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Safety in Breast Augmentation– A Risk Management Approach

Friday, October 19, 2018

All surgery involves risks.  The key to successful surgery is to manage the risk so that it is kept as low as possible.

Breast augmentation is a particularly high risk procedure.  In fact, the Chief Medical Officer has issued a warning stating that:-

“All silicone breast implants are considered high risk medical devices”.

Yet breast augmentation remains a popular procedure not for vanity’s sake, but because many women have feelings of inadequacy associated with their small bust.

How then can we reduce the risk of breast augmentation surgery.  It all comes down to choice.

  1. Your choice of surgeon

This is your first and most important choice.  A wise choice of surgeon will significantly reduce your risk with this procedure.  Your surgeon should be experienced in all methods of breast augmentation; he or she should be qualified with an FRACS or its equivalent; they should be supported by friendly, approachable and knowledgeable staff; they should be attentive to your requirements and offer you choices; they should only operate in an accredited surgical facility.

  1. Your choice of implant

First, it may be possible for you to avoid an implant altogether.  This is by far the safest option and it involves harvesting fat from areas of excess on your body and, after preparation, grafting it by injection into the breast tissue.  The volume produced by fat grafting is not as great as the volume available with breast implants but all the complications associated with the breast implants can be avoided.  The main risks associated with fat transfer to the breasts include lumpiness of the breasts with the possible formation of cysts and also irregularities in the donor areas resulting from vigorous liposuction.  Experienced surgeon will do their best to avoid these complications.

If you desire a larger breast augmentation (usually 2 cup sizes or more) then you will need a breast implant.  Breast implants come in many different shapes and sizes but they are not equally safe.  It is safer to choose an implant with a smooth wall rather than an implant with a textured surface.  This is because textured implants are associated with a rare but serious condition known as Anaplastic Large Cell Lymphoma (ALCL).  This is a type of indolent cancer that forms in the scar tissue capsule which surrounds the textured implant.  Because bacteria have been found in association with this disease, it has been postulated that the textured surface of the implant allows bacteria to grow and ultimately trigger this disease.  ALCL has never been associated with smooth-walled implants and on this basis, choosing an implant with a smooth wall, reduces your risk.

Implants can be filled either with a silicone rubber gel or with a salt water solution called normal saline.  An implant filled with saline will always incur less risk than an implant filled with silicone gel.  This is because, should the implant leak, saline will be harmlessly absorbed by the body whereas silicone will travel to the lymph glands and to other parts of the body where it can form lumps.  Implants are known not to be lifetime devices and therefore they are expected to leak at some stage.  When your implant reaches the end of its life and begins to leak, there is far less risk if the implant is filled with saline compared to silicone gel.

  1. Location of the implant – in front of or behind the muscle

It has been known for many years that when an implant is placed in front of the muscle, in contact with the breast tissue, it is likely to become surrounded by a thick wall of scar tissue resulting in the breast feeling hard.  Conversely, when the implant is placed behind the muscle, it usually becomes surrounded by a thin capsule of scar tissue allowing the breast to remain soft.  So from this point of view, there is less risk of an unsatisfactory result by placing the implant behind the muscle.  Interestingly, when implants are placed behind the muscle, it is difficult to tell the difference between a saline implant and a silicone gel filled implant or between an implant with a textured surface and an implant with a smooth surface.

A specific risk of placing the implant behind the muscle however, is what is known as “Animation Deformity”.  This refers to enhanced visibility of the pectoral muscles when these muscles are contracted on top of implants.  For most women this is not a significant problem but for some it can be distressing and result in the necessity to remove the implants.  On balance, however, it is usually preferable to place implants behind the pectoral muscles.

  1. Your choice of anaesthetist

Most women having breast augmentation leave the choice of anaesthetist to their surgeon.  Usually surgeons will have a good working relationship with their anaesthetist.  It is worth remembering however that the anaesthetic component of your procedure does involve certain risks such as drug allergies, and a good anaesthetic can make the difference between you being able to go home the same day or having to remain longer in hospital due to excess pain, nausea or vomiting.  It is worthwhile finding out who your anaesthetist will be prior to your procedure and making sure that you have some communication with your anaesthetist to discuss your concerns and to ensure that he or she is doing everything possible to provide you with a smooth and safe anaesthetic experience.

  1. Your choice of surgical facility

These days breast augmentation is usually done as a Day Case which enables you to avoid an overnight stay in hospital.  The reality is that hospitals are dangerous places!  The less time you can spend in a hospital the better.  However it is important to ensure that the Facility where your surgery will be performed is Accredited to the National Standards.  These standards are designed to ensure adequate equipment, staffing and management processes to ensure the highest level of safety.

So, in conclusion, all surgery, including breast augmentation surgery, involves risk.  Our task should be to minimise risk.  In other words, anything that is high or medium risk is unacceptable.  For each of the considerations above, you should choose a low risk option.

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