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• Periareolar: This incision is made around the nipple and is the most concealed incision. However, it is associated with a higher likelihood of an inability to successfully breast feed compared with other incision sites.
• Transaxillary: This incision is made under the arm and is less concealed than the periareolar incision. The ability to successfully breast feed with this incision is likely.
• Inframammary: This incision in made within the breast fold and is less concealed than the periareolar incision. The ability to successfully breast feed with this incision is likely.
Another incision site, the umbilical/endoscopic incision site, is not recommended by the companies who manufacture breast implants.

Breast Reconstruction
In breast reconstruction, most implants are placed through the mastectomy scar either immediately during the mastectomy procedure or after tissue expansion. Two-stage reconstruction is typical. In the first stage, a breast tissue expander is placed at the time of mastectomy. Tissue expansion typically lasts 4 to 6 months. The tissue expander is then replaced several months later with a breast implant. This is considered immediate reconstruction because the tissue expander is placed at the time of mastectomy. Delayed reconstruction is also a 2-stage process. This process begins with a breast tissue expander placed months or years after mastectomy. The tissue expander is then replaced several months later with a breast implant. This is considered delayed reconstruction because the tissue expander is placed after the mastectomy site has healed.

A potential advantage to immediate reconstruction is that breast reconstruction starts at the time of the mastectomy and is thus more cost-effective. However, with immediate reconstruction, there may be a higher risk of complications (eg, rupture/deflation) as well as longer initial operation and healing times.

A potential advantage to delayed reconstruction is that the reconstruction decision and surgery is delayed until other treatments, such as radiation therapy and chemotherapy, are completed. Delayed reconstruction may be advisable if healing problems with the mastectomy are a concern or if the patient requires more time to consider her options.

Potential Complications
Some women with breast implants have reported health problems (eg, rheumatoid arthritis, polymyositis, and fibromyalgia) they believe are related to their implants, but most studies of these diseases have failed to show an association with breast implants. Most of the health concerns about breast implants are related to the body reacting to a foreign material, such as silicone gel.

A report by the Institute of Medicine in 2000 indicates that breast cancer is no more common in women with breast implants than those without breast implants. While not conclusive, cancer rates have been reported to be slightly higher for some types of cancers. Cancer rates that have been higher in more than one study are lung cancer and cancer of the vulva. Because these cancers may be related to other factors that were not examined in these studies (eg, smoking), these studies are not considered conclusive.

Some women with breast implants have reported neurologic symptoms (eg, difficulties with vision, sensation, muscle strength, walking, balance, and memory) or diseases (eg, multiple sclerosis) they believe are related to their implants. Several studies have indicated that women with implants are at no increased risk of being hospitalized with neurologic disease compared with other women. The Institute of Medicine's 2000 report found no association between the presence of implants and neurologic diseases or symptoms.

It is important that patients considering the use of breast implants understand the following:
• implants do not last a lifetime and will likely need to be removed at some point in the future;
• complications are likely to occur and may require additional physician visits and reoperation;
• many of the changes to the breast after implantation may be cosmetically undesirable, as well as irreversible; and
• if implants are removed, unacceptable dimpling, puckering, wrinkling, loss of breast tissue, or other undesirable cosmetic changes of the breast may result.
Potential local complications include, but are not limited to, the following:
• asymmetry;
• inflammation/irritation;
• breast pain;
• malposition/displacement;
• breast tissue atrophy;
• necrosis;
• calcification;
• nipple/breast sensation changes;
• capsular contracture;
• palpability/visibility;
• chest wall deformity;
• ptosis;
• delayed wound healing;
• redness/bruising;
• extrusion;
• rupture/deflation [Figure 1];
• galactorrhea;
• scarring;
• granuloma;
• seroma;
• hematoma;
• unsatisfactory style/size;
• iatrogenic injury/damage;
• wrinkling/rippling; and
• infection, including toxic shock syndrome.

Figure 1. Deflation in a patient with previous augmentation. (Source: FDA)

Reoperation
Reoperation may be necessary to manage local complications. Examples of the types of surgical procedures that may be performed in a reoperation include the following:
• implant removal with or without replacement [Figure 2];
• capsule procedure;
• scar or wound revision;
• drainage of a hematoma;
• repositioning of the implant; or
• biopsy/cyst removal.

Figure 2. Implant removal without replacement in a patient with previous augmentation. (Source: FDA)

The following links review the current knowledge about breast implants that is available on MD Consult. Book chapters, recent journal articles, clinical practice guidelines, and patient education materials are included.

Related Information
Story List
Reference Books

Plastic Surgery
Breast Reconstruction
Breast and Aesthetic Surgery
Townsend: Sabiston Textbook of Surgery, 17th ed.
Copyright © 2004 Saunders, An Imprint of Elsevier

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