What should I do if the answer to any of these questions differs from what my doctor has told me?

These answers are the opinions of one surgeon. You need to follow the instructions of your own plastic surgeon. If conflicts exist, you may choose to discuss them with your doctor. These questions are intended to give general knowledge, but they are not a substitute for a visit with a plastic surgeon.

Saline Implants

What’s the one most important thing for me to know about saline breast implants?

After undergoing a procedure intended to improve the appearance of their breasts, some women continue to think about breast issues through the narrow point of view of aesthetics. But we must not forget that with or without implants, breast cancer still strikes about one in eight women. While appearance is important, never lose focus of the fact that the only issue of your breasts that truly matters is screening them for breast cancer.

How do I know if my saline implant is broken?

When a saline implant gets even a small hole, the saline leaks out, gets absorbed by the body, and the breast gets smaller. It is usually very obvious, deflating over several days or a week. As this happens, patients will see some rippling and note waviness in the now partially filled implant. If you have saline implants and one breast suddenly gets smaller than the other, the only thing it can be is a deflating implant.

What can I do to stop the sloshing feeling in my breasts?

Saline implants are obviously filled with water, and therefore it is not unexpected that some patients will be aware of a sloshing sensation within their implants. This seems to occur more in implants that were relatively less filled and in patients who developed thinner scar tissue around them. There is nothing abnormal or specifically problematic about the sloshing. If it bothers you enough to do surgery, then the implants can be replaced with silicone implants. It is also possible to add more fluid to the saline implants in an effort to make them fuller and less prone to sloshing.

Would an MRI, mammogram, or ultrasound help to diagnose a broken saline implant?

When a saline implant breaks, it always gets smaller. The diagnosis is obvious, and is made clinically. There is no need for any X-rays or special studies. If a breast with a saline implant suddenly gets smaller, then it is broken. If the breast size is unchanged, then it is not broken. If you have a leaking implant, your doctor may order you to get a mammogram, but the mammogram would be ordered for the purpose of evaluating your breast tissue for breast cancer, not for obtaining any information about the condition of the breast implant.

Is there any way to tell that a saline implant is about to break?

Unfortunately, there is no way to know if the shell is weak and that a breakage is imminent. Breakages happen in the first year; and there are many over twenty years old that have not broken. Leakage would be presumed to increase over time, but leakages are sporadic and unpredictable. Even if one side breaks it does not mean that the other side is about to break soon.

Is it an emergency to deal with a deflated saline implant?

It is definitely not an emergency. The implant was filled with IV fluid, so the implant contents are safe and will be absorbed by your body. It is something that you do not need to deal with until it is convenient for you to do so. However, there are two reasons to deal with it sooner rather than later. The first reason is obvious: it is hard to live with one breast augmented and the other not. Sometimes the deflated implant shell can be felt or seen and it can be an odd feeling. The second reason is that it seems that the capsule – the scar tissue surrounding the implant- tends to tighten up in the weeks after an implant deflates, requiring making cuts in it to expand it or even removing it entirely during the revision surgery. The sooner the operation is done, the greater is the likelihood that a simple swap of the implants is all that will be necessary.

Is there anything to I can do so I am not lopsided while waiting to schedule surgery?

After a patient has a leakage on one side, there is often a significant asymmetry that will be obvious both dressed and naked. Patients can use structured bras, "falsies," or those "chicken cutlet" bra inserts to even things out. But none of these is ideal. An excellent solution is to deflate the intact implant and withdraw the saline from it. This is done in an examining room with a small needle and is almost entirely painless.

What is the treatment for a deflated saline implant?

There are two main decisions: do you only want surgery on just the deflated breast or on both breasts? Particularly after having a saline deflation, most patients I see today want to have both implants switched to silicone. If not for the resistance to a sudden deflation, they want silicone because it looks better and feels softer. If someone has old saline implants, even if they want to stay with saline, they may choose to operate on both sides, figuring that if one implant just leaked, the other might leak soon. In contrast, patients who have a leak a year or two after their original surgery may be interested in just replacing the one implant. It is a time to look at whether there are other issues that can be improved in either or both breasts: is there hardening? Droopiness? Dissatisfaction with size? Once a surgery is necessary, it is worth taking inventory of all the outstanding issues and considering which if any of them should be addressed.

Why do saline implants deflate?

It is an obvious point, but we need to remind ourselves that unlike our own bones and other tissues, the implant is an inanimate object and it therefore can’t heal or repair itself. And it is nearly 100 degrees in the body, and the breasts are obviously subject to physical stresses, from motion as simple as breathing to vigorous physical activity. Implants can leak because of manufacturing defects – though all saline breast implants are individually inspected before leaving the factory. Damage can occur to them during the implantation, or even later during a breast biopsy. Saline shells are also prone to some degree of collapse. That is why many surgeons "overfill" them, but even still, some folding or wrinkling frequently occurs, and we suspect that these longstanding folds become weak spots, much the same as a newspaper left creased in a drawer for years will become brittle along the fold. Sometimes implants break after excessive force, such as from a seatbelt in a severe car accident, and ruptures have occasionally been reported to occur shortly after mammography. Whether coincidental or not, I would suspect that any implant made to rupture by a mammogram was already getting close to breaking on its own.

How long do saline implants last?

An important point is that most people undergo a second operation before the implant itself breaks or leaks; they have surgery because they droop, they want a different size, they get hard, etc. None of those involve a problem with the implant per se. That said, indeed saline implants do leak, and unfortunately we do not know the exact rates of deflation by product type, as breast manufacturers do not share that specific data, even with surgeons. There are smooth and textured round implants made by two companies in the United States, and there are probably differences in the rates of deflation between those four implants. There also were textured "anatomic" shaped implants that were also very popular in the United States in the past. The official data from each manufacturer as reported on the FDA’s website is the following: for Mentor implants, the deflation rate is 1% at 1 year, 3% at 3yrs, 10% at 5 years, and 16% at 10 years. The data for McGhan (later Inamed and now Allergan Natrelle) are 4% at 1 year, 5% at 3 years, 7% at 7 years, and 10% at 10years. That data mixes both smooth and textured implants. Other reports by individual surgeons have shown lower deflation rates, but these are the official numbers on the FDA website. Another way to look at it is that a patient has about a 1% chance per year of having their saline implant leak. Undoubtedly, there remain significant factors that are not understood such as surgical technique, body type, and physical activities that may impact these rates. The bottom line is that no one can tell you when your saline implant might leak.

Are some saline implants notorious for leaking more than other implants?

The lowest published rates were with the McGhan Style 468 textured anatomic saline implant, probably due to the fact that the manufacturer’s recommended fill volumes for that implant were optimized for preventing the type of shell folding that can lead to localized weakness and leakage. The highest rates were for a prefilled French saline implant called PIP used in this country from around 1995-2000 or so. But they leaked so often that I think most of them have already been replaced. A textured round saline implant made by Mentor also had a high leakage rate. But other than that PIP implant, none leak so frequently that surgeons would typically recommend prophylactic replacement of any saline implant in an effort to avoid leakage.

Is there anything harmful or unhealthy about allowing a saline implant to leak?

A saline implant is filled with IV fluid, which obviously is designed to flow directly into your veins. There is therefore nothing unsafe about a leaking saline implant. The issue is simply the nuisance of suddenly developing an asymmetry and needing to undergo an unplanned surgery that may need to be done at a time that is not convenient for you.

Will all saline implants eventually leak?

There are many women who have had saline implants for decades that have not yet leaked. It stands to reason that all man made bags filled with saline will eventually leak, since saline can escape from even a microscopic hole. Some women with saline implants will live long enough to experience a leak and others will not. Some of the women whose implants never leak may still have a revision operation because of issues such as rippling, size change, droopiness, etc.

Do I need to change my breast implants after ten years?

No! I don’t know who started that rumor. There is nothing that happens or needs to happen at ten years. You replace saline implants when there is a rupture or when you and your surgeon think that your breasts can be improved. I think this rumor began because it sounds like a nice, round number. But it has no bearing on reality whatsoever. None. Forget you ever heard about it.

What happens in dealing with saline implants when I become an old lady?

