Although breast cancer is a relatively common disease (1 in 8 women, lifetime risk), less than 0.5% of these cancers are Non-Hodgkin’s Lymphomas. Historically, the few rare cases of breast lymphoma that have occurred have been B-cell Lymphomas. In the last few years, there have been about 42 cases diagnosed of T-cell Lymphomas in women with breast implants in place. Thirty-five of these cases have been the rare ALCL type, Anaplastic Large Cell Lymphoma, found within the breast capsules surrounding breast implants. ALCL has been previsously shown to occur as a primary entity within the skin. Those particular types of Lymphomas have a fairly good survival rate: the ten year survival is over ninety percent. Investigators think that this new breast implant-associated ALCL may behave in a similar fashion as the cutaneous types have. A recent article (Taylor, Webster and Prince, Anaplastic Large Cell Lymphoma and Breast Implants: Five Australian Cases,Plast Recon Surg, Vol 129, No 4, p808, April 2012) has provided an update to this new entity.
According to the article, the diagnosis of ALCL should be considered in any patient who presents with a peri-prosthetic seroma formation six months or longer after they had their implants put in. Historically, there have been no studies that have linked any types of breast cancer to breast implants. However, older studies that looked at breast cancers that occurred in patients with breast implants did not report on the occurrence of lymphomas in the breast.Currently, there have only been about 42 cases of T-cell lymphoma associated with breast implants reported in the literature. Thirty-five of these cases were ALCL, Anaplastic Large Cell Lymphoma. Of cases that have been reported, they have occurred in patients with both saline and silicone implants. However, in one of the studies all of the patients who had developed ALCL did so in the presence of textured implant devices. Of the previously reported patients who developed breast implant associated ALCL (37 cases, of which only 31 had complete data) available in the literature, 13 of the cases occurred in patients with SALINE implants. In all of the cases that were reviewed that had accurate data available, textured surface implants were used. Although inconclusive, these cases suggest that the entity of breast implant associated ALCL occurs only in the presence of textured surface breast implants, irrespective of being filled with saline or silicone. Importantly, all but two of the patients that have developed this diagnosis have had a good prognosis.
If you have developed swelling of one breast more than six months after breast augmentation surgery and are considering breast implant removal, you should contact Dr. Brenner.
1. Implants too old: The lifespan of a breast implant is generally thought to be about 10 to 12 years. However, age of an implant alone is not necessarily a reason to remove them. Especially with respect to saline implants, if a patient is not having any issues with the implant, it is likely safe to leave the implant alone. Conversely, silicone gel implants may require imaging once they reach a certain age. This is best done with anMRI, which has the best detail and the most sensitivity for detecting damage to the outer shell. If a silicone implant is noted to be damaged, then breast implant exchange is indicated.
2.Implants ruptured or leaking: Breast implants are mechanical devices and will develop “wear and tear” over time. When a breast implant sustains an injury to its shell (i.e.a tear) it will begin to leak its contents. With respect to saline implants, the saline will leak out slowly and be absorbed by the capsule and into the blood stream. Silicone implants can leak as well. However, silicone implants (in particular the new cohesive gel silicone implants) will tend to maintain their shape, even when the shell is compromised. When an implant leak leads to a change in shape of the breast, this is known as symptomatic rupture. When an implant leak is undetectable to the eye or on physical examination, this is known as silent rupture.
3. Want an implant size change: Some women have breast implants that they are very happy with; they just simply would like a size change. For most patients that fall into this category, they have grown familiar with their size and would prefer to exchange them for a bigger size. For the minority of women who desire a smaller size, they may choose to “downsize” their implants.
4. Want to change from saline to silicone breast implants: Both saline and silicone are great choices when it comes to breast augmentation. However many patients were implanted with saline implants prior to silicone implants becoming approved by the FDA in 2006 for cosmetic use. Therefore, there is a large subset of women who want to switch to silicone simply for the advantage of having breast implants that feel more natural.
5. Capsular Contracture: Breast implants are mechanical devices. Following implantation, the body forms a capsule around the breast in order to “wall off” the implant as a foreign body. Rarely, people will have an overwhelming inflammatory reaction within the breast capsule that causes it to tighten around the implant. When severe, this may require removal of the breast capsule along with removal and replacement of the involved implant.
Breast revision surgery may occur for several reasons, including altering the size or shape of the implants, correcting implant malposition, removing and/or replacing old or ruptured implants and correcting a condition known as capsular contracture.
Dr. Brenner is a double board certified plastic surgeon specializing in breast & body contouring with an emphasis on breast revision surgery. His extensive training in general, reconstructive and aesthetic surgery has helped him to develop advanced techniques for natural, lasting results.
