Breast augmentation with implants

    The appearance of the female breast, its size and shape are a central part of female identity. The breast changes with weight gain and loss, pregnancy, breastfeeding, menopause and with age. The reasons for a breast enlargement are individually very different.

    Commonly expressed desires include a more feminine silhouette, a natural balance to the rest of the body, a better love life, wearing clothes without worry, and a more attractive appearance. Breast augmentation is one of the most common aesthetic procedures in the world. It is estimated that over 1.5 million breast augmentations were performed in 2017. Scientific studies show that breast augmentation is usually associated with high patient satisfaction and a significant improvement in quality of life.

    Breast augmentation by means of implants is one of the classic medical procedures in plastic and aesthetic surgery, which makes it possible to achieve the desired size. Often after pregnancies or severe weight loss, women want to regain the lost volume of their breasts and their previous cup size. In case a correction of the breast shape is desired at the same time, a breast augmentation can also be combined with a breast lift.

    On this page you will find detailed information on surgical methods for breast augmentation with implants and receive help in deciding on the right implant for your needs. In addition, common questions are answered and you will receive a lot more information and details that you should know if you want a safe breast augmentation with a natural look. For the creation of an individual treatment plan you have of course the possibility to contact us for a first consultation.

    Things to know about breast implants

    What should women who decide to have breast augmentation look for?
    Round and anatomical implant and their difference

    Implants are selected based on their shape, whether anatomical (teardrop-shaped) or round, and also based on their size, outer wall and the filling material. CE and FDA certifications attest to compliance with European and American quality standards. In order to select the right implant, your change requests and your individual anatomical conditions of the body should be taken into account.

    Breast implants are usually inserted through a few centimeters access (skin incision) in the area of the planned underbust fold. Alternative approaches are the armpit or on the edge of the areola. They can be placed under or over the large muscle (pectoral muscle) or under the mammary glands.

    What reference points are used in the examination of the breast?

    1 Middle clavicle 2 Jugulum 3 Décolleté 4 Upper inner breast quadrant 5 Groove between the breasts 6 Nipple 7 Base of the breast 8 Underbust crease 9 Crook of the elbow

    Changes in breast shape and bust size can be emotionally distressing after puberty or later in life. Certain features and proportions are generally associated with beauty, harmony, youthfulness and health. In order to get a comprehensive picture, various reference points are measured during the investigation. These individually different characteristics are taken into account when creating a treatment plan.

    What are the costs for breast augmentation with an implant?

    The costs for a breast augmentation with implants are determined during the personal consultation. Should you wish to get an idea of the price range in advance, please visit our cost page.

    Choosing the right breast implant

    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 [1]. 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 [2]. 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.

    Breast augmentation simulation

    3D simulations and VR glasses have become very popular in recent years. The problem with current algorithms is that they feign accuracy that is not realistic, especially when combining different methods. The variety and complexity of breast augmentation are not captured by most programs. We develop an individual treatment plan for each patient, which may include different techniques such as autologous fat treatment, a tightening of the skin mantle or the correction of fat deposits in front of the armpits. Since current simulation programs are not able to show such changes, we explain the expected changes on before and after pictures during the consultation. In addition, we offer the possibility of using silicone bra inserts to get a feel for the size change before surgery.

    Choosing the right breast implant

    When choosing the right implant, decisions must be made regarding shape (round or teardrop), projection (implant thickness), surface (outer wall), filling material (inner material), strength level, manufacturer and size. We will be happy to advise you on how to achieve the optical result of a natural breast in the desired size. Take a look here at which implants can be used for breast augmentation.

