less cohesive gel and thinner shells. These implants had a greater tendency to rupture and leak, or "bleed" silicone through the implant shell, and complications such as capsular contracture were quite common. It was predominantly implants of this generation that were involved in the class action-lawsuits against Dow-Corning and other manufacturers in the early 1990s.

Another development in the 1970s was a polyurethane foam coating on the implant shell which was effective in diminishing capsular contracture by causing an inflammatory reaction that discouraged formation of fibrous tissue around the capsule. These implants were later briefly discontinued due to concern of potential carcinogenic breakdown products from the polyurethane. A review of the risk for cancer from TDA by the FDA later concluded that the risk was so small so as not to justify recommending explantation of the devices from individual patients. Polyurethane implants are still used in Europe and South America, but no manufacturer has sought FDA approval for sale in the United States.

Second-generation implants also included various "double lumen" designs. These implants were essentially a silicone implant inside a saline implant. The double lumen was an attempt to provide the cosmetic benefits of gel in the inside lumen, while the outside lumen contained saline and its volume could be adjusted after placement. The failure rate of these implants is higher than for single lumen implants due to their more complex design. The contemporary versions of these devices ("Becker Implants") are used primarily for breast reconstruction.

Third & Fourth generation

Third & fourth generation implants, from the mid 1980s, represented sequential advances in manufacturing principles with elastomer-coated shells to decrease gel bleed, and are filled with thicker, more cohesive gel. These implants are sold under restricted conditions in the U.S. and Canada, and are widely used in other countries. The increased cohesion of the gel filler reduces potential leakage of the gel compared to earlier devices. A variety of both round and tapered anatomic shapes are available. Anatomic shaped implants are uniformly textured to reduce rotation, while round devices are available in smooth or textured surfaces.

Fifth generation

Evaluation of "gummy bear" or solid, high-cohesive, form-stable implants is in preliminary stages in the United States but these implants have been widely used since the mid 1990s in other countries. The semi-solid gel in these type of implants largely eliminates the possibility of silicone migration. Studies of these devices have shown significant potential improvements in safety and efficacy over the older implants with low rates of capsular contracture and rupture. Implant pocket placement

Subglandular breast implant diagram

The placement of implants is described in relation to the pectoralis major muscle. Subglandular- implant between the breast tissue and the pectoralis muscle. This position closely resembles the plane of normal breast tissue and is felt by many to achieve the most aesthetic results. The subglandular position in patients with thin soft-tissue coverage is most likely to show ripples or wrinkles of the underlying implant. Capsular contracture rates are also slightly higher with this approach, and placement of implants in this pocket might be inappropriate in women who are at risk for capsule formation (smokers, multiple breast surgeries).

Subfascial - the implant is placed in the subglandular position, but underneath the fascia of the pectoralis muscle. The benefits of this technique are debated, but proponents believe the (sometimes thick) fascial sheet of tissue may help with coverage and sustaining positioning of the implant. Implants that undergo capsular contraction are unlikely to displace upward or toward the underarm.

Subpectoral ("dual plane") - the implant is placed underneath the pectoralis major muscle after releasing the inferior muscular attachments. As a result, the implant is partially beneath the pectoralis in the upper pole, while the lower half of the implant is in the subglandular plane. This is the most common technique in North America and achieves maximal upper implant coverage while allowing expansion of the lower pole. Animation or movement of the implants in the subpectoral plane can be excessive to some patients. Submuscular - the implant is placed below the pectoralis without release of the inferior origin of the muscle. Total muscular coverage may be achieved by releasing the lateral chest wall muscles (serratus and/or pectoralis minor) and sewn to the pectoralis major. This technique is most commonly used for maximal coverage of implants used in breast reconstruction.

Recovery

Depending on the level of activity required, patients are generally able to resume normal activity in approximately one week's time. Women who have their implants placed underneath the muscle (submuscular placement) will generally have a longer recovery time and experience slightly more pain due to the muscle being cut during surgery. During initial recovery it is important not to use the arms or strain the body in any way, and to avoid cigarettes. Scars from a breast augmentation surgery will last six weeks or longer and usually begin to fade several months after surgery.

Claims of systemic illness and disease

Since the early 1990s, a number of independent systemic comprehensive reviews have examined studies concerning links between silicone gel breast implants and systemic diseases. The consensus of these reviews is that there is no clear evidence of a causal link between the implantation of silicone breast implants and systemic disease. Thousands of women claim that they have become ill from their implants; complaints include neurological and rheumatological problems. Some studies have suggested that subjective and objective symptoms of women with implants may improve when their implants are removed.