Capsulectomy to correct capsular contracture is amongst one of the most common breast revision procedures performed by Dr. Brenner.
What is Capsular Contracture?
Breast capsules are formed as the body’s natural response to wall off the breast implant from the surrounding tissues. This process occurs any time a foreign device is placed into the body whether it is a pacemaker, artificial joint or breast implant.
During breast augmentation, a pocket is created either over or under the muscle for the implant to sit. A breast capsule consisting of fibrous tissue is formed along the outside border of the pocket to allow for natural movement of the implant. In some instances, an exaggerated response by the body may cause the breast capsule to develop excess tissue and tighten around the implant. This is a condition known as capsular contracture.
Although capsular contracture may occur anytime after breast augmentation, most instances occur in the first few months following the procedure. Common indications of capsular contracture include hardening and distortion of the breasts experienced with moderate to severe discomfort. Overdevelopment of the breast capsule cannot be predicted prior to surgery and is amongst the most common complications of breast augmentation.
The degree of capsular contracture varies from person to person and is explained using the Baker Grading System
Baker Grading System – 4 Grades of Capsule Contracture
Baker Grade I – The breast is normally soft, and looks natural.
Baker Grade II – The breast feels a little firm, but appears natural.
Baker Grade III – The breast feels firm, and is beginning to appear distorted in shape.
Baker Grade IV – The breast is hard, and has become distorted in shape. Pain or discomfort may be associated.
How to Prevent Capsular Contracture
Placement of Breast Implants
Although capsular contracture may occur whether the implant is placed above or below the muscle, studies have shown that breast implants placed over the muscle have a 10%-25% higher instance of developing excess tissue in the breast capsule. For this reason, Dr. Brenner prefers to place breast implants under the muscle. His no-touch technique for placement of silicone implants using the Keller Funnel also decreases the instance of capsular contracture by decreasing the likelihood of contamination.
Using Drains After Revision Breast Surgery
A condition where fluid accumulates in the breast capsule, known as a seroma, has also be linked to the occurrence of capsular contracture. This most often occurs during secondary or breast revision surgery. For this reason, Dr. Brenner utilizes small surgical drains after revision surgery to remove any excess fluid.
Breast Augmentation Massage
Whether after a primary or breast revision surgery, it is important to perform breast massage at least twice a day for about 10 minutes beginning two weeks after surgery. During your post-operative appointment, Dr. Brenner will discuss and demonstrate how to properly perform a breast massage to help drop the implants into place and keep them soft. Displacement of the implant inside the breast capsule will help break up any excess tissue which may form around the implant, reducing the chance of capsular contracture.
Accolate to Help Treat Capsular Contracture
Accolate is a popular prescription used by plastic surgeons to help treat capsular contracture. Used primarily as an asthma medication, doctors have found that its anti-inflammatory properties have helped reduce the severity of capsular contracture in up to 50% of cases according to several studies.
Accolate typically works best for patients in the early stages of capsular contracture and is often recommended as the first stage of treatment before breast revision surgery is considered.
Breast Revision Surgery for Capsular Contracture
If capsular contracture does not improve with massage or the use of Accolate, breast revision surgery, known as a capsulectomy, is performed release the hold of the breast capsule around the implant.
Some surgeons will perform what is called a closed capsulectomy where the implant is squeezed tightly to forcibly “pop” the implant out of the breast capsule. This can be performed as a quick office procedure without the use of anesthetics, but is not recommended by most board certified plastic surgeons and implant manufacturers. Closed capsulectomy has demonstrated a low rate of success and a high rate of implant rupture.
Dr. Brenner only performs open capsulectomy for patients seeking breast revision surgery for capsular contracture. Open capsulectomy is a safe and effective procedure with lasting results. An incision is made, usually in the same location as the initial breast augmentation scar, and the fibrous tissue that creates the capsule is scored to release its grasp on the implant. The implant is then removed along with the breast capsule and excess fibrous tissue.
During capsulectomy, patients may choose to remove the implant entirely or to replace the implant after the breast capsule has been removed. Depending on the age and condition of the implant, Dr. Brenner may recommend removing the existing implant and replacing it with a new one. If the implants were originally placed over the muscle during primary breast augmentation, while performing breast revision surgery Dr. Brenner will often revise the pocket and relocate the breast implants under the muscle for a more natural appearance and reduced chance of recurrent capsular contracture. Occasionally, Dr. Brenner will place an acellular dermal matrix graft (such as Alloderm, Strattice, or Flex HD) into the pocket around the implant. Some studies have shown a decreased incidence of recurrent contracture with the use of these products.