BREAST AUGMENTATION SURGERY: COMPLICATION PROFILES
There are inherent risks involved with all surgical procedures, when they involve a prosthetic device (such as breast implants) these are considered more significant and have to be considered over longer follow-up time periods. Some may be considered trivial others are devastating to both patients and surgeon. Regardless of estimated likelihood, these all should be discussed in detail with patients undergoing aesthetic surgery like breast augmentation. They generally pertain to aesthetic outcome and surgical complications.
Aesthetic outcome: capsular contractures, malposition of implant, implant visibility/palpability/rippling, sensory and asymmetrical position changes to NAC, breast size asymmetry, contour deformities, galactorrhea, skin stretch deformities, glandular atrophy over time and need for device change with passage of time are salient in the discussion with the patient.
Surgical complications: Postoperative haematoma, device failure/rupture/rotation (anatomical implants)/infection, hypertrophic/keloid scarring as well as implant related T-cell lymphoma need to be addressed.
Aesthetic Outcome of Breast Augmentation
- Capsular contractures: This is by far the most common reason for reoperation. Premarketing studies from Inamed, Mentor and the Danish registry reports are among comprehensive studies addressing complications following breast augmentation. The topic of capsular contractures, the study outcomes and preventative strategies have been discussed at length in the previous section. During follow up of 5373 women the Danish registry study indicated that 4% of women over a mean follow up period of 3.8 years underwent secondary surgery. Once the patient presents with a significant capsular contracture of Baker III/IV grades the only option is surgery. This surgery can take the form of capsulotomy, scoring and device exchange alone, capsulectomy and device exchange or neo-pocket creation and device exchange. Considering the discussion in the previous sections about the cause of capsular contractures and the roles of biofilms, bacterial inoculation and contamination of the capsule, the authors feel that it is good surgical principle to excise the capsule; where and when possible to create a new implant pocket and exchange the device.More recently the use of Acellular Dermal Matrix (ADM) has found a place in the debate on capsular contractures. Much like the concept of a “fire break” skin graft in Dupuytren’s disease, ADM has been found to prevent incorporation into the forming capsule. Histologic, basic science and clinical evidence indicate that placement of ADM yields an abrupt disruption of the forming capsule thereby alleviating capsular contractures. The authors favour the use of ADM in revisional augmentation surgery.
- Malposition is the second most common problem associated with breast augmentation and one of the most common reasons for revisional surgery. This occurs in about 1.2-1.6% of cases. The implant can be displaced in any direction, medially, laterally, superiorly or inferiorly. Resulting in synmastia (when medial displacement is bilateral), fall into the axilla, result in a double bubble deformity respectively. Double bubble deformity is defined in type I, the so called “waterfall deformity”, the implant sits superiorly to the breast and skin envelope that have “slipped” over the implant with ptosis. This type is most commonly seen when complete sub-muscular pockets are used or when the breast is suffering from significant ptosis (grade III) prior to surgery and augmentation rather than augmentation mastopexy is performed. Type II deformity is related to incorrect lowering of the IMF during surgery when the implant sits below the well formed IMF and breast tissue. Malpositioned implants can be difficult to treat. In the lateral implant displacement, which is most commonly due to over-dissection of the implant pocket or contraction of the pectoralis major muscle, the lateral part of the pocket can be excised and closed or simply closed to tighten the pocket more medially. Use of ADM in all malposition revisional surgery has been described and must be considered in the planning stage. Synmastia is notoriously difficult to treat, it is the result of over-dissection of the medial pocket and the sternal origins of the pectoralis major muscle in the sub-muscular planes. Here the use of ADM can be most useful, the capsule can be used to augment the medial border of the pocket in addition to a layer of ADM placed medially. A reduction in implant size where possible is helpful.
- Wrinkling/rippling: This is most commonly reported with the saline implants, particularly in textured subtypes. In a recent study this was reported to be observed in 37.5% cases and was not related to underfilled, recommended filled or overfilled devices. It is also more common when implant to parenchymal ratio is greater than 50%.