As studies have followed women with implants for a longer period of time, more data have become available on systemic diseases as well as autoimmune symptoms. Several large studies from the national health registry in Denmark found implant recipients no more likely to be diagnosed with an increased incidence of classic auto-immune symptoms as compared to women of the same age in the general population, and that musculoskeletal symptoms were generally lower among women with implants compared with women with other cosmetic surgery and women in the general population. Recent longitudinal follow-up of these patients has confirmed previously reported findings.

Several studies have established that won who elect to undergo breast augmentation or other plastic surgery tend to be healthier and more affluent than the general population, prior to surgery and afterwards. For example, two large studies of plastic surgery patients found a decreased standardized mortality ratio in both breast implant and other plastic surgery patients, but an increased risk of respiratory cancer deaths in breast implant recipients compared to other forms of plastic surgery. Smoking was statistically controlled in one study and not in the other, but the authors speculated that there could potentially be differences in smoking that might contribute to the higher lung cancer deaths among women with implants. Another large study with long-term follow-up of nearly 25,000 Canadian women with implants reported: "Findings suggest that breast implants do not directly increase mortality in women.

In 2001 a study suggested an increase in fibromyalgia among women with extracapsular silicone gel leakage, compared to women whose implants were not broken or leaking outside the capsule. This association has not been repeated in a number of related studies, and the US-FDA concluded "the weight of the epidemiological evidence published in the literature does not support an association between fibromyalgia and breast implants.

While there is a general international consensus that silicone implants have not been shown to cause systemic illness, excluding the possibility that a small group of patients may become ill through (as of yet) unknown mechanisms may prove difficult. The US-FDA notes that "researchers must study a large group of women without breast implants who are of similar age, health, and social status and who are followed for a long time (such as 10-20 years) before a relationship between breast implants and these diseases can conclusively be made.

Complications

Surgeries involving breast implants, whether for cosmetic or reconstructive surgery, carry risk common to many types of surgery. These include adverse reactions to anesthesia, post-operative bleeding (hematoma)or fluid collection (seroma), surgical site infection or breakdown, breast pain or alterations in sensation, unfavorable scarring (6-7%), interference with breast feeding, visible wrinkling, asymmetry, thinning of the breast tissue, and synmastia (disruption of the natural plane between breasts which is sometimes referred to as 'bread loafing'). Complications and reoperations related to surgeries with breast implants or tissue expanders can add signifigant long term costs to patients and health care systems.

Specific complications to indwelling breast implants that have received notable attention involve surveillence and treatment for implant rupture and the phenomena of capsular contracture.

Rupture

Ruptured silicone implant with removed capsule Breast implants can potentially remain intact decades in the body, but all such devices will fail at some point. When saline breast implants break, they often deflate quickly and can be easily removed. Prospective studies of saline-filled breast implants showed rupture/deflation rates of 3-5% at 3 years and 7-10% at 5 years for augmentation patients. Among the suspected mechanisms for rupture are damage during implantation or other procedures, degradation of the implant shell, blunt or penetrating chest trauma, and in rare instances from the pressure of traditional mammograms.

The age and design of the implant are the most important factors in rupture, but estimating ruptures rates of contemporary devices has been difficult, as most previous reports mixed heterogeneous groups of devices in non-randomized populations. The only available literature with longer term available MRI data on single lumen 3rd/4th generation silicone implants comes from Europe and has reported silent rupture rates of an implant at between 8% to 15% at or around a decade (or 15-30% of patients). The first series of MRI evaluation of the highly-cohesive (5th generation) gel implants suggests improved durability, with a rupture rate reported at 1% or less at a median age of six years.

Its been suggested that clinical exams alone are inadequate to evaluate suspected rupture after a study reported that only 30% of ruptures in asymptomatic patients are accurately detected by experienced plastic surgeons, compared to 86% detected by MRIs The US-FDA has recommended that MRIs be considered to screen for silent rupture starting at three years after implantation and then every two years thereafter. Other countries have not endorsed routine MRI screening, and have taken the position that MRI should be reserved only for cases involving suspected clinical rupture or to confirm mammographic or ultrasound studies suggesting rupture.

When silicone implants break they rarely deflate, and the silicone from the implant can leak out into the space around the implant. An intracapsular rupture can progress to outside of the capsule (extracapsular rupture), and both conditions are generally agreed to indicate the need for removal of the implant. Extracapsular silicone has the potential to migrate, but most clinical complications have appeared to be limited to the breast and axillae in the form of granulomas (inflammatory nodules) and axillary lymphadenopathy (enlarged lymph glands in the armpit area). The specific risk and treatment of extracapsular silicone gel is still controversial.