The first breast augmentation patient was implanted in 1962 and died of natural causes in 2010. The first large group of women to get breast augmentation in the world was therefore probably born in the 1930s, so there are many women already in their 70’s and 80’s with breast implants. Many of the women who received breast implants in the 1960s, 1970s, and even 1980s have probably had revisions for one reason or another by now, but not all of them. I know this because I see women all the time with these very old implants who have no problems whatsoever. But I also see some of these women whose implants are firm or deformed but simply don’t care enough about them to undergo surgery. But remember that most but not all of these older women have silicone implants. Some saline implants were used in the 1970s and 1980s, but it is my impression (no one knows for sure) that these implants must have mostly long since deflated because it has been many years since I’ve seen any patient with saline implants from those years. Saline became widespread in the United States after the silicone moratorium of 1992, and were the only choice in this country for first time augmentation until silicone was reapproved in 2006. I see patients all the time with these implants whose implants are perfectly fine. As women grow older, little issues with their implants often bother them less than when they were younger, such as a bit of rippling, firmness, droopiness, etc. Some will ignore these issues. Some will just remove the implants. Others may remove them and get a lift. Of course, there are some older women who are healthy and undergo a complete "tune up," replacing their old saline implants with silicone implants and doing whatever else is necessary to optimize their breasts. If an elderly or weak patient were to develop a severe breast implant problem that required surgery of some sort, such as a deflation or an infection, even if she were not a medically good surgical risk, in most cases something relatively minor could be done to solve the immediate problem. For instance, with a small incision an infected, leaking, or very hardened implant could be removed with a minimum of morbidity, but other issues such as removing scar tissue or lifting the breast may be ignored. The outcome may not be perfect, but may be acceptable to someone in such a debilitated overall medical condition.

Is there any saline implant age that you think no matter what I should get them replaced?

Unless there is something that is bothering you about your breasts now, or unless you don’t want to have to stop everything and deal with a deflated saline implant on an unplanned basis, I do not believe that there is ever a time that a saline implant must be replaced. Still, even if you think everything is okay, at some point you should see a plastic surgeon. I have revised old breast implants on many patients who had gotten so used to the problems of their implants, that they didn’t realize how much better they could be. So you owe it to yourself to look into whether you can be improved, even if you do not actually recognize that there is a problem. It would of course still be up to you to decide if any improvements in look or feel would be worth the expense and risk of surgery.

Should I change my saline implants to silicone implants?

If you love your saline implants, then leave them alone. But if you wish that your breasts looked or felt better, are concerned that your breasts seem to be drooping more and more over time, are concerned that your implants are getting older and don’t want the nuisance of dealing with a deflated implant occurring as a surprise, then it is reasonable to discuss changing to silicone. It is also an opportunity to deal with any capsular contracture, asymmetries, implant malpositions, droopiness, or dissatisfaction with the current size. For instance, at 3 years after surgery, rippling occurs in <1% of silicone implants and in 20% of saline implants. But remember that surgery is surgery; this isn’t changing your hair color. All surgery has risk. Perhaps your saline implants are soft but you just want to be a bit softer with silicone. What if you change your implants and the new implants get infected or you develop a capsular contracture? Complications can occur, so you and your surgeon need to discuss the costs and risks of replacement surgery to determine if it is really prudent to undergo surgery to change your otherwise intact and satisfactory implants.

What are the advantages of silicone implants?

Silicone implants tend to be less spherical, softer, and more natural looking and feeling than saline filled breast implants. In order to keep a saline implant from collapsing and folding, surgeons need to add more saline relative to the size of its shell than they would with silicone with the same size shell. Not only does saline not squish like gel, but the greater amount of filler inside of the shell makes the implant more tense. This also makes the implant look more roundish and less natural. Despite the practice of overfilling, saline implants still tend to ripple more than silicone implants do, but even silicone implants can ripple in patients with thin tissue and stretched out breast skin. Size for size, silicone implants are lighter (silicone floats), which is one reason why some surgeons believe that they cause less stretch of the skin of the lower breast (leading to bottoming out) than saline implants. Saline implants have what has been termed "the water hammer" effect, which refers to a sloshing effect of the saline within the shell, which some surgeons believe contributes to a greater degree of lower breast skin stretch.

If silicone is better, then why do I have saline?

The FDA imposed a moratorium on silicone breast implants in 1992 and lifted the ban in 2006. This was not done because they thought silicone was dangerous; it was because there was not evidence they deemed adequate demonstrating that they were safe. So just about all of the 200,000-400,000 women per year who received breast implants yearly in that period received saline implants. (The only way to have received silicone implants at that time is if a woman was having a revision of a prior breast implant procedure, had cancer, had a lift, or had some other type of a "reconstructive" situation.) Since they were reapproved in 2006, increasing numbers of women are now getting silicone implants, and today most women are getting silicone. But there are still reasons to use saline: some women and surgeons are still wary of silicone; saline is less costly; only saline can be used through the belly button incision; saline incisions can be shorter than silicone because saline implants are placed deflated and filled only after they are inside the patient.

Do saline implants cause breasts to droop with time?

Gravity causes breasts to droop, whether they are all natural or augmented. The more they weigh, the weaker the skin, and the less they are supported by a bra, the more they will drop. Saline implants do weigh more than silicone implants of the same size. And saline implants have what some surgeons call a "water-hammer" effect, meaning that the contents slosh up and then push down on the skin repeatedly, day by day, contributing to stretching of the skin of the lower part of the breasts. Many surgeons have a strong clinical impression that there is greater droopiness with saline implants than with silicone breast implants.

Is it normal to feel rippling?

About 20% of saline patients feel some rippling when polled three years after augmentation. The thicker their tissue, the less likely they are to notice it. A saline implant that was "overfilled" will tend to ripple less than one that was "under filled," though the more an implant is overfilled, the rounder and firmer it gets. And if overfilled enough, then the implant can start to get "stippling" or "scalloping" around its perimeter. In general, textured saline implants seem to ripple more than smooth saline implants, though the textured anatomic saline implant made by McGhan (the Style 468) seemed to have been less prone to rippling than other implants when filled to the manufacturer’s suggested fill volume. Some rippling to the lower outside of the breast, particularly when bending over, is very common with any kind of breast implant. Rippling is often improved, though not necessarily eliminated by switching to silicone implants. If your implants are in front of the muscle, then moving implants to behind the muscle will increase the thickness of coverage over them and will therefore often reduce the amount of rippling.

Is it normal to feel the fill valve?

In some very thin patients, it is possible to feel the valve on the surface of the implant where the implant was filled. This is not abnormal per se; it is just a consequence of being very thin, and it poses no problem. If you are very bothered by this, changing to silicone can be helpful, in that silicone implants are filled and sealed at the factory and do not have a valve. Or if your implant is in front of the muscle, it can be moved behind the muscle so that there is more coverage over the implant.

Should I have surgery now to prevent a deflation?

It is hard to justify having surgery to prevent a problem that doesn’t yet exist and is easy enough to manage when it does happen. But I have seen patients who have made this choice. Some have a busy travel or social schedule; I have seen others going through a divorce or breaking up with a boyfriend who want to not worry about the future financial obligation of replacing their saline implants. But usually there is something more tangible that they use to justify the operation, such as wanting a different size, having rippling, or being dissatisfied with the feel. If everything with your breasts is now to your liking, I do not personally condone surgery to change implants just to prevent a possible future deflation.

How do I know when I’ll need another operation?

The only time a saline patient really needs another operation is if it deflates. If you are perfectly happy with everything, you do not need to do anything. But if you have an issue such as firmness, rippling, asymmetry, or even anxiety about an unplanned deflation, then you need to discuss with your surgeon whether the likely benefits of a revision surgery offset its costs and risks. This is an extremely complicated subject, based upon subjective notions of what will be improved and by how much it will be improved; a calculation of the risks; the costs; the anxiety of the patient; and obviously the eagerness of the surgeon to reoperate on that patient.

How do I find out about the warranty on my saline breast implants?

If you cannot find the information card that you should have been given after your surgery, call your plastic surgeon's office and they should be able to obtain a copy for you. There have been only two domestic manufacturers of breast implants, and you can call them for the specifics of your warranty. Mentor can be reached in Santa Barbara at 805 879 6000, and Allergan can be reached in Orange County 800 624 4261. Note, Allergan purchased Inamed which purchased McGhan, so if you have Inamed or McGhan implants you should call Allergan.

What problems with saline implants do the manufacturers warranty against?

Deflation. They do not cover rippling, malposition, capsular contracture, or a desire to change the size.

Does that mean that I would be getting surgery for free if I have a leakage?

Not at all. The implant cost is usually just a small part of the total cost of a revision, as the surgeon fees, anesthesia fees, and operating room fees are much more than the implants. Some of the warranties cover a small part of those fees for a finite period of time after the initial surgery. Some plastic surgeons have a minimal charge for their own patients who experience a leakage, but others charge a full price. Given the wide variety of surgeon and warranty policies, it is impossible to give an accurate answer to this question.

Can’t I just have the surgeon "pop" the implant after it is removed and say that it was leaking?

You could, but you and the surgeon would be committing fraud. And the manufacturers have a very fastidious program to examine removed implants under the microscope, and they can determine whether the leakage was real or staged.

What does the breast implant warranty cover and for how much?