    A Ergonomic implant under the pectoral muscle B Ergonomic implant over the pectoral muscle C Round implant over the pectoral muscle

    1 Subcutaneous fatty tissue 2 Large pectoral muscle (Musculus pectoralis major) 3 Third rib 4 Décolleté 5 Intercostal nerves 6 Small pectoral muscle (Musculus pectoralis minor) 7 Round implant 8 Mammary gland 9 Intercostal muscle 10 External pleura

    The position and shape of a breast implant affect the contour of the breast. Teardrop-shaped (anatomical) implants have more volume in the lower half of the breast (breast pole). These implants offer the advantage of a natural transition in the décolleté. Unlike round implants, teardrop-shaped breast implants have a rough surface to maintain your alignment (more volume at the bottom than the top). The rough surface is suspected to cause blood cancer in rare cases. To make the implant less visible or palpable in the décolleté, it can be inserted under the large pectoral muscle. The large pectoral muscle is large enough to cover the entire implant in only a quarter of women (Madsen et al., 2015, Ann Plast Surg). In most cases, the origin of the large pectoral muscle extends to the 6th rib. The origin of the small pectoral muscle extends from the third to the fifth rib.
    Different shapes (different types) of the implant
    • Anatomical breast implants or implants in the form of drops: natural shape, possible risk of twisting the implant. Anatomical breast implants therefore have a rough surface.
    • Round breast implants: full décolleté. Round implants can accordingly have a smooth surface.
    Implant thickness
    • Medium projection: most natural results.
    • High projection: tends to be a full shape.
    Outer wall of the implant
    • Silicone shell with a smooth surface: tends to be smaller access, increased risk of capsular contracture.
    • Silicone cover with a rough surface: adheres better to the tissue (prerequisite for using anatomical implants), increased risk of ALCL.
    Filling material of the implant
    • Silicone: usually dimensionally stable material, lower risk of wrinkling.
    • Physiological saline solution: poorly dimensionally stable, increased risk of wrinkling.
    Degree of strength of the implant
    • Low strength: more natural shape, less projection.
    • High strength: unnatural shape, especially when lying down, high projection.
    Manufacturer of the implant

    Allergan, Inc. (USA, founded 1948), Establishment Labs S.A. (USA, founded 2004, Motiva®), Mentor (USA, founded 1969), GC Aesthetics PLC (Germany, founded 2015 with acquisition of Nagor Ltd. (UK, founded 1979), Eurosilicone (France, founded 1995), Polytech Health & Aesthetics (Germany, founded 1986, B-Lite®), Sebbin (France, founded 1986).

    Size of the implant

    Depending on age, size and weight, chest circumference and shape of the chest. As a rough guide, 130 to 150ml correspond to a breast enlargement of one cup size. In the US, 300 to 350ml is most commonly used and in Germany 250 to 300ml. Average cup sizes differ from country to country, but in general, the larger the body weight, the larger the cup size.

    1 Upper curve of the breast 2 Upper half of the breast (breast pole) 3 Breast fullness in lateral view (projection) 4 Lower half of the breast (breast pole) 5 Lower curve of the breast 6 Areola diameter

    How long do breast implants last?

    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.

    Ways (accesses) via which implants can be inserted

    Skin incisionAdvantagesDisadvantages
    Underbust creaseGood overview

    Placement of the implant under the pectoral muscle is possible.

    Use of an anatomical implant possible.

    Implant exchange possible via the same access

    Breastfeeding ability not affected.

    Scar visible when lying down or, in the case of small breasts, when standing up.

    areola borderInconspicuous scarNot possible with small nipples or large implants.

    Breastfeeding may be impaired.

    Possibly reduced sensation of the nipple.

    Further scar in case of implant change in the underbust fold.

    ArmpitNo scar on the breast itself.

    Advisable if there is a tendency to scarring.

    Advantageous for small to moderate enlargement of small breasts.

    Breastfeeding ability not affected.
    Precise placement of the implant is difficult.

    Increased risk of asymmetrical underbust folds.

    Keyhole technique with limited overview.

    Risk of damage to cutaneous nerves of the arm and lymphatic vessels

    Interferes with the examination of sentinel lymph nodes for the detection and treatment of breast cancer.

