A Plastic Surgeon on What to Know about Breast Implant Illness
A Plastic Surgeon on What to Know about Breast Implant Illness
Breast augmentation is the most common cosmetic surgery in the US. But most may not be aware of the complications that can occur. Little is known about the condition called breast implant illness except that patients are attributing symptoms including brain fog, joint and muscle pain, hair loss, sleep disturbance, and infertility to their implants. Evidence for a connection between these symptoms and implants is lacking, and many doctors do not recognize breast implant illness as a diagnosable condition. But according to Kevin Brenner, MD, a plastic surgeon who specializes in breast surgeries and implant complications, implant removal is helping these patients feel better.
Other complications of breast implants are better characterized, with the most common being capsular contraction. One estimate puts the incidence at 10 percent of implant recipients. A much rarer complication is breast implant-associated anaplastic large cell lymphoma, a type of cancer caused by textured implants. An estimate of the lifetime risk of BIA-ALCL among people with implants is 1 in 7,000.
A Q&A with Kevin Brenner, MD
Breast implant illness is a constellation of symptoms that people are reporting that they think are being caused by their breast implants. The biggest problem with breast implant illness is that it’s not a well-defined issue or disease process. The symptoms are varied and overlap with other disease processes. As a physician, my biggest problem is ruling out other serious medical problems.
Some of the most common symptoms of breast implant illness are brain fog (lack of clarity of thought), joint and muscle pain, hair loss, sleep disturbance, and infertility. Some people get skin rashes; some have breast pain. Some people have tingling in their extremities or on their torso. There are also many symptoms that overlap with autoimmune and endocrine diseases, such as hypothyroidism. Some studies have also shown an increased rate of scleroderma in patients with silicone implants.
To date there’s no firm data showing that implants are the cause of these symptoms. There certainly seems to be an association. Breast implant illness has been a patient-driven phenomenon, mostly on social media. And to the patients’ credit, they’ve banded together and said, “Hey, I have this. Do you have this?” They’re sharing stories and experiences and realizing that many of them have similar symptoms. It’s still in a really small percentage of people, but it’s a significant number of people.
My goal as a surgeon is to say, “What can I do to help you get better and move on with your life and feel better about yourself and your health?” I’ve been seeing a lot of breast implant illness patients for the last few years, and this issue has been increasing every month. For some people, I can take out their implants and then do a breast lift to restore their breast aesthetic. For other patients with smaller amounts of native breast tissue, I will inject some of their own fat into the breast to give them a little bit more volume. It’s not usually the same amount of volume as they had with their implant, but at least it’s something.
The body forms a specialized version of scar tissue, called a capsule, around all implants, whether it’s a knee or a breast implant. When I remove an implant I also remove the breast implant capsule.
Patients have told me that many physicians either don’t recognize breast implant illness, aren’t paying attention to it, or don’t believe their patients. I’ve had a lot of patients say, “I saw my plastic surgeon, and they just shushed me up and said, ‘You’re fine; your breasts are fine; get out of my office.’”
That data does not exist. We don’t know that taking the implants out changes anything. In my practice, I’ve noticed that most patients feel better when I take them out along with the capsules. Some of them feel only 5 percent better; some, 85 percent better. And some of them feel better a week later, while for others, it’s several months before their symptoms subside. It depends what the symptoms are, and it depends how sick they seem to be.
In my practice, the overwhelming majority of people do get better after the implants are removed, and I don’t have a really good explanation as to why other than perhaps there’s a subset of people who are genetically predisposed to having an inflammatory response to their breast implants. But we don’t have any tangible evidence. There’s no marker in the blood we can measure yet.
I’m the first plastic surgeon in Southern California I’m aware of who has created a breast implant illness team. My practice has a breast implant illness liaison, who is a former breast implant illness patient of mine. We ended up teaming up, and she’s a huge patient advocate. I perform the surgery, and she helps guide patients in other ancillary services they might need—whether it’s ultrasonography, correction of pigmentation, psychotherapy, or detoxification. We’ve assembled a team to make these practitioners available to my patients.
It’s important to start doing some research as to why this illness is happening and what we can do to avoid it. I also counsel my patients and discuss whether they want their breast implants and capsules removed alone or in conjunction with a breast lift, or fat transfer. Breast reconstruction can be important for a patient who’s had breast cancer. There are great surgeons who do reconstruction with the patient’s own tissue, but not everyone is a candidate. It’s going to be really important for us to figure out who’s at high risk for breast implant illness and who’s not.
BIA-ALCL and breast implant illness are completely different things. They have nothing to do with each other. People confuse them all the time because of the acronyms and because they’re both associated with breast implants.