While the two manufacturers have been competitive, the warranties have had subtle differences, have changed over time, and there have been optional warranty upgrades that some patients have purchased or their doctors automatically purchased for them. In general, they cover the implant for lifetime and some amount towards the operating room and/or the surgeon. For instance, Mentor saline implants placed prior to May 1 2005 have a lifetime product replacement policy and $1200 in financial assistance for the operating room for five years, which obviously ended in May of 2010. But if you had the enhanced warranty, the $1200 in financial assistance for operating room and anesthesia would last ten years, and there is also up to $1000 towards the surgeon fee. For surgeries after May 1, 2005, they offer lifetime product replacement, $1200 in financial assistance for operating room for ten years, and free opposite implant replacement. If you had the enhanced warranty after May 1, 2005 you get up to $2400 of financial assistance for the operating room.

Will the warranty cover the non-deflated breast implant?

In most cases the manufacturer will cover the non-deflated breast implant. But you need to call the manufacturer and get the details on your warranty.

Can I use the warranty to change to silicone implants?

In most cases you can change to a silicone implant, but the manufacturer would usually charge you the difference in list price between a saline implant and a silicone implant, which is usually about $300.

Will the warranty let me change to a different size implant?

You are allowed to order whatever replacement size you and your surgeon select; you are not limited to your original implant size.

Lifestyle Issues for all Implant Patients

What should I do if the answer to any of these questions differs from what my doctor has told me?

These answers are the opinions of one surgeon. You need to follow the instructions of your own plastic surgeon. If conflicts exist, you may choose to discuss them with your doctor. These questions are intended to give general knowledge, but they are not a substitute for a visit with a plastic surgeon.

Do I need antibiotics when I have dental work?

There has been an observation that hardening of the breast – capsular contracture – sometimes occurs after dental work or even just a dental cleaning. The chances of this are small, but the significance of having a capsular contracture is so great that plastic surgeons are increasingly suggesting that patients get antibiotics at the time of teeth cleanings or dental work. When you have dental work, bacteria gets into the blood, and it is believed that this bacteria can "seed" your breast implants.

Which antibiotics should I use?

Your dentist will know which to give to you. Most dentists understand the importance of giving antibiotics to patients with breast implants, and the antibiotic regimen is the same as given to patients with artificial joints or heart valves.

From whom should I get the antibiotics?

Since the dentist or their hygienist will be the one doing the procedure, the dentist is usually the person who prescribes the antibiotics.

Are there limitations on physical activities after breast augmentation surgery?

Each patient should follow the specific advice of their own surgeon. In general, a woman should be able to do any physical activity after the surgery that she was able to do before it. Both saline and silicone implants are strong. No physical force you could put on your body without causing great discomfort or even damage to yourself would harm your implants.

Should I always sleep in a bra?

Different surgeons have different opinions. If you have large implants and pendulous breasts, some believe that sleeping in a bra may reduce the stretch effect of the implant on your skin. But if you have relatively small or perky breasts, a bra would probably be of little benefit while sleeping. Unless you perceive that your breasts slide much relative to your chest wall when you sleep, I would think that a bra would not be necessary to wear while sleeping.

Should I always wear a bra during the day?

Breasts sag because of gravity. The more you support them, the less effect we believe the weight of the implant will have on the tissue of your breasts. There are some women with large implants and pendulous breasts; it seems that these women have a greater tendency to droop over time, and perhaps they would benefit the most from a bra. But big or small, there is little doubt that a bra reduces the pressure of the implant on your skin. So the more you wear a bra, the better your breasts should age over time. That doesn’t mean that from time to time and with certain outfits you can’t go braless; just understand that in general, gravity wants to stretch your breast skin and make them sag, and the more you support them with a bra the less this should happen.

Do I need to wear a special bra?

You should wear whatever bra is comfortable. Some surgeons have marketed special bras for patients who have had implants. To me, needing such a bra would be an indication that by definition, the surgery was not done naturally the first time. I believe the point of a breast augmentation is to make the breasts fuller and larger, but if it is done to the point that a woman does not fit into normal clothes, then the surgery was not done in a balanced and proportionate manner. But the bottom line is that you should just find a bra that is comfortable, supportive, and of course, pretty as well.

Should I wear a bra when playing sports?

When you do anything that would make your breasts bounce, then it is important to support them. Depending upon the size and the mobility of your breasts, it may even be a good idea to wear two sport bras when you jog or do aerobics.

Do I need to keep massaging my breasts?

Some surgeons really believe massage helps. Other surgeons tell patients to do it in order to "give them something to do." If your surgeon told you to do it, then you should. But I do not think it is important and I do not tell my patients to do it. And remember that if you have either a teardrop implant or a textured surface implant, that those implants are specifically not supposed to be massaged.

Is it safe for my baby to breastfeed if I have breast implants?

Most women with breast implants are able to nurse normally, and it is safe for your baby to drink milk from augmented breasts. This has been well studied and there is nothing to worry about.

Will breast feeding damage my implants?

Breast feeding itself will not damage breast implants, but there can be change to your surrounding tissues. Most women that breast feed experience no significant changes to their implants. Some will have skin that stretches, occasionally enough to need a lift. Others will develop some scar tissue around their implants that will require surgery to have it removed. One cannot know ahead of time whether or not breastfeeding will lead to these sorts of changes. If a woman feels that breastfeeding is good for her baby she should not let issues with her breast implants deter her from doing so.

Will I have to redo my breast surgery if I breastfeed?

There is no way to know ahead of time. Most of the time, patients breast feed and though their skin is looser, their tissue thinner, and their areolas darker, there is not much of a change. But sometimes a lot of sag occurs, requiring a lift. This happens to many women without implants, but the additional weight of the implant might contribute to more stretch than they might have had were they not to have had the implant, though it is impossible to ever know. The second thing that can happen is that the woman gets a little bit of a capsular contracture while breast feeding, leaving the implant a little firmer and more round. Combined with the slightly stretched skin envelope, this can make the breast feel a little firm and empty. In the worst case, this has been described as a "rock in a sock."

Can my implants swell on an airplane that loses pressure?

No. And you can climb Mt Everest with both saline and silicone implants. The changes in pressure are not enough to make a noticeable difference with your implants. There are many stories about airplanes losing pressure and breast implants expanding or exploding, and they are totally false. Nor would they compress if you went to very low altitude such as the Death Valley or the Dead Sea.

Can I SCUBA dive with breast implants?

Yes. You can safely scuba dive with both saline and silicone breast implants. The water pressure has no effect, and there is no issue with absorption of gases within the implant. Silicone is positively buoyant, but the amount of volume is probably too small to affect the amount of weight you will need on your weight belt. But your old BC and wetsuit may feel a bit tight on you after the surgery!

Can I skydive with breast implants?

Yes. There is no problem from the pressure when you leave the aircraft, and the implants are strong enough to not be damaged by the parachute harness.

Are there restrictions on sexual activity after breast augmentation?

Any force strong enough to damage your implants would cause you severe pain or even damage to your tissues first. So from a practical point of view, there is no restriction on sexual activities at all after breast augmentation surgery.

Can my breast implants rupture in a car accident?

I have seen patients whose implants ruptured after a severe car accident. Sometimes there is a clear history that a patient’s breast were normal the day of the accident, and then after shoulder belt trauma, one of their saline implants starts to deflate in the days after the accident or their silicone implant changes in its feel or shape. In other cases the patient notices no difference, but being involved in a lawsuit after the accident, they get an MRI that demonstrates a silicone rupture. Unless they happened to have had an MRI just before the accident, then we usually do not know for sure whether the rupture had been longstanding or occurred from the accident itself.

Can I do heavy weightlifting with breast implants?

Weightlifting will not damage breast implants. If your implants are behind the muscle and you build your pectoralis muscle up a lot, there is some tendency for the implants to migrate a bit down and to the outside, widening the gap between your breasts. This is not a significant issue for women that are exercising for general health, fitness, and appearance, but seems to be an issue for women who are extreme weightlifters. Part of the problem in these women is anatomical in the sense that an implant that is behind the muscle can never be more towards the center than the point at which the muscle inserts on the breast bone. As these highly fit women became just skin, muscle, and bone, they lose all of their fat which would have covered over the implant and also contributed to their cleavage. Their problems can be very tricky to deal with, but the ultimate issue for them is recognizing the limitations imposed by their extreme thinness.

How often should I follow-up with my plastic surgeon after breast augmentation?

When silicone implants were reapproved in 2006, many patients were enrolled in follow-up studies. If you were part of one of these, you should follow up according to the schedule that you were given. If not for your own benefit, it is helpful that you contribute to the creation of a large databank of information about breast implants. I invite all my breast augmentation patients to come back annually for a physical examination. In addition to your breast exam by your gynecologist, it is a good idea to also see your plastic surgeon for an annual visit. But there is no problem with a breast implant that your surgeon is likely to detect: you are the one who ultimately decides if you have a problem with your breast implant, e.g. that the rippling is so bad that you want to do something about it. If you are otherwise happy with your implants, it is not for the surgeon to point out the rippling to you and convince you need to replace. The real reason you should follow up with your plastic surgeon is to get yet another experienced person to reexamine your breasts for a lump that could be breast cancer. Some women get so fixated on minor cosmetic issue with their implants that they lose sight of the issue of breast cancer.