    Further scar in case of implant change in the underbust fold.

    Expensive equipment required.
    BellybuttonNo scar on the breast itself.

    Breastfeeding ability not affected.
    Only water-filled implants possible.

    Keyhole technique with limited overview.

    Further scar in case of implant change in the underbust fold.

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    Los Deline © liquid implant

    The tissue filler Los Deline© was developed in 2005 and initially marketed under the name Aquafilling© (Biomedica, Prague, Czech Republic). The colorless, transparent gel consists of 98% saline and 2% of a multiple bond of acrylamide and N,N′-methylenebisacrylamide. There may be minimal differences in the bond structures between the structure of Los Deline© and other polymethyl methacrylate (PMMA) tissue fillers. However, the overall composition of these tissue fillers appears to be very similar [3]. With other PMMA tissue fillers (for example Aquamid®) complications such as inflammation, pain and nodule formation were seen in over 18 percent of cases [4]. The complications of Aquafilling© occur afterwards, in the time frame of 5 months up to 12 years after the injection (on average 3 years). The complications occasionally have to be treated by surgery. The reasons for surgery are hardening in more than 80 percent, pain in more than 50 percent and inflammation in 7 to 8 percent (Cheng N, et al. 2002, Aesthet Plast Surg). The enlargement of a breast by injecting a liquid implant is seductive. All too often, these treatments are offered by doctors who, unlike plastic surgeons, are not proficient in alternative breast augmentation techniques. “Non-invasive” procedures are neither harmless nor without risk. Tissue fillers for breast augmentation were therefore banned by the U.S. Food and Drug Administration in 2015 [5]. Since the term cosmetic surgeon is not protected, there are also providers of highly dubious methods of breast augmentation, such as a 24-hour push-up augmentation with a saline filling. We therefore recommend that you not only question the quality of the implant, but also research the qualifications of the doctor in whom you place your trust. Always rely on high-quality implants of the latest generation. The combination of modern implants and experienced specialists in aesthetic surgery are the basic prerequisites for success. Inform yourself comprehensively.

    When can the end result be seen?

    This is one of the most frequently asked questions. The increase in size of the breast can be seen immediately after the operation, so that 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. The consistent massage of the scar and the use of a silicone plaster three to four weeks after the surgical procedure promote and accelerate the healing process and so that the scar can 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.

    Before and after pictures of a breast augmentation with implants

    With cosmetic surgery, many patients expect to be able to view before and after pictures (after pictures / before and after photos). When it comes to the topic of breast augmentation with implantation, women naturally insist in particular on placing themselves in the hands of an extraordinarily trustworthy expert in the field of plastic-aesthetic surgery in order to receive a detailed and competent individual consultation. You want to make sure you’ll be completely satisfied with the results by looking at after photos and getting an idea beforehand. In this context, they also expect to be shown before-and-after pictures (before-and-after photos) of any surgeries that may have been performed. You can view such photos for a before and after comparison when you make an appointment for a personal consultation. Of course, this is done in compliance with data protection regulations. In addition, a trial bra will be put on at the appointment so that you can visualize the target size.

    For further information, please consult the page on the subject of before and after pictures.

    Testimonials about breast augmentation with implants

    If you would like to read other patients’ experiences about their breast augmentation surgery with implants at Centerplast, you can check out our testimonials page.

    How can you prepare for breast augmentation with implants?

    The following instructions should be followed after breast augmentation with implants. General recommendations for breast surgery can be found on the Breast Surgery FAQ page.

    • For the first 6 weeks, sleep only on your back to avoid any risk of the implants slipping out of place.
    • All your questions about possible complications and alternative medical treatments should be answered in advance by the plastic surgery expert.
    • Avoid fast, sweeping and powerful shoulder movements. These could cause the breast implant to slip or twist. Chest muscle training should be paused for six weeks.

    How is breast augmentation performed with implants?