BIA-ALCL is not breast cancer. It’s a lymphoma, which is a different type of cancer that has been associated with breast implants—in particular, with the Biocell textured breast implants from Allergan. Those implants were taken off the market in the summer of 2019 by Allergan, following an FDA hearing investigating the association of ALCL and textured devices.
Unlike breast implant illness, the lymphoma is a very measurable thing. What you’ll see is a late-forming one-sided fluid collection around a breast implant, which is rare. Even more rarely, there may be a small mass within the surrounding capsule. The treatment is to take out the implant in conjunction with the surrounding capsule. Some people have required chemotherapy because of it. The main culprit behind BIA-ALCL has been taken off the market, but we need to keep an eye on the patients who already had the Allergan implants because there’s been no official recommendation yet to have Allergan Biocell implants removed or replaced with a different device.
When anything that gets implanted in a human body, the body recognizes it as foreign and walls it off, so to speak. The capsule tissue contains cells called myofibroblasts and fibroblasts. These cells produce the collagen that forms the matrix of the capsule. Should any bacteria find its way into the capsule space, they can form an entity called biofilm, which is a microscopic layer between the capsule and the breast implant.
A myofibroblast behaves like a little muscle cell and can contract like a muscle. In the condition called capsular contracture, that’s what’s happening. I think it may be inflammation that causes the myofibroblasts to contract and then tighten down around the implant. When the capsule tightens down, it can eventually change the shape of that breast implant. One hypothesis is that bacteria, from an upper respiratory infection, for example, could be seeding the capsule space and causing inflammation and capsular contracture.
Whether or not capsular contracture happens depends on a couple things: the type of implant (whether it’s silicone or saline), the implant surface type (smooth versus textured), and where you’re putting the implant (above or below the muscle). Depending on which study you read, saline implants have a slightly lower rate of capsular contracture than silicone implants, and textured implants have a lower rate of capsular contracture than smooth implants. That was one reason textured implants were developed in the first place. The second reason textured implants were developed was because a textured surface is much less likely to rotate or slide.
My practice for the last decade has really been focused on a lot of revision breast work, such as redoing breast reductions or breast lifts. And I focus on a lot on implant complications, like capsular contracture, implant ruptures, and when the implant may have started in the right place but ends up in the wrong place.
Yes, I tell all my patients that they’re not lifetime devices. And the implant manufacturers are not shy about that. They do not last forever. Much like parts on a car, they have wear and tear on them. They rupture, they break, and you can get a tear in the outer shell.
Every implant needs to be monitored. The ways we monitor saline versus silicone are different. For the most part, if saline implants rupture, you’re going to get a flat tire effect. Your body will absorb the saline fluid and your breast size will decrease. Since 2006, the new-generation silicone implants are a cohesive gel. If you have a rupture of the outer shell, for the most part, the gel’s going to maintain its shape and you may not even know. That is why the implant manufacturers and implanting surgeons recommend that if you choose a silicone breast implant, you need to monitor them. And the best way that we know to monitor them and detect damage is with a non-contrast MRI. Sometimes a bad rupture can be seen on mammography or ultrasound, but MRI is the gold standard.
I recommend my patients get a baseline MRI at three years and then a follow-up every other year. It used to be several thousand dollars to get MRI. I think now it’s maybe $700 to $800. But if you sign on for implants, that’s one of the extra costs you sign on for.
When people with breast implants get a mammogram, the radiologist will move the implant out of the way. For the most part, the implant is behind the breast, so it’s pushing the breast up, and you usually can still see most of the breast tissue. However, it is possible that the implant could affect your imaging results. An implant is not likely to affect anything with an ultrasound or MRI. [Editor’s note: You’ll find more information on screening procedures for people with implants in our Q&A with Barbara Hayden, MD.]
My hunch would be that if an implant is ruptured during a mammogram, it probably was going to rupture at some point soon anyway. Implants are pretty strong. They’re pretty hard to rupture. I’ve talked to many breast imaging radiologists, and they say, “Oh no, it’s safe.” But implants can rupture sometimes, especially if they’re older ones.
Overall, the rate of implant ruptures is a little bit higher for saline implants than it is for silicone. Silicone implants have a risk of rupturing slightly under 1 percent per year, while saline implants have a risk of 2.5 percent per year.
Kevin Brenner, MD, FACS, is a plastic surgeon specializing in all aspects of breast surgery, including breast augmentation and reduction and implant complications. A Los Angeles native, he attended college at the University of Wisconsin and medical school at Loyola University in Chicago, and he did a general surgery residency at Cook County Hospital. After a year doing research in a tissue engineering lab, he completed a second residency in plastic and reconstructive surgery at UC Irvine. Brenner is board-certified in general surgery and in plastic surgery, and he has been in private practice in Beverly Hills since 2006.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.