In breast augmentation (enlargement; also known as augmentation mammaplasty) bags of saline or silicone gel are implanted under the breast (and sometimes also under muscle) in order to make the breasts look larger. Silicone gel implants usually provide a more natural look and feel than does saline, but both kinds of implants are prone to certain problems because they are foreign bodies. For years gel implants were favored by physicians and patients; their use was severely restricted by the FDA for the decade following the early 1990s until further research could be completed, but they are expected back on the broader market soon. Other effective and safe filler materials have yet to be developed.
There continued to be negative press about breast implants throughout the final stages of the testimony that led to the FDA’s recent decision to allow gel implants back on the market. Much of the press was generated by consumer opposition groups; however, when challenged, neither these groups nor the FDA was able to produce any credible, peer-reviewed research demonstrating a correlation between breast implants and systemic diseases such as arthritis and other autoimmune diseases, the most serious charges previously leveled against gel implants. In a congressional briefing held in May 2005, epidemiologist Dr. Joseph McLaughlin pointed out that no device in the history of the FDA, including heart valves and vascular stents, has ever been subject to a comparable level of review and study.
Breast augmentation surgery is performed with the patient asleep or heavily sedated in an office or ambulatory surgery suite. The incisions are usually small and hidden in discreet locations but do leave visible scars.
Any operation in which a foreign object is implanted in the body has unique risks associated with presence of the implant. Infection or bleeding around the implant is more likely to lead to additional surgery than would similar complications of operations that do not involve insertion of a foreign body. If an implant has to be removed because of a complication, reimplantation is usually possible after an interval appropriate to the situation.
Breast implants are prone to a condition called capsular contracture, which refers to the undesirable hardening of the natural scar that forms around the implant over time. Capsular contractures can be mild and asymptomatic or they can be severe, causing pain and breast deformity. Severe capsular contractures often require further surgery and even then can recur. Some degree of capsular contracture is a very common event after breast augmentation surgery, although most capsular contractures do not require treatment.
Breast implants can also leak. Leaking saline-filled implants eventually deflate; the saline is safely absorbed and the affected breast looks smaller. The patient may opt to have the leaking implant removed or replaced. For a woman with a leaking silicone gel implant, the presence of free gel usually is not harmful per se, but the implant should always be removed to minimize the possibility of gel migration to other parts of the body.
Breast implant technology has improved over the years, but even so, no one knows for sure how long a breast implant will last. Women with breast implants should keep a copy of the technical information about their implants for future reference.
The presence of breast implants make the performance and interpretation of mammograms (breast x-rays) more difficult, and special techniques must be used to maximize breast visualization. A woman at high risk for breast cancer should consider carefully before choosing to have breast augmentation.
Subsequent pregnancy may affect augmented breasts in undesirable ways. Breast-feeding is feasible, but if a breast infection develops, the underlying implant may be affected and have to be removed. The forces of gravity and the effects of aging and weight changes will alter the appearance of augmented breasts and not always for the best. Sometimes the breasts drop, but the implants do not.
Other risks associated with breast augmentation include asymmetry (uneven positioning), poor quality scars, nipple numbness (usually but not always temporary), and abnormal breast contour. The last can occur in thin patients in whom the upper border of the implant is visible; in patients in whom the implants are placed under the chest muscles, causing an unnatural deformity of the implant with muscle activity; and, most notoriously, when excessively large implants are inserted.
Breast implants can cause pressure-related molding of the underlying rib cage, which can be permanently noticeable in very thin patients who have had their implants removed. Smokers are at higher risk for complications than are nonsmokers. Breast augmentation patients can expect moderate discomfort, swelling, and bruising for a week or two after surgery and will have some activity restrictions for about four weeks. Final breast size and contour will not be evident for about six months, and because of the unpredictability of the scar that forms around the implants, augmented breasts have the potential to change shape indefinitely. Dissatisfaction with size is very common with breast augmentation patients, and the same patient will at various points feel her breasts are too big or too small.
The bottom line: Breast augmentation is by no means a risk- free operation, and a woman should be fully aware of all risks, including the significant potential for symptomatic capsular contracture. The best results are seen in women who choose moderate rather than dramatic enlargement.
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