    • Before the start, a before picture (photo with specific settings) is recorded so that the result can be optimally compared.
    • The medical intervention is not only carried out under local anesthesia, but also under general anesthesia as part of an outpatient procedure in the practice, in a special operating room.
    • The wound after the operation is mostly sewn with self-dissolving skin threads.
    • Depending on the findings, drainage tubes can be inserted into the wound as part of the breast augmentation operation in the operating room, which can be removed again after a short period of time.
    • The duration of the operation including general anaesthesia is about 60 minutes.
    • According to the legal requirements, you will receive an implant passport or implant ID card. In this way, the origin of the implants can be traced back to the manufacturer at any time.

    What routine examinations are necessary after breast augmentation with implant?

    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.

    What is breast implant associated anaplastic large cell lymphoma (BIA-ALCL)?

    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.

    BIA-ALCL – What is the risk?

    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).

    How should the risk of developing BIA-ALCL be classified?

    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).

    What are the symptoms of BIA-ALCL?

    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.

    Are there any deaths attributable to BIA-ALCL?

    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.

    Recommendations for patients with textured breast implants

    Every woman should palpate her breasts regularly. After the age of 30, the breasts and armpits should be palpated annually by a gynecologist. After that, after the age of 50, an annual mammogram is recommended. Ultrasound or MRI examinations may be necessary if the mammography examination is not conclusive enough. Immediate examination by a plastic surgeon is required if you notice a change in the size, feel or shape of your breasts.

    Why are implants with a rough surface used?

    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.

    How is BIA-ALCL treated and what is the prognosis?

    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.

    Should implants be removed because of the risk of BIA-ALCL?

    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.

    What are the alternatives to removing the implants?

    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.

    Should women with breast implants be screened for BIA-ALCL?

    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.

    How does the BIA-ALCL develop?

    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.

    Is the use of implants with rough surfaces discouraged?

    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.

    What is breast implant disease or “Breast Implant Illness (BII)”?

    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.

    What is silicone?

    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.

    Is there a link between silicone and certain autoimmune diseases?

    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.

    Is there a test to confirm BII?

    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).

    Will patients with BII be cured by the removal of the implant?

    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.

    What can be done if Breast Implant Illness is suspected?

    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.

    What is the risk of breast implant disease (Breast Implant Illness)?

    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.

    What is a breast implant removal en-bloc?

    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 .

    Connection between silicone implants and “Breast Implant Illness”.

    For many years, it has been intensively discussed that silicone implants cause numerous complaints. Many of these complaints are summarized under the term “Breast Implant Illness” (BII). Causal relationships are investigated in medicine according to the Bradford Hill criteria. A causal relationship, such as brain tumor disease and cell phone use, must be factually and substantiated using these nine criteria. The explanation of terms, an illustrative example and the reference to Breast Implant Illness help to better understand the complex relationships.

    1) Strength of association

    • Explanation of terms: The more frequently a disease is observed after an event, the more likely a causal relationship is.
    • Example: All students in a class get excellent high school graduation grades in mathematics. They probably had a good teacher.
    • Breast Implant Illness: Scientific studies come to different conclusions. The overall quality of studies is still insufficient.
    • Sources: Janowsky EC, et al. 2000. N Engl J Med 342(11):781-790. Balk EM, et al. 2016. Ann Intern Med 164:164-175. Colaris MJL, et al. Immunol Res. 2017 Feb;65(1):120-128.

    2) Level of agreement.

    • Definition: if the conclusions of different studies, in different countries, at different times are the same, a causal relationship is likely.
    • Example: Climate scientists around the world agree – CO2 emissions are responsible for climate change.
    • Breast Implant Illness: the conclusions of studies contradict each other, with a current preponderance of voices denying a link.
    • Sources: Perkins LL, et al. 1995. Ann Plast Surg 35:561-570. Hochberg MC, et al. 1996. Curr Top Microbiol Immunol 210:411-417. Wong O. 1996. Regul Toxicol Pharmacol 23:74-85. Whorton D, Wong O (1997) et al. West J Med 167:159-165. Janowsky EC, et al. 2000. N Engl J Med 342:781-790. Rubio-Rivas M, et al. Clin Rheumatol. 2017 Mar;36(3):569-582.