How often should I have a doctor examine my breasts?

Unless you are in a high-risk group, you should examine your breasts monthly yourself, and have them examined by your gynecologist or internist once a year. In addition, it is a good idea to also get an exam from your plastic surgeon.

How will weight fluctuations change my breasts?

When you gain weight, your breasts skin will stretch. At some point, that effect will reduce some of the elasticity of your skin, and it will not snap back. It is hard to know how much of a change it takes to change your breasts, because it is different for each woman.

What can I do for stretch marks?

If your stretch marks are red or pink, then they can be improved with a laser. If they are dark, they might be improved with a laser or with skin bleaching creams. But if they are just fine lines that are faded relative to the rest of your breast skin, there is generally nothing to do to improve them.

What can I do to improve the scars?

It depends upon why you notice the scar and how long it has been since surgery. Scars usually look great in the first month or so, but by the third to sixth month, they thicken and redden a bit. Between six months and a year, there is a rapid fading and flattening that occurs. While we usually tell patients that scars are mature at a year, scars look much better at two years than one year, and they are even better still at three years. Beyond that there is little change. In order to decide whether and what to do for a scar, it depends upon what stage you are in healing, how atypical you are relative to others in your healing, and the tendency of patients in your ethnic group to make good v. bad scars. Some surgeons recommend a scar regimen for all of their breast augmentation patients after surgery, though there is no strong evidence to support that this really makes a difference. Other surgeons wait and treat only those patients whose scars get redder or thicker than normal, and then give them treatment at that point. I offer all patients silicone ointment to buy two weeks after surgery, but I don’t push it given how little we know of its necessity in breast surgery. If they get redder or thicker than usual during the healing period and are not using the silicone ointment, I suggest they use it. If we cannot control the scar with the ointment, then I refer them to a dermatologist for laser treatment if the scar is red. If it is very thick, then we may inject it with either a steroid or another medicine called 5FU. Oftentimes longstanding scars look good themselves, but have a halo of pink or brown around the scar itself. These problems are often improved with a laser.

What information about my surgery should I keep for my personal records?

At a minimum, you should hold on to the implant warranty card with the type, size, and serial number of your implant. Even if everything is okay, you should still call your plastic surgeon and get a copy of that card. In addition, it is always a good idea to have a copy of the "operative report." This is a dictation made by a surgeon at the time of surgery. Should you ever need a surgery even in the distant future, it can help your next surgeon understand exactly what was done to you.

Can an insurance company deny me health insurance coverage because I have breast implants?

Insurance companies are able to do just about whatever they want. There are sporadic cases reported of women being denied health insurance because of their implants. This does not make sense, because nearly all insurance policies exclude the coverage for follow-up surgery for breast implants placed for cosmetic purposes. Since breast implants do not otherwise affect a woman’s health, there is no plausible basis to deny coverage, yet these companies sometimes do. But most of the denials have been for "individual plans," which is for people seeking coverage on their own and not through a place of work. Insurers are very finicky about coverage for individual plans.

Cancer Screening for Breast Implant Patients

What should I do if the answer to any of these questions differs from what my doctor has told me?

These answers are the opinions of one surgeon. You need to follow the instructions of your own plastic surgeon, radiologist, or breast cancer surgeon. If conflicts exist, discuss them with your doctors. These questions are intended to give general knowledge and prepare you for a more fruitful visit with your own doctors.

Why is breast cancer screening such an important issue?

Cancer is the only thing that can go wrong with your breasts that really matters. It is common and it is better to catch it early. Studies show that women with breast implants have their cancers caught early, and that is probably because patients with breast implants are already motivated to think about their breasts and see doctors. But we must maintain vigilance.

Do breast implants impair mammography?

Mammograms cannot see through implants, so if there is implant caught in the mammogram plate, any breast tissue caught alongside it will not be visible. That is why mammographers get special views in which the breast tissue is pulled away from and off the breast implant. When implants are large, hard, or in front of the muscle, this maneuver can be difficult. For most women today, a good mammogram center can visualize most all of a woman’s breasts with breast implants. But if you hear the tech make disparaging comments about breast implants, then I would suggest you leave and go to another center that demonstrates their expertise in doing mammograms on women with breast implants.

What do I need to tell the mammogram center?

Tell the mammogram tech that you have breast implants. Ask them to be sure that they are confident they have imaged all of your breasts and tell them that you want extra views if they are not sure. If they cannot tell you that they had an excellent view of all of your breasts, ask about getting an ultrasound or an MRI to see the rest of the breast. Any good center will do this already, but you ultimately you are the one responsible for your own health and therefore you should not be afraid of demanding to know that your breasts have been thoroughly visualized by the mammogram. Also tell them to fax a copy of your mammogram to your plastic surgeon.

Can breast implants help mammograms?

Some mammographers say that breast implants can help them get better studies in women with very small breasts. Imagine a woman with very little breast tissue that is held tightly against her chest: you can imagine how it would be extremely difficult to get that tissue into a mammogram machine. But with an implant pushing that tissue away from the body, the study may possibly be easier to do.

What is done differently when performing a mammogram on someone with breast implants?

Women with breast implants get two sets of mammograms. The first set is the four standard views, with the breast tissue as well as the implant placed between the mammogram plates. The second set is composed of the same angles, but with the implants pushed back against the body and the breast tissue pulled forward onto the plates. These are called "displacement" views. There are therefore eight views in a complete set of mammograms on a woman with breast implants. A good tech can get beautiful views of a breast that has breast implants.

Will insurance pay for these four extra views?

Most insurance companies will pay for these extra views, but policies will vary. In any case, the additional cost of those views is insignificant relative to their benefit and a mammogram of a woman without displacement views would be considered incomplete.

What determines how effective the displacement views will be at visualizing the breast?

When the breast is soft and behind the muscle a near perfect mammogram is possible because it is easy to pull the breast tissue forward and away from the implants. But when the implant is firm for any reason, whether in front or behind the muscle, then it is very hard to pull the tissue forward and image the breast. Sometimes this problem is so severe that we suggest women to remove the scar tissue even if they don’t mind the feel of the hard breast simply so they can get better mammograms.

How does the radiologist know if the displacement views succeeded in visualizing the entire breast?

The radiologist looks at one of the displaced views to be sure that they can see some of the armpit and skin that is below the crease that is underneath the breast. If they are not sure that they have seen all of it, then they can do additional studies.

What does a radiologist do if they do not see everything on the displacement views?

They may choose to repeat the study, because it is technologist dependent. If that doesn’t work, they may recommend either an ultrasound or an MRI depending upon the expertise of the center and the technologies that are available. Since insurance will typically not pay for these additional studies in women who do not have a history of breast cancer or are not at high risk for developing breast cancer, the patient’s ability to pay may become an issue at some centers.

Is mammography affected by whether the implant is in front or behind the muscle?

Having the muscle between the implant and the breast tissue can make it easier to separate the breast tissue from the implant. But mammogram is still generally effective even if the implant is in front of the muscle, so long as it is soft and the breast tissue is mobile relative to the implant. The biggest advantage to being behind the muscle with mammogram probably has more to do with the fact that implants are less likely to get hard behind the muscle, and it is a hard implant that really creates the difficulty in getting a good mammogram.

Will breast implants affect the chances I will get a breast cancer?

Very large studies have been done in many countries looking at the development of breast cancer in women with breast implants. All of these studies have shown that in no case do women with breast implants develop any more cancers than women without implants. In fact, the largest and scientifically most valid of all of these studies actually showed a lower incidence of breast cancer in women with breast implants. The study showed an amazing 31% reduction of breast cancers in women with augmented breasts. There is disagreement as to whether this actually means that breast implants help prevent breast cancer or if there are other lifestyle issues that are relevant. It is an area of active research.

Do breast implants impair physical examination of breasts?

In studies of women with breast implants, more cancers are picked up by physical examination than in women without breast implants. So it seems that the implants make examining the breasts easier. That is probably because the implant is a relatively smooth surface, and by being behind the breast and pushing it forward, it provides a smooth surface upon which the breasts can be examined. These observations point to the fact that breast examination for cancer is extremely important for women with breast implants.

Can mammograms break my implants?

It doesn’t happen often, but I have seen patients who give a clear history of a change in the shape or feel of their silicone implant or a deflation of their saline implant after a mammogram. So too are there women without implants who have had bruising after a mammogram. Those machines can indeed be uncomfortable and even brutal, but the pressure in the plates is necessary to spread out and flatten the breast tissue to get a good image. But do not let this discourage you from getting them; the preponderance of evidence supports mammography as an important way to detect breast cancer, and that is too important to give up for the unlikely event of it breaking your implant. And beside, if your implant is in such a fragile state that an mammogram might break it, I would imagine that such an implant is already in a precarious state and might be destined to break before long anyway. Most radiology centers make women with implants sign a consent acknowledging that breaking of an implant is a possibility, but the chances are extremely remote.

