Breast Implant Complications

What is a Breast Implant?

A breast implant is a medical device that is surgically placed under the breast tissue or the chest muscle to increase the size of the breasts (breast augmentation) or to rebuild breast tissue, usually after a mastectomy or other damage to the breast (breast reconstruction). 

Implant Screening

Breast implants can affect how breast screening is performed and interpreted. Mammograms can be more complicated for women with implants, as silicone or saline implants can obscure the mammography image of the breast tissue. 

• Specialised Mammograms: Women with breast implants should undergo mammograms with specialised techniques known as implant displacement views or Eklund views. This method pushes the implant back against the chest wall and pulls the breast tissue forward, allowing better imaging of the front part of the breasts.
• Ultrasound and MRI: Ultrasound can evaluate breast abnormalities and is effective in showing the area around the implants. MRI is also used to assess implants, especially silicone implants, and check for leaks or ruptures without exposing the patient to radiation.
• Self-examination and clinical examinations: Regular self-exams and clinical breast exams are important for women with implants, just as they are for all women. However, palpating (feeling) the breasts can be different due to the presence of the implants.

Breast Implant Complications

Breast implants are not intended to be lifetime devices; their estimated lifespan is 10 to 15 years. The risk of adverse events accumulates as soon as the implants are inserted. 

Although many women with breast implants will not experience any issues, there are some common and some less common complications that can occur. In 2019, the three most common complications of revision surgery were capsular contracture (37%), implant rupture (23%) and implant malposition (19%). 

Women with breast implants are recommended to have annual reviews with their surgeon or GP to assess for complications for the duration of the breast implant. 

Capsular Contracture 

Capsular contracture occurs when scar tissue that normally forms around the implant tightens and squeezes it, resulting in progressive hardening, distortion, and deformity of the breast. Severe capsular contracture can cause secondary implant rupture. 

Capsular contracture is graded clinically using the Baker classification. 

Breast Implant Rupture

All breast implants have an outer shell that can potentially develop a tear or hole, i.e. a rupture. The risk of implant rupture increases as the implant ages, and 50% of implants will show signs of loss of integrity ten years after surgery.

Implant rupture are classified into intracapsular and extracapsular rupture. 

• Intracapsular rupture means the implant has ruptured inside the tissue capsule the body has formed around it. It is usually asymptomatic, meaning the breast and implant look and feel normal. Intracapsular rupture is usually diagnosed incidentally on an ultrasound performed for other reasons. 
• Extracapsular rupture means the silicone has broken through the tissue capsule the body has formed around the implant, and silicone can spread into the breast tissue or surrounding muscle. Extracapsular rupture can also be asymptomatic (known as silent rupture) but may result in breast pain, lumps in the breast or armpit, or a change in the size and shape of the breast.

An intracapsular rupture will eventually progress into an extracapsular rupture, but the rate of progression is unpredictable.

Implant rupture can be detected on ultrasound and confirmed by MRI. 

Ruptured implants can interfere with breast screening. Silicone deposits in the breast tissue may mask an underlying breast cancer. Mammograms may worsen the implant rupture due to pressure applied to the implant.

Generally, it is recommended that ruptured implants be removed.

Implant rupture is a risk with both saline and silicone breast implants:

• Saline Implant Rupture: When a saline implant ruptures, the implant will typically deflate, causing a noticeable change in the size and shape of the breast. The body will absorb the saline solution without posing serious health risks, but surgical implant replacement will be necessary.
• Silicone Implant Rupture: A rupture in a silicone implant might not be immediately noticeable (silent rupture). Silicone may remain within the implant shell or escape into the breast implant pocket. For those with silicone implants, an MRI scan is recommended to detect a rupture. Removal of the ruptured implant and any leaked silicone is usually recommended.

Implant Malposition 

Implant malposition is a complication that occurs when a breast implant shifts from its original placement, leading to aesthetic or physical discomfort. It can happen due to several factors, either soon after the surgery or over some time. Here are some of the common types of implant malposition:

• Bottoming Out occurs when the implant moves downward below the natural fold of the breast (inframammary fold). This makes the nipple appear too high on the breast and the lower part of the breast overly full.
• Lateral Displacement: The implants move towards the armpit, which is especially noticeable when lying down. This can make the cleavage appear wider and the outer breast disproportionately full.
• Symmastia (Uniboob): This happens when implants move too close to each other, crossing over the breastbone and creating the appearance of a single large breast. This is often due to over-dissection of the tissue during surgery.
• High Riding: This occurs when implants are positioned too high on the chest, either due to not settling into place after surgery or due to surgical error. The nipples may appear to point downwards.
• Double Bubble: When the implant sits below the natural fold of the breast, creating a visible line across the bottom of the breast that looks like a “double bubble.”

Breast Implant Cancer (BIA-ALCL)

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of non-Hodgkin's lymphoma that can develop around breast implants. BIA-ALCL is most frequently associated with breast implants that have textured surfaces. This immune system cancer is not breast cancer, but it can appear in the fluid surrounding the implant or in the fibrous capsule.

The risk of BIA-ALCL is estimated to be between 1 in 1000 and 1 in 10000, meaning one woman will be diagnosed with BIA-ALCL for every 1000 to 10000 women with breast implants.

All Australian cases have occurred in women with textured implants (and no cases in women with smooth implants as of January 2020). The risk of BIA-ALCL is significantly higher for "macro" textured (e.g. Silimed Polyurethane, Allergan Biocell) compared to "micro" textured (e.g. Mentor Siltex) implants. BIA-ALCL occurs with both saline and silicone implants. There is no difference in risk in women who have implants for breast augmentation or reconstruction. 

The main symptoms of BIA-ALCL are persistent breast swelling or pain. It can also present as a lump in the breast or armpit. Most cases occur between 3 and 14 years after surgery.

The first line of investigation is a breast ultrasound to assess for the presence of fluid. If fluid is present, a sample will be taken to look for cancerous cells. Fluid collections (seroma) are common after breast implants, and most are not BIA-ALCL. Mammograms are not helpful for the diagnosis.

Treatment for BIA-ALCL often involves the removal of the implant and the capsule surrounding it, and in some cases, chemotherapy and radiation may be required.

It is currently not recommended that breast implants be removed in women without any symptoms. This is because:

• BIA-ALCL is considered relatively rare
• BIA-ALCL has a high rate of cure once diagnosed
• Any surgery and anaesthetic have risks 

The Breast Implant Hub by the Therapeutics Good Administration has information to support women with any concerns about their implants.