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Potential Breast Implant Complications

Rupture

After we have determined that an implant has ruptured whether it be saline or silicone, it becomes evident that the implant must be removed and may or may not be replaced if the patient decides to remove the contralateral implant. Patients who present with a ruptured implant may present with pain, swelling and a decrease in size of the breast. Ruptured saline implants can be associated with the edge of the bag becoming distorted, causing physical and visible obvious deformity of the breast which can cause pain associated with the pin cushioning of the lateral aspect circumferentially of the implant into the tissue itself. Ruptured silicone implants can spread both intra and extracapsular which can spread external to the breast, the lymph nodes, axillary region as well as to any lymphatic structures in the body, including spleen, liver, bone marrow, etc. Patients with Dow Corning implants placed from the 60’s, 70’s and early 80’s will usually present with severe encapsulation with a Baker IV capsular contracture with hardened calcified granulomas. These require both complete open exenteration and removal of all scar tissue, calcified granuloma, silicone material as well as breast reconstruction.

Capsular Contracture

There are four classes of capsular contractures. Baker I capsule is soft. Baker II is palpable. Baker III is palpable and visible and Baker IV is palpable, visible and hardened with severe distortion. They may also present with severe pain and coldness to the breast. Capsular contracture is one of the most common problems that I see in my practice in Beverly Hills and Las Vegas. These patients present with severe pain, with visible distortion, often superior retroposition of the implant with hardening around the bag causing pain and visible distortion. This surgery will usually require an open capsulectomy and/or open capsulotomy, removing and/or circumferentially releasing the scar tissue in order to relieve the pain due to severe encapsulation. Open capsulectomies are performed under general anesthesia. Patients are placed under general anesthesia by a Board Certified Anesthesiologist. The chest should be prepped and draped. The patients are given intravenous antibiotics.

The incisions can either be through the periareolar of the inframammary approach. At which time the capsule will be removed and complete scar tissue release for patients with Dow Corning implants should be performed in order to remove all calcified granulomas. The selected capsulectomies can be performed; however, on patients with less breast tissue in order to prevent visibility and loss of tissue coverage of the saline or silicone implant. Silicone implants do have a higher rate of capsular contracture and capsulation then saline due to the small pores within the silicone shell where it does leak silicone gel. Therefore, all of our patients are given the information preoperatively with silicone versus saline of a higher incidence of the capsulation would gel. Severe encapsulation will require surgical correction.

Capsular contracture has been treated by some plastic surgeons with the use of antiasthmatic medications, including Accolate and Singular. These are not FDA approved for capsular contracture. They may reduce the scar tissue from a Baker IV to III, but usually it is not enough to reduce the pain and patients you will eventually undergo surgical correction. There is a slight history of hepatic toxicity of the use of these two drugs and therefore, I do not recommend Accolate of Singular on my patients for capsular contracture.

Removal of the implant

Although implant removal can be performed, it may be a best option in patients who have had multiple surgeries that continue to undergo severe encapsulation of their breasts with minimal breast tissue left. With removal of the implants, a mastopexy or formal breast lift may be required, depending upon the position of the nipple areolar complex to the inframammary fold. We do perform explantations without reimplantation and normally a drainage tube is placed for 7 days and the patients are placed on antibiotics to prevent seroma formation within the pocket. Compression garments such as the new LinderBra may be useful for tightening up the tissue and skin postsurgically in order to reduce the skin laxity and it will form with exenteration of implants.

Changes in breast sensitivity

Sensitivity may be reduced by 5 percent. Patients who undergo breast enhancement surgery which can be increased up to 16 percent in those who undergo augmentation plus a mastopexy. The denigration of the nipple areolar complex by the fourth lateral intercostal nerve may be damaged during lateral dissection of the pocket and therefore only Board Certified Plastic Surgeons should perform breast enhancement reconstructive surgeries. Patients may also have problems with lactation and ability to breast feed and a similar percentage as those to loss of sensitivity from breast augmentation 5 to 8 percent and breast lift up to 18 percent.

Hematomas and Seromas

Patients who undergo augmentation mammoplasty procedure may end up with a hematoma which is simply a tear or a clot coming off of an artery which may lead to an arterial bleed, contained after a significant amount of pressure within the breast pocket. Large hematomas should be evacuated to prevent the increased incidence of scar tissue contracture. Hematomas are approximately one to two percent with seromas half that incidence. These should be evacuated immediately due to pain, and increased swelling. Hematomas are also associated with uncontrolled bleed; however, they usually will tap it on but the size of the breast may double in size. Patients will present with numbness to the hand and arm associated with ulnar nerve palsy or brachial palsy associated with the blood tracking to the lateral breast and extending into the brachial plexus from the axillary region. Hematomas should be taken seriously. Large ones should be taken to the operating room under general anesthesia. The incision should be reopened, implant removed and pockets should be irrigated, packed and hemostasis should be acquired. Vessels off and will clot and may be difficult find the actual area where the artery had opened. In any case, a drain may or may not be placed. The implant can then be replaced back in the pocket and closed. The patient should be maintained on antibiotics for seven days.

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