Breast augmentation with implants: finally feel good again

Decisive for the optimal bust size is the preference of the patient and a harmonious relationship to the circumference of the waist and hips. The width of the chest, the amount of subcutaneous fat must also be considered. If relatively large implants are chosen for a narrow chest, the implant may become visible and palpable at the sides (also known as the rippling phenomenon).

In very thin or very athletic patients, there is often little fatty tissue under the skin. This should be considered when choosing the size of the implant, the shape of the implant and the choice of surgical technique. Otherwise, implants that are too large in the décolleté look unnatural, as if they have been placed on top. Clothing sizes differ significantly from manufacturer to manufacturer. Although there are studies that estimate an increase in volume of approximately 200ml for an increase in cup size from B to C or from C to D, these values are only rough guides ^[14]. In fact, depending on the manufacturer, the volume increase from a bra size 75B to 75C differs from 85 to 230ml, from 75C to 75D from 100 to 140ml, and from 75D to 75E from 80 to 180ml ^[15].

Most patients have very specific ideas and expectations regarding the desired upper width. Since there is no standard bra cup size, the idea of a C or D cup for a patient who wears Victoria’s Secret® bras is quite different than for the patient who wears Triumph® bras. It is not uncommon for these misunderstood expectations regarding cup size to lead to great dissatisfaction after surgery. That’s why we take the time our patients need to explain the goals and limitations of breast augmentation in detail.

Silicone implants have no expiration date. And yet, silicone gel-filled breast implants do not come with a lifetime guarantee. They do not last a lifetime. Despite constant development of the shells and the filling (silicone), the shell of an implant can develop a crack afterwards. As a rule of thumb, the American Society for Aesthetic Plastic Surgery (ASAPS) puts the risk at one percent per year. Other reasons for follow-up surgery after breast augmentation include implant slippage (37 percent), capsular contracture (33 percent), or patient request for a different implant size (20 percent) (Khanna J, et al. Aesthet Surg J. 2019.).

The risk of slippage is greater when the implant is placed under the pectoral muscle than over the pectoral muscle. Capsular contracture is the formation of scar tissue around the breast implant that appears as hardening, deformity, or pain of the breast. Capsular contracture forms in approximately 10 percent of women after 10 years (Calobrace MB, et al., 2018, Plast Reconstr Surg). Implant surface, implant placement, and certain precautions during the surgical procedure influence the risk of capsular contracture.

The risk of another breast surgery varies from ten percent two years after breast augmentation to 20 percent after six to ten years (Maxwell GP, et al, 2012. Aesthet Surg; Adams WP Jr, et al, 2012, Plast Reconstr Surg, Stevens WG, et al, 2016, Aesthet Surg J). Reasons for implant removal may also include concern for BIA-ALCL (breast implant-associated anaplastic large cell lymphoma) or BII (breast implant illness) and thus a medical indication. The larger the implant, the greater the risk of slippage, injury to the shell or capsular contracture afterwards. The additional treatment with autologous fat in hybrid breast augmentation offers many advantages. The additional breast augmentation with autologous fat allows the selection of a smaller implant. In this case, the breast feels more natural. If necessary, the expert plastic surgeon can shape or correct the breast more individually. There is also the possibility to specifically emphasize the décolleté.

This is one of the most frequently asked questions. The increase in size of the breast can be seen immediately after the surgery, so you already have a first picture of it. The swelling, which is unavoidable in the first few days, recedes after a few weeks and the exact shape of the contour can then be seen more precisely. However, the adjustment of the skin’s elasticity and the healing of the scars take a few months.

The final shape of the breast will therefore take some time to emerge. The scar is often a little red or raised in the first few months. Consistent massage of the scar and the application of a silicone patch three to four weeks after the surgical procedure promote and accelerate the healing process, allowing the scar to heal inconspicuously. Age, state of health and the size of the selected implant influence the duration of healing. In 90 percent of the patients, the end result can be seen three months after the breast operation, this of course varies slightly from patient to patient.

The FDA recommends an MRI examination afterward, approximately three years after surgery at an appropriate clinic, and every two years thereafter. This medical examination can detect ruptures of any kind that would remain undetected even at first glance during a physical examination by a physician.

There are two main reasons for this: First, research suggests that capsular contracture (formation of firm scar tissue around the implant) is less likely to occur with rough surfaces compared to smooth surfaces. Second, all teardrop-shaped implants/anatomical breast implants have a rough surface to keep you from slipping. Some surgeons believe that anatomical shape implants, as opposed to round implants, result in a more natural breast shape.