How often do I need mammograms?

The American Cancer Society suggests getting a mammogram at age 35 and then every year starting at age 40. This is adjusted if a patient has a family history of breast cancer. Some studies have recently come out saying that this is more often than necessary, and that the financial benefits of so many mammograms may not be justified. Get up to date advice from your plastic surgeon and the best mammographer in your community.

How often should I do self-exam?

You should do breast self-exam every month about seven days after the beginning of your periods.

How should I do self exam?

Most patients like to do it standing in the shower, while others do it lying in bed. Some do it in both positions. Raise up the arm of the breast you are examining and put it behind your head. This will make the breast as flat as possible against your chest. Then examine your breast with the pads of your three middle fingers. You are just trying to give your fingers a subconscious lay-of-the-land. Don’t stress about it. The point is that if you do it month after month, year after year, God forbid something should change you’ll recognize it right away. So take your fingers and move them in a predictable pattern. It doesn’t matter what you do; just do it the same way every time. Some women move their fingers out from the center like spokes in a wheel; others start in the center and make circles radiating out from the center; some go back and forth from left to right like reading a book. All that matters is that you don’t just grope your breast or do it randomly. Also do not forget to feel your armpits. Also squeeze your nipple. Some discharge is normal. But if it is bloody, you should see your doctor as that is possibly a sign of a cancer, though most oftentimes it is not.

Is self-exam any different for women with breast implants?

Having breast implants does not change what you need to do on exam. If anything, it makes it a bit easier. That is because having a relatively smooth implant behind your breast tissue rather than the irregularities of you rib cage makes it easier to feel irregularities in your breast tissue. Remember, whether in front or behind your muscle your implants are behind and not within your breast tissue.

Is it normal to feel my breast implants when I do self exam?

Everyone can feel their breast implants at least some of the time. Can you feel your ribs or your muscles? Then you will feel your breast implants which are in front of them. It is unusual for a woman to have implants that are imperceptible, but this can happen in women with small implants, little scar tissue, and lots of her own tissue covering over them. In general, the larger your implants and the thinner you are, the more you will be able to notice your implants with time.

Can patients tell on self exam that a silicone breast implant has broken?

Just like you want to develop a subconscious memory in your fingertips of the general feel of your breast tissue, so too do you want to get a general feel of your implant. When an implant breaks, the most common change is that instead of your ability to move the implant around as a circumscribed entity, the implant feels more amorphous, without distinct borders. When you push on an intact implant you may feel the whole implant move as a solitary mass in one direction with distinct borders. When it is broken and you push on it, you may feel it give in to your push but you may not feel the whole implant move as a unit. In other situations, you may feel an irregularity

Why do I receive different recommendations about the frequency and need for mammograms, ultrasounds, and MRIs?

You will receive different answers because simply put, this issue is not thoroughly understood. The reason is that x-rays aren’t perfect: some are expensive, they are occasionally wrong, some subject the patient to radiation, they will lead to many surgical biopsies for benign things for every cancer they detect, and in the final analysis it is very difficult to quantify an actual survival benefit for lots of routine imaging in large populations of women. The ultimate answer is therefore as much philosophical as it scientific. Moreover, the high cost of screening large parts of the population becomes a public policy issue. Politicians, doctors, insurance companies and different patients have different approaches to these issues. If I have a bias in these questions, it is to encourage patients to be proactive in imaging their breasts for early cancers. But you need to find a group of doctors who will work with you and your philosophy.

What is your recommendation for screening?

I am a plastic surgeon, not an expert in breast cancer screening. However, I am frequently asked this question. Without taking into account differences in family history, breast characteristics, medical history, anxiety, and ability to pay (all very relevant issues,) I have been told by my breast cancer specialist and mammogram colleagues to suggest the following: "Every woman should get a screening mammogram at age 35. If her breasts are dense and reduce the sensitivity of the mammogram, an ultrasound should be added. Digital mammography has substantial advantages over traditional mammography for all women, but particularly for those with denser breasts. If everything is normal, she should get another digital mammogram at age 40 and annually thereafter, as well as an ultrasound if the breasts remain dense. A baseline MRI for cancer screening should probably be obtained at around age 40, but they are expensive and insurance will not pay for it. And realize that MRIs will possibly lead to extra biopsies of suspicious lesions that turn out to be benign. There is no simple answer about how often to repeat the MRI. Some say every three years; some say every year for those who can afford it. I suggest you discuss it with a radiologist or a trusted physician who has met with you, reviewed your risk factors, understands how diligent you want to be in your screening, and has seen your mammogram and baseline MRI. One nice thing about an MRI is that unlike mammogram and ultrasound, it is not technique dependent, and is therefore more reliable in situations in which the expertise of the mammogram and ultrasound techs is not known to you. If a patient has a family history of breast cancer, the mammograms and MRI screening should start earlier and be done more frequently, as determined by their situation. In general, intensive screening should probably commence when the patient is ten years younger than her relative was when she developed her cancer. If you have a breast implant and it is soft and you have more than just a thin layer of your own breast tissue over it, then mammograms with additional views can usually visualize the entire breast. Even if you choose not to get routine cancer screening MRI’s, you should speak to the radiologist about getting an ultrasound or MRI if there is ever any question about whether the mammogram adequately visualized all of your breast tissue. But since MRI’s "see around" implants, patients with implants need no longer be disadvantaged when screening their breasts for cancer.

Should I get MRI’s to screen for cancer?

With the FDA’s recommendation of biennial MRI’s to screen for silent rupture of silicone implants, it is easy to forget that the lifesaving role of MRI’s is in picking up breast cancers. MRIs are appropriate for women whose breast implants for some reason are shadowing part of their breasts, rendering mammogram or ultrasound studies incomplete. They are also valuable to screen the breasts of women who have a strong family history of breast cancer, in general beginning about ten years younger than the age at which her first degree relative developed breast cancer. The big question is whether and how often to get routine MRIs to screen the breasts of women (with or without implants) for cancer, as there are some cancers that can be picked up on MRI before they can be felt or seen on mammogram (likewise there are cancers that can be seen on mammogram but not MRI, so having an MRI does not mean that you do not need a mammogram.) While this will pick up cancers, it will also pick up things that are not cancer, inevitably leading to anxiety and unnecessary biopsies. These studies are also very expensive, and the question of whether insurance companies will or should pay for these changes every day, though in general they will only cover these studies when there is a strong family history of breast cancer.

If I get an MRI, does that mean I no longer need a mammogram?

There are cancers that are picked up on mammograms that cannot be seen on MRIs. So both studies are needed, though there are some protocols in which they are alternated year by year.

How much do breast MRIs cost?

The cost varies all around the country, but it is in the $1000-$1500 range. Knowing that patients frequently have to pay for it themselves and that it is an important part of cancer screening, many centers will individually negotiate special cash prices with patients.

How much of a family history is necessary to consider being tested for the breast cancer gene?

There are many locations on the internet where you can find in depth advice about this topic, and it is so important that if you are even thinking about it you should visit with your own doctor. In general, it is recommended that Ashkenazi Jews with one first degree relative (sibling, parent, child) and all others with two first degree relatives who develop premenopausal breast cancer or ovarian cancer at any age get tested.

Can breast pain be a sign of breast cancer?

Breast pain is very common but is rarely a sign of breast cancer. Still, 6% of women with breast cancers learned about their cancer because they went in to see their doctor for breast pain. How often the cancer was unrelated to the pain and just found incidentally at that visit and how often the pain was actually associated with the cancer is unclear. But that means that pain cannot be ignored. In general, pain that is diffuse, on both breasts, and varying with periods is hormonal. But pain still justifies a visit to the doctor.

What is ALCL?

It stands for analplastic large cell lymphoma. It is a very rare form of cancer that is seen in the general population, but in recent years it was reported in about 80 patients with breast implants, which is a greater frequency in the general population.

If I have implants, what is my risk for ALCL?

It is extremely rare, perhaps one in a million for each year the implant is in their body. For some women that is such a small number that it means little to them. But for others it can be a source of fear and apprehension.

Is it a bad cancer?

ALCL is almost universally fatal in the cases with women who did not have breast implants. But in the women who have breast implants and have been diagnoses with ALCL, the course is very benign, quite different than non-implant ALCL. As of this date, two women with implants have died from it. That is very small considering the many millions of women with implants, but even a single death possibly associated with an elective, totally unnecessary surgery must be considered seriously. In all likelihood, what we are now calling "implant-associated ALCL" will probably – but not definitely – be reclassified as a non-cancerous problem. But for now, it is still considered a lymphoma.

How would I know if I had it?

