Breast augmentation

Breast enlargement is achieved by positioning an implant behind the breast. The implant can be placed directly behind the breast tissue or under the chest wall muscle. The surgical incision can be placed in the fold under the breast, around the areola or in the armpit. There is a range of implants available to suit different situations. They all have an outer layer of silicone and can be filled with either silicone gel or saline.

Capsular contracture - The breast tissue around the implant can react by thickening and hardening as it treats the prosthesis as a foreign body and tries to wall it off. This causes pain and changes the shape of the breast as the implant is distorted by the capsular tissue. the capsule can be broken down by the surgeon by applying firm pressure. This is called a closed capsulotomy. In severe cases  the capsule has to be excised and the implant replaced.

Migration - The implant can move from it's original position resulting in a change in the shape of the breast. This problem will require further surgery to reposition the prosthesis.

Infection - the tissue around the implant can become infected. Response to antibiotics may be slow and occasionally the implant has to be removed to allow the tissue to heal properly.

Rupture - The lining of the implant can burst allowing silicone gel to ooze into the breast tissue. This can cause tender lumps in the breast called silicone granulomas.The implant will have to be removed or replaced.

Assessing breast problems in women with implants

The number of women with breast implants is increasing rapidly. In Australia it is estimated that 6000 breast augmentation procedures are performed annually. In addition approximately 3000 women undergo removal or replacement of their implants. These figures do not include the many patients who have implants inserted for breast reconstruction after mastectomy.

Medsafe Information on Implants

American FDA Information on implants

Implants create three different possible challenges for the breast surgeon.

First is the assessment of breast symptoms.

Second the challenge of breast screening/ surveillance.

Thirdly the diagnosis and management of specific implant related problems.

Breast assessment can be difficult in these women.

Clinical examination and mammography are both limited.

The presence of implants should not however delay appropriate investigation.

Triple assessment consisting of clinical examination, imaging and biopsy, is required. Ultrasound assisted clinical examination within the breast centre environment is the ideal way to initiate assessment. It allows us to distinguish solid from cystic lesions and the ultrasound findings usually permit categorisation of lumps as benign, indeterminate or suspicious. It clarifies the position of the implant relative to the pectoral muscle and gives an indication of how close the abnormality lies to the implant.

Breast implants are radio-opaque. Mammography is difficult and is less reliable in this situation as it is not easy to apply compression or to displace the breast tissue off the implant. If the presenting complaint is pain or discomfort the patient may be understandably concerned about the possibility of compression aggravating her symptoms or rupturing the implant.  A sensitive and well trained radiographer who takes time to explain things, and demonstrates awareness of the women's concerns can make a dramatic difference to the quality of the images and the patients tolerance of the procedure.

Cysts are easily identified and can be drained under ultrasound guidance. Solid lumps require a biopsy to establish a tissue diagnosis. Ultrasound guided needle biopsy minimises the risk of damage to the implant. If excision biopsy or wire localisation is required it is important to discuss the possibility of damage to the implant. A pre-operative diagnosis should be obtained whenever possible to allow optimal planning of the surgical procedure.

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