ABC of breast implants
In our daily work as surgeons, we are confronted with the question of the right technique and the optimal implant when discussing and performing reconstruction and augmentation of the female breast. Breast implants have been available in various forms for over 50 years. They have been constantly improved. Surgical techniques have been refined. Despite the new developments, the question of the advantages and disadvantages of breast implants still arises for every patient. Should I have breast implants? What alternatives do I have? How do I choose my surgeon? Which implants, which size and shape? What surface finish? What is the best approach for me? In which tissue layer will the implant be placed?
Weighing the benefits and risks and choosing the right implant is a difficult personal process. In 1995, the Federal Office of Public Health, together with experts from patient organizations and the medical profession, developed a brochure to answer the most important questions. The information brochure was revised in 2001 and served as the basis for the present brochure. It was revised and updated by a group of specialists from the Swiss Society for Plastic, Reconstructive and Aesthetic Surgery and the Swiss Society for Aesthetic Surgery. Its usefulness has been verified by patient organizations.
With this brochure we want to provide women with basic information about breast implants and thus reduce their fears.
The decision to get an implant is neither easy nor quick. You should only decide for or against an implant after a detailed explanation and sufficient time for reflection. If necessary, you should seek a second opinion. The goal of the consultation is achieved when you are aware of the possible side effects of the procedure and are prepared for regular follow-up examinations and, if necessary, follow-up operations.
Breast corrections may be necessary for a variety of reasons. The consequences of accidents, breast cancer operations or psychological problems caused by subjectively unsatisfactory or missing breasts can be a major stress for the women concerned.
Silicone implants are used, among other things, for reconstruction after breast removal and for reconstruction of a missing breast. Procedures should only be performed if medically and psychologically justifiable. The aim is to offer help to the women concerned. Patients generally feel more confident after the operation and experience less inhibition and feelings of inferiority.
The female breast is considered a sign of female identity and has an important function in a woman's life. However, it is precisely the social emphasis placed on the breast that stylizes it into a central symbol. The loss of a breast or deviations from the ideal can cause great problems for the women concerned. Plastic surgery has always helped to solve breast-related problems.
Any implant inserted into the body causes a so-called "foreign body" reaction. Such a reaction, which consists of the formation of a capsule around the implant, is normal and always occurs. In some cases, this capsule may thicken and shrink (capsular fibrosis) and eventually lead to calcium deposits. These can lead to painful hardening and changes in shape, which necessitate removal of the capsule and possibly replacement of the implant.
This procedure is covered by basic health insurance.
The operation can be performed on an outpatient basis, i.e. one day of surveillance at the surgical establishment and then a return home at the end of the day, or with an overnight hospital stay.
The operation is performed under general anesthesia or local anesthesia under sedation and usually lasts from one to two hours.
In principle, all activities are allowed as before the operation. Seat belts can be worn without hesitation. For extreme sports, you should consult your doctor.
As a rule, the ability to breastfeed is not affected by the implant. However, it may be affected by certain surgical procedures.
The shape of the breast is defined by the volume, diameter, projection and the shape of the implant itself. A breast prosthesis therefore has 4 parameters:
the shape of the shell
the volume in cc
the projection in cm
diameter in cm
The most common shapes are: the anatomical or drop-shaped prostheses which have a major projection in the lower pole in order to give a more natural curve, and the round prostheses which have the same projection on the whole diameter and give a more rounded curve.
Currently, there are round prostheses that behave like anatomical prostheses thanks to a silicone gel that can be shaped more easily. Once the volume is chosen (which is expressed in cc), the ideal diameter is defined according to the patient's original breast and the projection. All these parameters will give different types of breasts.
The shell of the prosthesis is almost always made of silicone. The inside of the prosthesis is made of gel. In most cases it is a silicone gel.
On the market, there are different alternatives: water gel, saline solution, etc...
Currently, silicone gels are cohesive for safety reasons.
In case of rupture, the gelatinous mass remains compact and does not come out of the capsule of the prosthesis. Silicone gel can also be ergonomic. This gel gives a more natural look and feel to the breast.
Plastic surgery has always helped to solve breast problems. Silicone gel-filled implants were first inserted in the United States in 1962. In 1963, the first implantation with a saline filler took place in France. The shell was always made of silicone. Silicone implants are also used for other purposes, for example to augment the chin or to replace testicles or joints. After 1980, individual cases were described in which a link between silicone implants and diseases such as breast cancer or autoimmune diseases was suspected. The US Food and Drug Administration (FDA) ordered expert consultation. Because there was insufficient data on the safety of silicone-filled implants, the FDA decided in 1992 to ban their use. One exception was implantation in controlled scientific studies. Saline-filled implants remain approved. In Europe, silicone implants could continue to be used. In 1999, the Institute of Medicine (IOM) published a report on the safety of breast implants. It clearly showed that problems with breast implants are local and that there is no evidence of systemic diseases such as cancer or autoimmune diseases according to recent studies. In 2001, the German TÜV introduced a quality label for breast implants. In the United States, silicone implants were approved again in 2006. This was followed in 2010 by the PIP implant scandal, which contained substandard silicone as a filler, and in 2015 by the recommendation to stop using implants from the Brazilian company Silimed. These incidents occurred under strict regulatory requirements. They show us that we are dependent on strict quality control by the authorities and that we must constantly document and follow up on patient histories.