The women who have been diagnosed with ALCL either felt a mass around their implant or developed a late swelling of their breast tissue. When there is swelling, the fluid can be aspirated and sent to a laboratory for "cytology," which is a way of looking for abnormal cells.

Silicone Gel Breast Implant Patients

What should I do if the answer to any of these questions differs from what my doctor has told me?

These answers are the opinions of one surgeon. You need to follow the instructions of your own plastic surgeon. If conflicts exist, you may choose to discuss them with your doctor. These questions are intended to give general knowledge, but they are not a substitute for a visit with a plastic surgeon.

What’s the one most important thing I need to know?

After undergoing a procedure intended to improve the appearance of their breasts, some women continue to think about breast issues through the narrow point of view of aesthetics. But we must not forget that with or without implants, breast cancer still strikes about one in eight women. While appearance is important, never lose focus of the fact that the only issue of your breasts that truly matters is screening them for breast cancer. And one of the problems with the "silicone scare" of the nineties is it led some women to worry about their breasts from the point of view of silicone safety rather than cancer safety. I have seen women pay to get MRIs to examine their breasts for silicone rupture before they paid to have an MRI to examine their breasts for a small cancer, which in my opinion is a confusion of priorities.

How long do silicone implants last?

Asking how long silicone implants last and when you’ll need another operation are two different questions. The reason is that silicone breakage is not one of the common reasons that patients with silicone implants have another operation: far more common is operating to do a lift, to remove scar tissue, or to change size, none of which has to do with the longevity of the implant per se. When a saline implant breaks, it deflates and you have to do something because one breast suddenly shrinks. But when a silicone implant breaks, you may not know it; and if you did, but you were otherwise happy, you would not have to operate.

How do I know when I’ll need another operation?

The clearest reason to undergo another breast augmentation would be finding out that one of your implants is broken. But that is actually not a common reason for revision. The common reason is changing size, progressive firmness, increasing droopiness, and the implant being out of position. While these problems are often severe, they are more often subtle, and a patient will typically think for a while about whether or not it is worth have a revision surgery before they decide to do it. So other than rupture or severe encapsulation (hardening), a patient comes to know they will want a revision over time.

How would I know if my silicone implant has broken?

If the breast suddenly gets softer or changes its shape, we may suspect that there is rupture. Other times there may be no apparent change in the breast. But the only way to prove that there is a rupture or disprove that there is a rupture is to have surgery and look at the implant. Sometimes mammograms will show that there is a rupture, but just because a mammogram did not note a rupture does not mean that the implant was not ruptured. Ultrasound is becoming increasingly useful to examine implant rupture, but the state of the art for evaluating implants for rupture remains the MRI. But MRIs are "over-sensitive," meaning that about 10 or 15% of the time the MRI is interpreted as showing a rupture, there isn’t a rupture. I have operated on patients with suspected ruptures on MRIs quite a few times whose implants were fully intact. As the MRI machines, computer algorithms, and radiologist interpretations improve, so does the accuracy of the test. But the point to remember is that the only thing that proves that there is or is not a rupture is actually seeing the implant at surgery.

What is the difference between a "silent rupture," "asymptomatic rupture," and suspected rupture?

A suspected rupture is a rupture noted on MRI or mammogram but that has not been confirmed at surgery. A rupture suspected on physical exam but not yet confirmed at surgery is also considered a suspected rupture. An asymptomatic rupture is a rupture that is not causing any symptoms at all; such a patient would not know that anything is wrong with the implant. Silent rupture is closely related to asymptomatic rupture, but it is slightly different. Asymptomatic rupture refers to what is presumed to be a rupture that is not causing symptoms, and a silent rupture is one that is asymptomatic and not even suspected. For instance, if a patient gets an MRI that shows a rupture, it would technically just be a suspected rupture because we do not know for sure that it is ruptured. If that same patient were asymptomatic, we would technically call it an asymptomatic suspected rupture, but people would usually shorten that to just call it an asymptomatic rupture. But if that same asymptomatic patient never had an MRI to even make the diagnosis of a suspected rupture, and a rupture were found at the time of surgical exploration for some reason, we would say the patient had a silent rupture.

What is the debate on silent rupture?

We have learned that some patients live with ruptured silicone implants with no apparent problems. They would therefore be living with "silent rupture." There are two schools of thought on this. One is that since it is "silent," by definition there is nothing wrong. If they develop a problem, such as hardening or a change in appearance, then that would be the time to operate. But there is no reason to operate on someone happy with how they look and feel before a problem becomes apparent. Others would argue that we do not really know what happens to a ruptured implant that is left in the body a long time. Patients who have suspected ruptures usually have their implants replaced, so that a large group of patients with suspected rupture not undergoing replacement has not been followed over time. To rebut that, some surgeons would argue that we remove very old ruptured implants all the time, implants that have been presumably ruptured for years or even decades, and that these patients have no health problems related to the rupture. And thus the debate rages on.

What did the FDA make the manufacturers put in their "implant labeling" about MRIs and silicone implants?

When the FDA reapproved silicone gel breast implants in 2006, they required that manufacturers be sure that surgeons using the implants tell patients that the FDA recommends an MRI three years after augmentation and every other year thereafter to check for silent rupture. This recommendation had not previously been made by the licensing agency of any other country, nor had it been the recommendation of any plastic surgery group, to the best of my knowledge. In fact, the suggestion took all plastic surgeons I know by surprise, since I had not known of any plastic surgeon who had been suggesting biennial MRIs for patients.

If I have silicone implants, do I have to have these MRIs to screen for "silent rupture?"

The FDA regulates the manufacturers of devices and the manner in which they may advertise and promote their products. The FDA does not regulate doctors; it does not create a standard of care for medicine. Nor can it force patients to do anything. The FDA can force the manufacturers to be sure that doctors tell patients that the FDA suggests MRIs to screen for silent rupture, and to remove their implants if a rupture is suspected. But they do not require the doctor or manufacturer recontact the patient in the future to remind them about this test, to encourage them to do the MRI, and certainly they cannot force the patient to undergo the test.

Other than cost, what’s the problem with getting MRIs to screen for rupture?

An MRI is not a perfect test; sometimes it will say that there is a rupture when there is not. And silent rupture is probably so uncommon, that the number of tests that say that there is a rupture when there isn’t may actually exceed the number of MRIs that say that there is a rupture that is really a rupture. Theoretically, that could mean that widespread MRI screening for ruptured implants could result in more unnecessary explorations when implants are not broken than surgery for implants that actually are broken. And beyond that, if there is no problem with the breast, then why have surgery?

What do you tell patients to do about getting MRIs after silicone breast augmentation?

When I see a patient today contemplating silicone breast augmentation, I tell them that the FDA recommends MRI’s three years after augmentation and every other year thereafter. If they ask me my personal opinion, I say that I do not believe in such frequent and costly screening for silent rupture, because I think silent rupture is uncommon and does not represent a bona fide problem. I furthermore tell them that if they are predisposed to be concerned about silent rupture, what they are really saying is that they have reservations about the safety of silicone. If that is the case, then I do not believe that they should have augmentation with silicone. In my opinion such a patient should have augmentation with saline, or no augmentation at all. It just doesn’t make sense to me to have such a high level of suspicion that silicone is dangerous that someone would get an MRI every other year. So my personal attitude is that if someone is planning on getting those MRIs, that they probably should not get silicone implants.

One breast seems smaller: could my silicone implant be ruptured?

The silicone used in implants since the early nineteen nineties is so thick, that even when the shell breaks, the gel almost always stays in the capsule the body makes that surrounds the implant. The silicone gel does not get absorbed or migrate throughout the body enough to result in a decrease of the size of the breast. But it is possible that the breast may be a little softer, or sometimes the shape may change enough so that the patient perceives a subtle change in size.

Do I need to change them after ten years?

No. I don’t know who started that myth. There is nothing magical about ten years. You replace them when you and your surgeon think that your breasts can be improved, or if you have a rupture that you would like to fix. But there is no required routine, preventative maintenance surgery. I think this rumor began because it sounds like a nice, round number, far off into the future. But it should have no bearing on an individual patient’s decision making whatsoever.

What happens when a silicone implant breaks?

In the seventies and early eighties, manufacturers increasingly thinned the shell of implants and made the silicone less viscous, all in an effort to make implants softer. But these efforts reduced the durability of the implants. The thin shells broke more easily, and the more liquidy gel was more apt to migrate than the thick gel used since the early nineties. Worse still, was that up until the mid-nineties, surgeons would sometimes still treat hardening (capsular contracture) with a "closed capsulotomy" – a forceful squeezing of the breast externally, in an effort to break the scar tissue surrounding the implant. Though it often softened an implant, the implant would usually harden again. Worse, the force sufficient to break the scar tissue was often sufficient to break the implant, and the force of the squeeze would sometimes force the gel throughout the breast tissue. With today’s thicker shells, denser gels, and the practice of "closed capsulotomy" abandoned, the gel from a broken implant usually stays within the capsule. When the gel stays within the capsule, we call it an "intracapsular" rupture; when the gel goes outside of the capsule, it is called an "extracapsular" rupture. Extracapsular ruptures are rare in the era of thicker gel and no closed capsulotomies.