The CE certification of textured implants from the manufacturer Allergan was not renewed on 12/17/2018. On 5/04/19, textured implants from the following manufacturers were banned in France: Allergan Inc, Laboratoire Arion, Nagor Ltd, Eurosilicone, Polytech Health & Aesthetics, Sebbin. American and German professional societies do not advise against the use of such implants. Patients in Germany can decide to use these implants after a full explanation of the risks and alternatives.

Here, the implant is removed in one piece with the capsule. For the removal en-bloc a larger access in the area of the sub-breast fold is necessary. Removal of the implant en-bloc is associated with a higher risk of rib, muscle or lung injury. For more information, please visit our Implant Removal en-bloc page .

BIA-ALCL is not a cancer of the breast tissue itself, but a form of blood cancer that affects the white blood cells. A link between the development of anaplastic large cell lymphoma (ALCL) and breast implants is considered to be established. Alternative procedures (breast augmentation with autologous fat) should therefore be considered.

Most cases of anaplastic large cell lymphoma occurred with implants with a roughened (textured) surface. For this reason, the CE certification of textured implants from the manufacturer Allergan was not renewed on 12/17/2018. On 5/04/19, textured implants from the following manufacturers were banned in France: Allergan Inc, Laboratoire Arion, Nagor Ltd, Eurosilicone, Polytech Health & Aesthetics, Sebbin.

The risk can be divided according to the outer wall of the implant as follows:

• For smooth surface only in very rare cases: 0.0001% (1:704,000).
• With fine rough surface (microtextured implants, Siltex® and similar): 0.001% (1:82,000)
• For coarse rough surface (macrotextured implants, Biocell® and similar): 0.031% (1:3,200)
• For a polyurethane coating: 0.035% (1:2,800) (Hamdi M, et al, 2019, Aesthet Surg J. 2019).

The following figures may be helpful to better classify the risk of developing BIA-ALCL after breast augmentation with silicone implants.

• Risk of rupture of an implant over a 10-year period: 8.7% (1:11.5).
• Risk of capsular contracture over a 10-year period: 13.5% (1:7.4).
• Risk of reoperation over a 10-year period: 31.6% (1:3).
• Risk of breast cancer over a woman’s lifetime: 12.5% (1:8).
• Risk of breast cancer recurrence after mastectomy for breast cancer: 5% to 8% (1:12.5-20).
• Lifetime risk of being killed in a car accident: 0.15% (1:645).
• Risk of a life-threatening complication from cosmetic surgery: 0.002% (1:50,000).
• Risk of developing advanced BIA-ALCL with lymph node metastases after breast augmentation with silicone gel implants: approximately 0.0004% (1:250,000).
• Risk of developing BIA-ALCL after breast augmentation with silicone implants that is not treated within 3 months: 0.0002% (1:500,000) (Calobrace MB, et al. 2017. Aesthet Surg J).

The first symptom of BIA-ALCL is swelling of the breast, which occurs on average eight years after breast implant placement (range from two to 28 years after breast surgery). The swelling is due to a buildup of fluid surrounding the implant. This fluid can cause the breast to become significantly larger afterward, over a period of days or weeks. There may also be lumps in the breast or armpit, firmness of the breast, or pain. BIA-ALCL is usually easily treatable and curable if patients seek treatment immediately after the first symptoms appear.

Since the disease was first reported nearly 20 years ago, there have been 16 confirmed deaths worldwide. If detected early, before it develops into lymphoma, BIA-ALCL is highly treatable and curable by removing the implant and surrounding scar or capsule.

If detected early, BIA-ALCL is readily curable. Current recommendations for treatment of BIA-ALCL include bilateral capsular resection (removal of all scar tissue) and removal of breast implants. Such procedures are also performed by plastic surgeons when an implant is damaged or capsular contracture has developed. The majority of patients do not require additional treatment. However, if BIA-ALCL has spread to the lymph nodes or adjacent tissues in the body, chemotherapy or radiation may be required.

Neither the German Federal Institute for Drugs and Medical Devices, nor the German professional societies, nor the U.S. Food and Drug Administration (FDA) recommend preventive removal of implants with rough surfaces. However, there are women who decide to remove their implants afterwards because of concerns about BIA-ALCL.

