Minimizing risk in breast augmentation surgery
It is impossible to make surgery risk free, but there are things that a can be done to keep the level of risk to a minimum.
The important risks can be split into those that are minor (which can be dealt with without further surgery), and those that are major risks (which may require further surgery and affect the outcome).
In the first few hours and days after surgery the early risks include bleeding, infection, and thrombosis. In the months and years after surgery the risks include formation of a tight capsule around the implant (capsular contracture), and an extremely rare but usually treatable type of cancer BIA-ALCL ((breast implant associated – anaplastic large cell lymphoma).
Bleeding in the first few hours after surgery can cause one breast to rapidly swell. The patient will often need to have a second operation at which the bleeding will be stopped, before the implant is replaced. This requires fairly prompt action and can result in blood loss, a longer stay in hospital, and an increased risk of long-term problems with the implant.
The rate of reoperation for bleeding is commonly reported as between one in fifty and one in two hundred patients. There is no evidence that placing a drain at surgery or use of any drugs before or during surgery reduces this risk. The key measure is careful surgical technique, with meticulous attention to detail.
Infection in the first few weeks after surgery can be a relatively minor problem affecting the skin, or it can be a much more serious with the infection spreading to the implant. In some patients the implant has to be removed to avoid sepsis.
There are things that can be done to reduce this risk which include: antibiotic drugs given at the start of the operation, keeping the incision in the crease below the breast, an antibiotic or antiseptic rinse used before inserting the implants, and measures to minimize the exposure of the implants to potential contamination (for example using an adhesive dressing over the nipple during surgery, fresh gloves before touching the implant, and using a soft sterile plastic funnel to insert the implant).
In one series of about 1600 patients undergoing breast augmentation, the introduction of these techniques resulted in a fall in rate of superficial infection from 1.2% to 0.8% and a fall in the rate of serious infection around the implant from 0.5% to 0%. These measures should also reduce the potential for bacteria can form a “biofilm” around the implant. The “biofilm” may in later years help stimulate the development of a capsular contracture.
Patient related factors are also important. Smokers have an increased risk of superficial infections and are likely to have a higher risk of serious infection. I ask that patients stop smoking six weeks before surgery. Chronic illness such as poorly controlled diabetes or obesity may also increase the risk (interestingly patients with well controlled diabetes, or treated HIV infection do not have a higher risk).
Venous thrombosis is a very rare but potentially serious risk, the likelihood of which has been estimated to be approximately one in every five thousand patients undergoing breast augmentation. There are factors that can increase the risk which include recent pregnancy, obesity, use of an oestrogen based oral contraceptive, and an age of more than forty. The hospital should complete a risk factor assessment for all patients. Where appropriate compression stockings, intermittent calf compression in theatre (patient’s calves are squeezed during surgery using an intermittent pneumatic compression device), and the injection of blood thinning drug six hours after surgery (if the operation is prolonged or the patient immobile) will reduce the risk. The injection of long acting local anaesthetic at surgery, giving 3-6 hours of very good pain relief, will also help allowing patients to get out of bed very soon after surgery.
Capsular contracture is the build-up of tight scar like tissue around the implant in some patients a visible deformity. A review of over five thousand breast augmentation patients suggested that at ten years approximately one in ten patients had a visible or palpable contracture. This was more common in patients with implants placed behind the breast (rather than partially behind the chest wall muscle), in smaller and smoother implants, and in patients with an incision on the edge of the areolar rather than the crease under the breast. The choice of implant, the position of the implant, and the surgical technique can influence the risk of capsular contracture.
BIA-ALCL an extremely rare lymphoma, a type of cancer, which has been found in the thick capsule around breast implants. It has been estimated that the lifetime risk for a woman undergoing breast augmentation is between one in four thousand and one in thirty thousand. In most patients this is treatable with surgery to remove the capsule.
We do not fully understand the cause, almost all of the patients have had “macro-textured” implants (as opposed the smooth implants). One implant manufacturer (Allergan) has temporarily withdrawn its textured implants from the UK market. The recently established national breast implant registry should, over the next ten years, tell us whether any one implant is more of a risk
Picking the correct surgeon may help reduce the risk. There is good data that suggests that complaints and litigation against a surgeon are most common in the first year or two after she / he starts his / her practice and in the last year of practice. So perhaps when picking as surgeon ask if she or he has just started as a consultant and whether she or he is imminently about to retire. In addition, standardized practice, concentrating on the issues mentioned in this article, has been shown to reduce risks. In one study looking at about 500 patients, surgeons with a standardized approach to breast augmentation, using protocols know to achieve a marginal reduction in risk, had a re-operation rate three times lower than surgeons who did not adopt this approach.
The UK national breast and cosmetic implant registry was introduced in 2016. To date over fourteen thousand women have had their details recorded after cosmetic breast augmentation. We hope that this data base will allow a much better understanding of how to reduce these risks even further and allow women considering breast augmentation surgery to be better informed.