    3) Specificity.

    • Definition: if there are no other risk factors, an association is likely.
    • Example: If a new watch with a new battery stops after one day when handled properly, it is likely a manufacturing defect.
    • Breast Implant Illness: The symptoms described vary widely and occur in a variety of conditions. The causes and triggers of autoimmune disease are still insufficiently understood.
    • Source: Colaris MJL, et al. Immunol Res. 2017 Feb;65(1):120-128.

    4) Temporal association.

    • Definition: the accumulation of a disease at a certain time after a harmful influence, makes a causal relationship likely.
    • Example: If abdominal pain occurs before or weeks after a restaurant visit, food poisoning is unlikely.
    • Breast Implant Illness: The length of time to symptoms varies from one to 15 years in scientific reports.
    • Source: Pavlov-Dolijanovic S et al. 2017. Rheumatol Int 37(8):1405-1411

    5) Biological gradient

    • Definition: if there is an association, a harmful influence over a long time, should be associated with a higher probability of disease.
    • Example: the more cigarettes someone smokes, the greater the increase in risk of lung cancer.
    • Breast Implant Illness: Different morbidity rates for unilateral or bilateral breast implants, saline implants, pacemakers, or small joint prostheses could not be found.

    6) Plausibility

    • Definition: The presence of a biological explanation supports a causal explanation.
    • Example: UV rays can damage the human genome and therefore cause skin cancer.
    • Breast Implant Illness: Foreign bodies are recognized in the organism by the defense cells and trigger an immune response.

    7) Coherence

    • Definition: Matching observations from laboratory experiments and observations in patients are more likely to indicate a causal relationship.
    • Example: The harmful effects of particulate matter can be observed consistently in animal studies and in traffic-intensive environments.
    • Breast Implant Illness: study results in humans and studies in the laboratory are very different.

    8) Experiment

    • Definition: Eliminating the risk factor should reduce the incidence of the disease.
    • Example: If a smoker stops smoking, the probability of getting lung cancer decreases.
    • Breast Implant Illness: A temporary improvement in symptoms was observed in 38 patients after implant removal.
    • Source: Rohrich RJ et al (2000) et al. Plast Reconstr Surg 105(7):2529-2537

    9) Analogy

    • Definition: Similar risk factors should lead to similar diseases.
    • Example: as smoking leads to lung cancer, an influence is likely in the development of bladder cancer.
    • Silicone implants in other body sites are not suspected to cause disease.
    • Breast Implant Illness: With the exception of ALCL, there is no known disease caused by silicone.


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    The author

    Dr. med. Stéphane Stahl

    “We provide you with extensive expert knowledge so that we can work with you to select the best possible treatment path.”

    Dr. med. Stéphane steel is the former director of the Clinic for Plastic, Reconstructive and Aesthetic Surgery / Hand Surgery at the Lüdenscheid Clinic. Dr. Stahl studied medicine at the Universities of Freiburg and Berlin. In 2011 he passed the European and 2012 the German specialist examination for plastic and aesthetic surgery. Further specialist qualifications and additional qualifications followed (including quality management, medical didactics, physical therapy, emergency medicine, laser protection officers, hand surgery) as well as prizes and awards. In 2015 he completed his habilitation in plastic and aesthetic surgery in Tübingen. He is an experienced microsurgeon, a sought-after expert and a regular speaker at specialist congresses. After a multi-stage selection process, Stéphane Stahl became a member of the American Society for Aesthetic Plastic Surgery (ASAPS), one of the world’s largest and most influential specialist societies for aesthetic surgery. His authorship includes numerous articles in respected peer review journals and standard surgical textbooks.


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