If due to concerns about the BIA-ALCL the implants are to be removed, there are the following options to get a beautiful breast shape afterwards:

If due to concerns about the BIA-ALCL the implants are to be removed, there are the following options to get a beautiful breast shape afterwards:

• Replacing the previous implants with new ones with a smooth surface.
• A breast augmentation through a treatment with the patient’s own fat, which usually has to be repeated three times.
• A breast lift.

There is no blood test that can detect BIA-ALCL. According to experts, women who do not have any change in the female breast do not need additional examinations. However, if a patient has noticed a change in her breasts, such as swelling or a lump – an examination, imaging and consultation (in person) with a plastic surgeon should be arranged immediately. If there is fluid around the implant, the fluid should be aspirated under ultrasound guidance and sent for analysis.

Plastic surgeons, scientists and the manufacturers of implants are intensively studying this question. Possible risk factors are the implant surface and chronic inflammation (germs called Ralstonia picketti, pseudomonas, brevundimonas). Since very few cases have been reported in some regions of the world (for example, Asia), a hereditary predisposition is also being discussed as a favoring factor. It is possible that several factors must come together for BIA-ALCL to develop after some time.

It is estimated that 1.5 million breast augmentations with implants were performed worldwide in 2017. Yet, breast implant disease is a rare and under-researched condition. Other names for breast implant disease include “autoimmune/inflammatory syndrome induced by adjuvants (ASIA)” or “silicone implant incompatibility syndrome (SIIS).” A connection between breast implants and very inconsistent complaints has been discussed for about thirty years. These complaints include joint pain, fatigue, breast pain, hair loss, headaches, chills, sensitivity to light, digestive problems, night sweats, skin rashes, weight gain, heart palpitations, body odor, anxiety, difficulty concentrating, sleep disturbances, depression, neurological and hormonal problems. These complaints are described regardless of the manufacturer of the breast implants, the surface of the implant (rough surface or smooth surface) and the filling material (physiological saline or silicone). There are numerous reports about this on social media.

Silicones are artificially produced compounds. The compounds consist of silicon (Si) linked together in chains with oxygen (O) and two organic hydrocarbon groups. Silicon is the third most abundant element on earth after oxygen and iron. In nature, silicon occurs in combination with oxygen as silica (silicon dioxide). Silicon dioxide, also known as E551, is also approved as an additive for organic foods. E551 is found in instant coffee, sliced cheese, grated cheese, spice powder, packet soups or table salt. Inhalation of silica as fine dust can cause quartz dust lung and inflammatory disease of the joints (Caplan syndrome). These are occupational diseases in miners, stonemasons or cast iron cleaners. Silicone is found in deodorants, skin and hair care products, ointments, lubricants and baking pans. In medicine, silicone is found in pacemakers, heart valves, artificial joints and breast implants. Medical silicone is freed from antioxidants, dyes and plasticizers during production.

In the early 1990s, there were several case reports linking silicone implants to connective tissue diseases, cancer and autoimmune diseases. The use of silicone implants was stopped in the U.S. in 1992. A US non-profit, non-governmental organization (National Academy of Medicine) denied a risk after reviewing 1078 scientific reports (Bondurant S, Enster V, Herdman R. Safety of Silicone Breast Implants. Washington, DC: National Academy Press; 1999). In 2006, the US Food and Drug Administration (FDA) re-approved silicone implants. Causal relationships are investigated in medicine according to the Hill criteria.

Intensive research is being carried out on such a test. However, laboratory tests exist to detect certain autoimmune diseases. You can find more information on the subject on our page Removing breast implants (en-bloc).

Improvement after breast implants removal may be absent, temporary or permanent. There is no study that proves that implant removal with capsule removal would be better than without capsule removal.

There is no way to prove or disprove the connection of the complaints with the breast implants afterwards. We recommend a consultation with a specialist in internal medicine and rheumatology. If an autoimmune disease can be proven, drug treatment may be recommended. Removal of the implants used with the capsule (en-bloc) or without can be performed at any time.

Since the connection is not (yet) considered to be certain, it is currently not possible to speak of a risk. To the best of our knowledge and belief, there is no evidence from high-quality studies of a link between breast implants and autoimmune diseases.

Here, the implant is removed in one piece with the capsule. For the removal en-bloc a larger access in the area of the sub-breast fold is necessary. Removal of the implant en-bloc is associated with a higher risk of rib, muscle or lung injury. For more information, please visit our Implant Removal en-bloc page .