Capsular contracture

High grade (Baker IV) capsular contracture in the right breast around a subglandular gel implant. Capsules of tightly-woven collagen fibers form as an immune response around a foreign body (eg. breast implants, pacemakers, orthopedic joint prosthetics), tending to wall it off. Capsular contracture occurs when the capsule tightens and squeezes the implant. This contracture is a complication that can be very painful and distort the appearance of the implanted breast. The exact cause of contracture is not known. However, some factors include bacterial contamination, silicone rupture or leakage, and hematoma. Capsular contracture may happen again after this additional surgery.

Methods which have reduced capsular contracture include submuscular implant placement, using textured or polyurethane-coated implants, limiting handling of the implants and skin contact prior to insertion and irrigation with triple-antibiotic solutions.

Correction of capsular contracture may require surgical removal or release of the capsule, or removal and possible replacement of the implant itself. Closed capsulotomy (disrupting the capsule via external manipulation), a once common maneuver for treating hard capsules, has been discouraged as it can cause implant rupture. Nonsurgical methods of treating capsules include massage, external ultrasound, treatment with leukotriene pathway inhibitors (Accolate, Singulair), and pulsed electromagnetic field therapy.

Platinum

Platinum is a catalyst used in the making of silicone implant polymer shells and other silicone devices used in medicine. The literature indicates that small amounts of platinum leaches (leaks) from these implants and is present in the surrounding tissue. The FDA reviewed the available studies from the medical literature on platinum and breast implants in 2002 and concluded there was little evidence suggesting toxicity from platinum in implant patients.

In 2006, researchers published a controversial study that claimed to identify the previously undocumented presence of toxic platinum oxidative states in vivo. A letter from the editors of the publishing journal, Analytical Chemistry, subsequently expressed concern over the research's experimental design and urged the journal's readers to "use caution in evaluating the conclusions drawn in the paper." The FDA reviewed this study and the existing literature, concluding that the body of existing research did not support their findings, and that the platinum in new implants is likely not ionized and therefore would not represent a significant risk to women.

Cancer screening

The presence of radio-opaque breast implants may interfere with the sensitivity of screening mammography. Specialized radiographic techniques where the implant is manually displaced (Eklund views) may improve this somewhat, but approximately 1/3 of the breast is still not adequately visualized with a resultant increase in false-negative mammograms. A number of studies looking at breast cancers in women with implants have found no significant difference in stage of disease at time of diagnosis, and prognosis appears to be similar in both groups with augmented patients not a higher risk for subsequent cancer recurrence or death. Conversely, the use of implants for reconstruction after mastectomy for breast cancer also appears not to have a negative effect on cancer-related mortality.

An observation that patients with implants are more often diagnosed with palpable tumors (but not larger ones) suggest that tumors of equal size may be more easily palpated in augmented patients, and this may compensate somewhat for the potential impairment of mammography. This palpability is due to thinning of the breast by compression, innately smaller breasts a priori, and that the implant serves as a base against which the mass may be differentiated.

The presence of a breast implant does not influence the ability for breast conservation (lumpectomy) surgery for women who subsequently develop breast cancer, and does not interfere with delivery of external beam radiation (XRT) treatments that may be required. Fibrosis of breast tissue after XRT is common and an increase in capsular contracture rates would be expected.

Repair or revision surgery

Regardless of the type of implant, it is likely that women with implants will need to have one or more additional surgeries (re-operations) over the course of their lives. Breast implants do not last forever. According to studies conducted by implant companies for the U.S. FDA, they sometimes only last a few years. Most common indications for re-operations have included major or minor complications, capsular contracture treatment, and replacement of ruptured/deflated implants. Re-operation rates are predictably more frequent in breast reconstruction cases due to the dramatic changes in the soft-tissue envelope and anatomical breast borders after mastetcomy,

particularly when patients have received adjuvant XRT. Breast cancer patients also frequently undergo staged procedures for reconstruction of the nipple-areola complex (NAC) and symmetry procedures on the opposite breast.

It appears that re-operation rates in cosmetic cases can be improved by more carefully matching individual patients' soft-tissue characteristics to the type and size of implants used. Using appropriate device selection and proper technique, re-operation rates at up to seven years followup have been reported as low as 3 percent, as compared with the 20 percent re-operation rate at 3 years in the most recent Food and Drug Administration study.

Controversy

Since the early 1990s, nearly a dozen comprehensive systemic reviews have been commissioned by various governments' health ministries to examine the alleged links between silicone gel breast implants and systemic diseases. A clear consensus has emerged from these independent scientific reviews that there is no clear evidence of a causal link between the implantation of silicones and connective tissue disease.

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