- Asymmetries: All breasts are asymmetrical, a preoperative observation and documentation is a good practice. The patient is made aware of these and hopefully makes, possible asymmetries as a result of the augmentation procedure, more acceptable.
- NAC sensory changes: as discussed previously these are more common in peri-areolar approaches. In the normal course of an infra-mammary or trans-axillary approach, transient altered sensation may occur. Generally it is considered that permanent changes are more common when implants larger than 350 ml are used. Although Mofid and colleagues in assessing a small cohort of patients and controls using accurate measurements argued that changes occur in all patients undergoing augmentation operations, that generally the extent of this change is linear in relationship to the volume of the implants.
Surgical Complication Arising from Breast Augmentation & Implants
- Haematoma: This is not as common it is usually in order of 1% risk. These must be evacuated many authors have noted persistent haematoma or significant seromas lead to capsular contractures .
- Device failure: The more recent generations of implants have proved to be more reliable, as noted previously saline implants now enjoy an approximately 4% deflation over the first 10 years. The Inamed 6 year follow up study of silicone implants reports a 3.5% device failure.
- Infection and exposure: This is a dreaded complication for both patient and surgeon. The reported rates of infection are between 0.9%-1.9% . The clinical picture presents along a spectrum. Traditionally the implants were removed and the patient was prescribed antibiotics. However recently, salvage procedures have become more common. These range from closed system antibiotics irrigation, conservative wound care and passive drainage in addition to systemic antibiotics. The more aggressive end of the spectrum involves exchange of the implant, provision of coverage with muscle or using posterior capsule. Spear reports a very good salvage rate of infected or exposed implants with seemingly good medium term follow-ups. However, given the discussion above pertaining to capsular contracture and presence of biofilms, the authors are of the opinion that in the long term these patients will inevitably develop capsular contractures. Except in the mildest cases the authors advocate capsulectomy and exchange of implant after the initial infection has been treated and the tissues have regained some of their suppleness.
- Late seromas: Appearance of a late seroma in an augmented breast is a source of concern for both patient and surgeon alike. Its management despite flow charts and various reportsbecomes more a matter of surgical principles and judgement in the authors’ view. It is ultimately a decision related to the cause of seroma. There are three main possibilities and each broadly requires a different approach. Idiopathic, infective, neoplastic. The 20 ml estimated volume on ultrasound remains the threshold for seroma formation that the authors consider. Many authors treat seromas with antibiotics empirically and observe the clinical progression of the patient. We believe if a patient presents with a new onset late seroma an ultrasound guided diagnostic aspiration is mandatory. The fluids are all analysed for microscopy, culture and cytology with Wright Giesma stained smears, for positive immunohistochemistry for CD30 positive cells, Anaplastic Lymphoma Kinase protein, translocation studies and others indicated in consultation with haematology/oncology team. Where the fluid is sterile, the idiopathic seroma maybe an indication of a subclinical infection of the biofilm, which may not be picked up on microscopy or culture. In these cases if persistent and unresolved with a course of antibiotics, the authors advocate a capsulectomy and device exchange. Our assumption is that there is a subclinical biofilm infection, which will not be resolved with antibiotics treatment. The infective seroma, where clinically mild, can often be treated with antibiotics. Although this may not lead to capsular contractures in the short term. This has to be weighed against long-term anticipation of capsular contracture as a consequence of subclinical biofilm infection. The decision as to when and if the device should be exchanged along with a capsulectomy and where possible change of implant pocket must be discussed and weighed against secondary surgery and its inherent risks as a revisional augmentation procedure. Where the seroma is of a malignant nature (Anaplastic Large T Cell Lymphoma (ALCL)), the treatment option is referral to the breast and haematology/oncology teams. Removal of the implant and capsulectomy is part of the treatment regime.
- Rotation: This is not a problem with traditional implants. The anatomical implants, have the advantage of filling the lower pole and especially useful with patients with mild ptosis (grade II good skin envelope), not willing to or suitable for augmentation mastopexy. However, up to 1% of anatomical implants under go rotation in their pockets which requires secondary corrective surgery.
- Scar formation: Keloid and hypertropic scar formation need to be discussed with the patients preoperatively.