If an MRI says that my implant is broken, do I need to have it replaced?

If you would not remove an implant because an MRI says that it might be broken, then why would you have had the MRI in the first place? It does not make sense to me to get a test if you would not act upon its outcome. In other words, you should only have gotten an MRI to screen for rupture if you had already made up your mind to have it removed if the MRI indicated it were ruptured. Notwithstanding that opinion, the FDA suggests that an implant suspected to be ruptured should be replaced. It is the recommendation I give to all patients in that situation. But if the patient wants to engage in a more involved discussion, I would also tell them that it is my opinion that a patient with a suspect rupture on MRI does not necessarily have to replace it. First, there is a chance that the MRI is wrong, and that the patient will go through the whole surgery for no reason. Second, there is no evidence that shows that there is a harmful effect of ruptured silicone. Some would argue that just because there is no evidence showing that there is a harmful effect, there is insufficient evidence to prove that there could not possibly be some long term harmful effect. True enough, but the risks of replacement surgery are real enough: anesthesia, cost, recovery, chances of infection, etc. In my mind, weighing the possible risks of leaving in the ruptured gel may not be as great as the quantifiable real risks of undergoing replacement surgery. In reality, however, nearly all patients with an MRI that gives a suspicion of a leak simply want to have the implant out for their own peace of mind, and many others were waiting for an excuse to go a little bigger or smaller, may have wanted to have their eyes or some other part of their body operated upon, and therefore look at the rupture as a justification to undergo a new anesthetic experience and want to fix the breasts at that time. The decision to undergo surgery is extremely complex and multifactorial, and it is impossible for anyone to give you advice about this without actually meeting with you, examining you, and discussing your anxieties and wishes. But that being said, let me make it clear that the typical recommendation in the plastic surgery community for suspected rupture is removal and replacement.

If I’m getting an MRI to screen for breast cancer, can’t I just have them look at my implants? And If I am getting an MRI to look at my implants, can’t they check for cancer?

Cancer screening MRIs need IV contrast (dye put in your IV) and rupture MRIs do not. Though done on the same machine, they are entirely different studies. They are run separately, read by the radiologist separately, and are billed separately.

How often should I get MRIs to check for a ruptured implant?

The FDA recommended this to commence three years after augmentation and then to be done every other year thereafter. But it is not required: this was the recommendation of the FDA. You may choose to follow it or you may choose not to. But if you decide to get regular MRIs to screen for suspected rupture, you should know ahead of time what you would do if the study demonstrated a suspected rupture. If you would ignore the result, then why would you get the test? It makes the most sense to me to get the test only if you think that you would be inclined to have the implant removed following a positive MRI.

How do I get an MRI ordered?

Contact your plastic surgeon and they will send in a requisition to the local MRI center.

Who will pay for my MRIs?

Some insurance companies will pay for MRIs to evaluate implants placed for post-mastectomy reconstruction, but I have never heard of an insurance company pay for an MRI to evaluate an implant for rupture that was placed for elective cosmetic reasons. If you are at high risk for breast cancer, have a history of cancer, or have really excellent insurance, it might pay for an MRI to screen for cancer but not rupture. In that case, you could probably negotiate a discount to get the additional views for rupture while you are getting the MRI paid for by insurance to screen for cancer.

Can’t I just get an MRI to look for cancer and have my insurance pay for it?

An MRI to evaluate your breasts for cancer is different than an MRI to evaluate an implant for rupture. Though done in the same machine, the cancer screening is done with a special dye placed in your veins, and the study is optimized for your breast tissue. A test to look at the implant is an entirely different radiographic protocol, and no IV dye is used. They are two totally separate studies. Sometimes, however, a radiology center may be willing to negotiate with you a cheaper cash price for you to pay for your implant MRI at the same time that you are getting a cancer screening MRI. Still, most insurance companies are stingy about paying for cancer screening MRIs, even though they are very helpful at detecting some early cancers. Your local MRI center will best know the tendencies of your particular insurance company with regards to paying for cancer screening MRIs. Some companies will pay for them if there is a history in the family of early breast cancer, and some will never pay for them.

How much do MRIs for implant rupture cost?

There is a lot of variation, from a low of perhaps $500 if you were able to get it tacked on to a cancer screening MRI, to upwards of $2000, though most prices would be between $1000 and $1500.

How do I find out about the warranty on my silicone breast implants?

If you cannot find the information card that you should have been given after your surgery, call your plastic surgeons office and they should be able to obtain a copy for you. There have been only two domestic manufacturers of breast implants, and you can call them for the specifics of your warranty. Mentor can be reached in Santa Barbara at 805 879 6000, and Allergan can be reached in Orange County 800 624 4261. Of note, Allergan purchased Inamed which purchased McGhan, so if you have Inamed or McGhan implants you should call Allergan.

What problems with silicone implants do the manufacturers warranty against?

The warranty specifies "confirmed" rupture, so technically they do not cover a rupture suspected on MRI but not confirmed at exploration. They do not cover rippling, malposition, capsular contracture, or a desire to change the size.

Does that mean that I would be getting surgery for free if I have a rupture?

Not at all. The implant cost is usually just a small part of the total cost of a revision, as the surgeon fees, anesthesia fees, and operating room fees are much more than the implants. Some of the warranties cover a small part of those fees for a finite period of time after the initial surgery. Some plastic surgeons have a minimal charge for their own patients who experience a leakage, but others charge a full price. Given the wide variety of surgeon and warranty policies, it is impossible to give an accurate answer to this question.

Can’t I just have the surgeon break the implant after it is removed to "confirm" the rupture?

You could, but you and the surgeon would be committing fraud. And the manufacturers have a very fastidious program to examine removed implants under the microscope, and they can determine whether the leakage was real or staged. An unscrupulous surgeon may be able to get away with it once or twice, but if it became a pattern – as it has with several surgeons in the past – the manufacturers will quickly catch on and put an end to it.

What does the warranty cover and for how much?

While the two manufacturers have been competitive, the warranties have had subtle differences, have changed over time, and there have been optional warranty upgrades that some patients have purchased or their doctors automatically purchased for them. In general, they cover the implant for lifetime and some amount towards the operating room and/or the surgeon. For instance, both manufacturers now have a lifetime warranty on the broken implant, replacement of the opposite side, and $3500 towards surgery for ten years. In the past the warranty wasn’t always so robust. You will need to call the manufacturer to find out the details of your warranty.

Will the warranty cover the non-ruptured breast implant?

In most cases the manufacturer will cover the non-ruptured breast implant. But you need to call the manufacturer and get the details on your warranty.

Can I use the warranty to change to saline implants?

It would be very unusual to switch from silicone to saline, but you would be entitled to get saline if you preferred.

Can I use the warranty change to a different size implant?

You are allowed to order whatever replacement size you and your surgeon select; you are not limited to your original implant size.

Should the warranty affect my decision to have a revision surgery?

The revision only covers rupture. So the only situation in which it might would be if you had a suspected rupture on MRI, but were not inclined to do something about it. While you would have a lifetime warranty on the implants, most warranties are good for only five or ten years towards the operating room and anesthesia fees. Some people might choose to therefore do the surgery if the warranty were close to expiring (though the general recommendation is to remove an implant that is suspected to be ruptured.)

Since the warranties only cover suspected ruptures, how do I plan financially if the MRI says that there is a rupture since it is possible that it may not actually be rupture?

That is a great question, and it is always a big problem. There is no simple solution. Fortunately, MRIs are correct about 85% of the time, so it operating on a false rupture doesn’t happen very often. The manufacturers have some leeway with their warranties, and from time to time I have seen them cover suspected ruptures that turned out not to be real, but they are under no obligation to do so. This is the kind of situation you will need to discuss in depth with your surgeon.

Do I have to worry that silicone implants can make me sick?

Countless studies and massive reviews by impartial scientists have found no association between silicone breast implants and any disease. They can get hard, cause pain, interfere with mammograms, and require revision surgery among other problems, but their side effects are limited to the breasts themselves; they do not cause "systemic" disease. If one researches this matter, they are sure to find conflicting statements. But the important thing is to look at the qualifications and credibility of the person giving the advice, as well as their references to objective data. The only anti-silicone information I can find does not reference published scientific articles. They are based upon anecdote, hyperbole, and fear. These opinions are often disseminated by plaintiff lawyers, anti-implant "activists," anti-business "activists," holistic-types who are against anything "unnatural" and even plastic surgeons who are too politically correct to rely upon objective and vetted data. But don’t take my word on it. Do your own search of up-to-date original medical publications on Paper Chase or some other index of medical journals. Or you can read the massive Institute of Medicine Safety of Silicone Breast Implants Report which is located at http://www.iom.edu/Reports/1999/Safety-of-Silicone-Breast-Implants.aspx. If you want to learn the history about how science was bastardized by the media and the legal system, consider reading Science On Trial by Marcia Angell. She was the Executive Editor of the New England Journal of Medicine, the most prestigious position in medical editing. She explains that despite her bias as a feminist to be against breast implants, she was so appalled at the "breast implant crisis," that she wrote the book. Despite abundant evidence that they were safe, lawyers, the media, and "activists" nonetheless pursued their own personal agendas.