There are several options for inserting the prosthesis: using existing scars on the breasts, making a 5 cm long peri-areolar incision, a 5 cm incision in the infra-mammary fold or a 5 cm incision in the axilla.
In 1997, a case of ALCL (anaplastic large cell lymphoma) was described for the first time in a person who received a breast implant. It is a malignant tumor that is associated with an accumulation of fluid around the implant. The occurrence of this complication is very rare. However, if breast swelling occurs one year after implantation, this complication should be ruled out. Complete removal of the implant capsule is the treatment of choice.
Until now, only implants with a textured surface have been affected by this problem, and as of 2019 these are no longer available on the market.
In the context of an aesthetic breast augmentation, it is possible, in most cases, to carry out cancer screening checks by mammography. It is necessary to inform the radiologists of your situation. In other cases, a sonogram can be performed.
An operation of this kind should only be performed by a specialist who has received appropriate training. You should ask about the qualifications of the specialist during the consultation.
In Switzerland, the surgeon must have a title of specialist in plastic, reconstructive and aesthetic surgery. This title is associated with the term FMH which stands for Federation of Swiss Physicians, the only official body recognized.
The prosthesis can be positioned behind the mammary gland, i.e. retroglandular, or more deeply behind the pectoral muscle if the volume of the breast is not too large, this second technique is called retropectoral. Some surgeons use the dual plane system, the prosthesis is partially behind the pectoral muscle.
In the case of breast reconstruction using a prosthesis, the decision to place it in front of or behind the muscle is made on a case-by-case basis. The thickness of the tissue mantle, i.e. the layer of fat under the skin after removal of the mammary gland, is the decisive factor: if the tissue mantle is thin, the prosthesis is placed behind the muscle to hide it better. However, if it is rather thick, the prosthesis can be placed in front of the muscle.
It is essential that you request an operation report as well as the information attached to each implant regarding the type, brand, expiration date, filling and envelope material of the implant. This information should be included in the medical history and in your personal file.
In Switzerland, there is an anonymous breast registry that collects all the information about the prostheses implanted by all the accredited Swiss surgeons. Only the operating physician knows the identity of the patient. This registry allows, in case of a problem, to immediately inform the doctor and to have statistics on the quality, the life span and possible complications.
Finally, specific body reactions that can be attributed to silicone are described. Direct contact of liquid or gel silicone with the surrounding tissue can cause a reversible inflammatory reaction. The body's defense system (immune system) is also involved. Experts believe that the possibility of a so-called generalized immune system reaction is very unlikely and not scientifically proven.
A defective implant should be replaced if there are symptoms.
All implants after 2000 have a cohesive silicone gel so that it does not leak out of the capsule and infiltrate the tissue. For previous implants, it is possible that the filler material has infiltrated the tissue and should be removed.
The surface of the denture capsule is smooth.
In the past, there were several surface options: smooth, micro-textured, textured (rough surface). For medical reasons already described, textured prostheses are no longer in commerce.
It is essential that you request an operation report and the information attached to each implant concerning the type, brand, expiration date, filling material and envelope of the implant. This information should be included in the medical history as well as in your personal records.
All Swiss physicians should enter the data of anonymous prostheses into a national breast registry for quality control.
Lipofilling allows to give volume to the breast with injections of its own fat.
Breast implants age and wear out. They also have a limited lifespan, but this cannot be predicted exactly. The silicone shell can tear (rupture) and the filler material can seep into the surrounding tissue. Even through an intact shell, a small amount of filler can leak out (bleeding). For this reason, patients with breast implants should ideally be checked regularly, at one or two year intervals.
Women who have undergone surgery at a young age in particular should expect to have one or more implant replacements during their lifetime. However, some new generation implants have a lifetime guarantee.
If the patient wishes to undergo a breast augmentation for aesthetic reasons, she usually has to bear the costs of the operation, the implants, the hospital stay and the loss of working hours herself. The additional costs resulting from possible immediate complications (such as post-operative bleeding, infections, removal of implants) are covered by the insurance. If the operation is performed for medical reasons (e.g. reconstruction after a cancer operation) the health insurance will cover all costs.
In any case, prior consultation with the operating physician and the health insurance company is necessary. It is also necessary to clarify whether the costs of periodic check-ups will be covered.