Wrinkling

This is the most common complication of saline implants. Usually it is possible to feel, but not see the rippling in the envelope. But sometimes the rippling is apparent, especially in thin women.

Nipple Numbness

It is important to preserve the intercostal sensory nerve branches by using gentle finger dissection of the lateral pocket during surgery. Almost 40 percent of patients experience some degree of nipple numbness after surgery. In my experience, very few patients (2.3 percent) have persistent loss of feeling in one or both nipples after breast augmentation. Almost all patients (98.5 percent) would have the surgery again, despite any experience of nipple numbness.

Capsular Contracture

The body always forms a capsule around implants. This is normal and desirable. However, sometimes the capsule becomes firm and tight. This is called a capsular contracture. Why does this happen? We do not know. Perhaps it is part of the body's response to the implant. Some researchers think a "subclinical" infection might be responsible.

What causes the capsule to tighten? Tiny cells in the capsule lining perform a microscopic "tug-of-war" on the collagen fibers. There is nothing wrong with the implant. It is sitting innocently in the pocket while it is being squeezed by the lining that encases it. It is compressed into a more spherical shape. This shape is not a coincidence - a sphere is the smallest surface area-to-volume relationship. Not only do we not know why this complication occurs in women, we also do not understand why it usually happens on one side and not the other. You would think the body would react the same on both sides.

As a result of this tightening, the implant is pushed in the direction of least resistance, usually up. Treatment calls for a return to surgery to have the capsule released, called an "open capsulotomy." The implant is repositioned at a lower level.

Fortunately, an open capsulotomy, done under a brief sedation with the patient asleep, is not painful and patients can get back to most of their usual activities right away, even returning to work the next day, or after a weekend. The surgeon simply cuts the capsule lining on the inside.

The procedure is minimally painful because the amount of dissection is limited. The surgeon simply cuts the capsule lining on the inside. The pocket has already been developed, so there is no dissection lifting the muscle off the chest wall.

Once the capsule is released with an open capsulotomy, the pressure on the implant is immediately relieved and the breast softens. It is possible for a contracture to reoccur, but fortunately, this is unlikely. The capsule does reform, but it usually does not again tighten down on the implant sufficiently to cause a capsular contracture, although I have had occasional patients who required a second capsulotomy. In these patients, there is usually a history of ruptured silicone gel implants. Even though we do not know why capsular contractures occur in some patients and why it usually does not recur, in our ignorance perhaps we should be thankful that this complication does not always happen with implants.

Silicone gel on the surface of silicone gel-filled implants may be implicated in the development of this complication, especially in older, leakier implants. When silicone gel implants were widely used in the past, capsular contractures were a common complication, occurring in over 20% of patients. Fortunately, with the used of saline implants in a submuscular location, the incidence of this unwanted complication has diminished to about 10% at five years. Time will tell if this problem occurs less often after the newer cohesive gel implants, but, for the time being at least, patient who have saline implants are least likely to have a capsular contracture.

It is an irony of silicone gel implants that patients either had superb, natural-feeling breasts, or they developed hard capsules. In the past, these unfortunate patients who developed hard capsules were often treated with the now-condemned closed capsulotomy technique, which basically meant the surgeon squeezed the implant as hard as he could in the office, with the patient wide awake, until the capsule tore open, releasing the compression on the implant and softening the breast.

This was effective in correcting the problem, at least momentarily, but unacceptably uncomfortable for patients. Of course, this maneuver likely ruptured implants that were not already ruptured. Today, open capsulotomies are done instead, with the patient asleep.

Implant Leakage

Occasionally, breast implants leak, and lose volume. In the past, when I used textured implants, approximately 1% of my patients per year returned with an apparent reduction in breast size, usually on one side, indicating a leak. This is about the same as the leak rate reported by other plastic surgeons (3% in three years). Since making the switch to smooth implants, my implant deflation rate has dropped to about a tenth of this, 0.1% per year.

Implants do not typically leak because of physical or sexual activity and I counsel my patients that they do not need to treat their breasts any more carefully after healing from breast augmentation than before surgery. If an implant leaks, it does so without provocation. Indeed, the cause is usually a leak at a fold in the envelope. These problems are related to the implant itself and cannot be controlled by the patient. Typically, such a patient calls my office and reports that one side just seemed to deflate and she wasn't doing anything strenuous when it happened. The procedure to replace a deflated implant is very short, and there is almost no postoperative pain, because there has been very little new dissection at surgery. The pocket is already developed and it's just a matter of putting in a new implant through the same old incision. Patients are usually back at work in a few days.

The implant manufacturer guarantees the implant so that there is no charge for the replacement implant. For the first ten years (increased from five years in 2005), the manufacturer also provides $1200 reimbursement toward the cost of anesthesia and the facility.

Implants available today are imperfect. However, saline-filled implants are safe and easy to remove. Perhaps in the future, implants will have better filler materials, less mammogram interference, and better technical characteristics to make them feel more like breast tissue, deflate less, and resist wrinkling.

Hematoma

Bleeding is a possible complication after most types of surgery and breast augmentation is no exception. This complication is on the minds of all plastic surgeons and nurses in the period immediately after surgery. Detection requires vigilance on the part of the patient and surgeon. Hematomas typically occur within the first 24 hours after surgery and most of these occur within the first 12 hours. If one breast swells dramatically more than the other, filling the upper pole below the collarbone, and if there is much more pain on one side than the other, this probably indicates a hematoma - postoperative bleeding which requires immediate attention. Usually patients hold their arm on the affected side close to their body and cannot reach out without pain. A clot may have come loose from a small artery that was divided when the pocket was made at surgery. The wound must be reopened and the blood clot removed. Any bleeding is controlled with cautery.

Provided the hematoma is detected early, and treated, the outcome is excellent. One reason I see patients the day after breast augmentation is to make sure they don't have a hematoma. Also, I insist that out-of-town patients stay in the area at least 24 hours so they don't have far to come if they do develop this complication.

Implant Malposition

If the pocket is not developed in the right place, or moves after surgery, the implant may ride high or low and require repositioning. Sometimes one implant settles more than the other or there may be a small difference in the cleavage area. An implant may be pushed up by a capsular contracture. The treatment is the same - repositioning the implant.

Infection

Infection is a risk in all operations. Patients are given antibiotics as a preventative measure. Patients may develop infections that will necessitate removal of the implants to eradicate the infection. New implants may then be inserted once the infection is clear. Fortunately, this is a rare occurrence.

Hypertrophic scars

Excessively wide or thick ("hypertrophic") scars may develop at the sites of the breast incisions if a patient is predisposed to these unfavorable scars. Fortunately, the inframammary scars are in an inconspicuous location.

Other Complications

Occasionally, a seroma forms months or even years after a breast augmentation. This usually requires intraoperative evacuation. Implant exposure is very rare.