Should I have my implants removed if I develop any autoimmune diseases?

This is a matter between you and your doctor, and should be based upon the severity of your symptoms, your doctor’s opinion, and your personal desire to keep your implants. While there is no evidence that removing them will make you better, there is also no evidence that removing them will not make you better. When it comes to health, some patients will choose just to have them out to eliminate any possibility that they are contributing to the problem. Others like their breast implants so much that they will choose to leave them in given that no evidence suggests that they are in any way related to their problem. This is a very serious question and you need to discuss this in detail with both your rheumatologist and plastic surgeon.

Implant Problems and Complications

What should I do if the answer to any of these questions differs from what my doctor has told me?

These answers are the opinions of one surgeon. You need to follow the instructions of your own plastic surgeon. If conflicts exist, you may choose to discuss them with your doctor. These questions are intended to give general knowledge, but they are not a substitute for a visit with a plastic surgeon.

Is it normal to be able to feel my breast implants?

On careful examination, a breast implant can always be felt. The thicker the overlying tissue, the thinner the scar tissue, and the smaller the implant, the harder it is to find. The bigger the implant, the tighter the scar tissue and the thinner the coverage, the easier it is to find. Saline is generally easier to find than silicone, but even silicone implants are detectable. Think about this: your implant is in front of your ribs, and you can feel your ribs. So why wouldn’t you feel your implants? The real question is whether your implants could be less noticeable than they are. Whether you have enough scar tissues to remove, whether a different implant would help (saline v silicone, smooth v. textured), whether you would benefit from a smaller implant, or whether your could be made less detectable by moving your implant to behind the muscle if it is now in front are subjects to bring up in a visit with a plastic surgeon.

What can I do if my implanted breasts are too big?

If your breasts are too big, pendulous, or heavy, you might consider putting in a smaller implant or removing them altogether. Many women received implants at a time in their life when having more obvious and large breasts seemed like a good idea. Some did it for a boyfriend or for their career, but as time has moved on and relationships changed, the implants are a reminder of a time gone by and interfere with the image these women want to portray in the present. Other women’s natural breast tissue has increased, either from changes in hormones or body weight. In any case, the only reason to have an implant is if you want to be larger. So if you are larger than you want to be with your implants, you need to figure out whether you just want a smaller implant or you want them out altogether.

Does going smaller or removing the breast implants and not replacing them mean I will have to get a breast lift?

Going smaller or even removing implants does not mean that you have to get a lift, but there are some women who have the implants removed or made smaller who do need a lift. It just depends upon the measurements of your breast. It is a matter of the measurements of your breast, such as how low your nipples are, how empty your breast envelope will be, and how much skin there is between the nipple and the bottom of the breast.

Does getting a breast lift mean having to get that "anchor" scar?

While the anchor scar is the time honored method for lifting and reducing breasts, there are times in which excellent results can be obtained with a "lollipop" scar (around the areola and straight down the breast) or with a "donut" scar (a scar just around the areola.) Many patients pressure their plastic surgeons to shorten the length of the scars or to use a method that has less scarring. But there is a reason for the longer scars: it allows greater removal of skin and more reshaping of the breast. Listen to your surgeon’s recommendation and do not push them to use less scar than necessary for them to create the ideal shape out of your breasts.

Is there any way to know what I would look like with my breast implants removed?

Patients with saline implants have one advantage: the implants can be deflated with a small needle, allowing patients to see what they would be like without implants. They still will need to have surgery to remove the deflated implants, but it gives these patients a chance to live without the stuffing of an implant to see whether they really want to have an implant. It is impossible to do this with silicone implants. The best they can do is look at photos of patients with similar problems, but there are too many variables to take into consideration for them to get a reliable prediction of what they will look like after removal.

Is it normal for breasts to seem smaller as time goes on after an augmentation?

Aside from the obvious rupture of a saline implant, many women do have the perception that their breasts get smaller over time. This can be due to the implants sagging more in the breast pocket, resulting in less upper fill. And it is the upper fill that a woman most notices and confers to her the sense of her size. Of course there also can be changes in hormones and changes in weight. In addition, the body adapts to the pressure of a large implant. An implant puts pressure on the breast tissue over time, and the tissue can thin, much like carpeting will compress from the leg of a chair. The skin can also stretch and thin, and the rib cage itself can develop a bit of a concavity from the pressure of the implant. These sorts of changes are based upon the size and projection of the implant relative to the tightness of the tissues. While these changes are inconspicuous with a small implant, they can be significant with a large or highly projecting implant.

What can I do if my breast implants are too small?

You can put in larger implants. But the question to ask yourself is whether larger implants are ideal for your tissues. One of the biggest problems today is women with implants that are too large for their tissues. At best, this means that they look stuffed, round, and fake in the short term. And in the long term the pressure these implants put on their tissues causes irrevocable changes to their bodies. I encourage patients at the first operation to pick an implant that is ideal in size for their tissues; too small and it looks like a rock in a sock or the upper breast is empty, and too big and the breast looks too round and fake and has a bulge on top. So if the patient selects the right implant to start with, then by definition, they have the right implant and it is illogical to go larger (or smaller). To do so risks stretching the envelope more, and beginning a cascade of surgery and repeat surgery in a never-ending effort to keep the breast envelope full. Think about a sweater with a loose cuff. You can push it up to your forearm. It will be tight for a bit, but it will soon loosen. That’s what happens when you keep putting in larger implants. When implants are sized arbitrarily at the first surgery, such as asking a patient what cup she wants to be or by putting sizers on in a bra, then there is no objective criteria used in the decision. This always leaves open the possibility that a patient will later decide to be larger. I see many patients who were undersized at the first operation, which means that their tissue always had room to go larger, and for these women the decision is straightforward. There are other women who gain weight and breast tissue that become able to accommodate a larger breast implant now than they were able to handle at the time of the first operation. But I am reluctant to put in a bigger implant in a patient whose breast tissue is already filled out by the existing implant. Reoperations for size sounds simple, but it is actually a very involved topic if you want to be sure that you are selecting a size that is ideal for your body.

Should I switch my saline implants for silicone implants?

If you are totally happy with your saline implants, then there is no reason to switch. But silicone does feel softer, tends to ripple less, may cause less long term skin stretch, and will not suddenly and totally deflate if the shell breaks. This decision is not one to be taken lightly, and should only be made after extensive consideration. Please refer to the section on saline implants for a more thorough discussion of this topic.

What can I do if my breasts are drooping?

Breast droopiness is a common reason to have a revision surgery after a breast augmentation. It is often the result of droopiness that went untreated at the time of the first augmentation. Perhaps you or your surgeon did not recognize that the droopiness was there. With the weight of the implant and a few years of gravity, perhaps that droopiness got worse. In other cases the droopiness was noticed, but the patient did not want to have a lift, but opted for an implant instead. The weight of the implant may then have caused an increased degree of droopiness over time. In all cases, the treatment for droopiness is a lift. Few women want the scars of a lift, but the fact is that the treatment of droopiness is a lift, and not a bigger implant.

What can I do if my breasts are uneven?

Everyone’s breasts are uneven. Asymmetry is part of being normal. How uneven is it okay to be? So long as you can get dressed and the difference not be obvious, then you are normal. But there are many women who have differences so profound that it makes buying clothes and getting dressed difficult. It can be due purely because one breast is bigger than the other. It can be a result of one breast drooping more than the other. If an implant is out of its proper position it can create unevenness, and the scar tissue of capsular contracture can make breasts uneven. All of these can potentially be corrected, but usually that correction involves surgery.

Should breast pain concern me?

Women with and without implants can have pain in their breasts. The source of pain could be your own breast tissue just the same as if you didn’t have breast implants, or something related to the implants. Breast pain is the most common reason that women see breast cancer doctors, but these cases are usually just hormonal, and uncommonly are cancer. Still, it is sobering to note that 6% of breast cancers are diagnosed because the patient saw their doctor for breast pain. It is not clear whether the cancer was causing the pain or the cancer was detected incidentally while examining the woman for her pain. In either case, it is a reminder that pain should not be ignored and deserves an evaluation.

How does the doctor dismiss the pain as not being a sign of cancer?

That cannot be stated conclusively from your history. The doctor still needs to examine you and you’re your mammogram. In general, pain