Patients who are looking for breast augmentation need to know what questions to ask, so they understand fully what they are getting themselves into.
I mean, if I was the kind of surgeon who performed breast augmentation with implants (especially at a high volume), there are definitely a bunch of things that I would want to talk about with my patients. I would want to ensure my patients knew that they were signing themselves up to something that inevitably will need correction or revision, and that there will be ongoing costs associated with that, and that ultimately they will probably need or want to have their implants removed and that is a tricky operation, and of course there is BII to contend with. So, yeah, there is some stuff I would want to discuss.
And yet, it seems that many surgeons doing breast augmentation talk about none of that.
Which is a problem, because as far as I can tell, breast augmentation will always fail eventually...and I can't think of another procedure where that is true.
Breast augmentation is the only cosmetic procedure I can think of that, by design, will fail.
That sounds a bit harsh maybe, but I think it is a fair statement. What we have to do though is define what is meant by "failure".
Failure, in the context of breast augmentation, is a more diverse concept than you might initially think.
In general, people might only consider a failure to be associated with an early complication - something like an infection, for example - which requires the removal of a breast implant. Now, that is certainly a failure, and a dramatic one at that, but it is only one kind of failure.
Let's break this idea down a little.
Failure can be considered to occur in the short term (things like infection, as mentioned above) - that is, serious complications that result in breast implants being removed, or a patient suffering permanent disfigurement or deformity.
Failure can also be considered to occur in the longer term (which really means anything after about 4-6 months). This is something that should be discussed with every patient considering cosmetic breast augmentation, but if my experience is anything to go by, many women never have this discussion.
Long-term failure reflects the inherent flaw in the use of breast implants - they are inorganic, foreign bodies. The human body is a pretty good at many things but one thing it is no good at is "accepting" foreign bodies within it. Fundamental processes result in the human body using a number of strategies to either isolate or rid itself of any foreign body. Now, that is well known and accepted and it is why, over many years, smart people have tried to increase he "bio-compatibility" of breast implants by engineering them to be less, well, foreign. The current generation of Motiva implants are probably the only devices on the market that actually live up to this promise however, and whilst a deep dive into the engineering behind them, and how their interaction with immune cells (based on surface architecture) decreases the immune response, is not the purpose of this article, it is a topic that I should probably come back to at some stage.
Anyway, back to failure.
So, the idea of long-term failure has, in some ways been encapsulated by the discussion that surgeons have historically had of "revising" breast implants.
The consent process for every breast augmentation should involve discussion of the requirement for revision. Patients need implant revision because of rupture, revision because of capsular contracture, revision because the implant has moved or flipped or changed, revision because the breast has changed...revision is an implicit requirement of every breast augmentation.
Every breast augmentation will NEED revision. We don't say the same about any other aesthetic procedure. Why?
Facelifts, rhinoplasty, breast lifts, tummy tucks...pick any other aesthetic procedure, and the outcome of those procedures is expected to offer a permanent change without creating some future requirement for corrective surgery.
What this says to me is that breast augmentation is fundamentally flawed, as both a concept and a practice in aesthetic surgery.
Which begs the question of why breast augmentation has not be subjected to greater scrutiny. Why have patients (and surgeons) accepted a status quo for breast augmentation that would be totally unacceptable for any other cosmetic procedure? Why is it ok for breast augmentation to have such a limited lifespan?
I have a few ideas on this point (hint: it's the money).
Since the first breast augmentations in the 1970's, some plastic and cosmetic surgeons could legitimately be considered guilty of "salesmanship". After all, breast augmentation is totally elective and totally cosmetic. Whilst the patient may want a breast augmentation, the surgeon has to attract that patient in the first place, and then once they present for consultation, the surgeon has to "convert" her from a prospective surgical candidate into an actual surgical booking. So there is inevitably a bit selling that takes place.
In the pursuit of the exploding cosmetic surgery market, over the years breast augmentation has been sold as "simple". An easy procedure, with reliable outcomes. No discussion of the hows or whys of where it all goes wrong. Some small justification perhaps for those earlier surgeons was that we didn't really understand the underlying processes of how breast augmentation did go wrong.
When it did go wrong, and ladies presented to their surgeon with complications like capsular contracture, breast implant revision was sold as "routine", and even "simpler" than the original augmentation. And in many respects, the way that a lot of surgeons treat those revision procedures, it is - pull an implant out, shove a new one in, off you go. What that obviously fails to consider is the mechanism of failure and how that might be directly addressed to prevent further recurrence. And just to be clear, the recurrence of the problem was inevitable.
In a funny little mind trick (I mean, it's almost gaslighting one could argue), the blame for breast augmentation failure has been shifted back on to the patient, away from the surgeon. Because breasts (and patients) change over time, with body weight, pregnancies and age, surgeons have been able to convince themselves and their patients that it was all totally unavoidable and that there were simply no alternatives.
And in some respects, there is a truth to that.
If you want a breast augmentation, you simply have to accept that you are signing up for multiple operations across your lifetime. You have to accept that the results will not remain stable over time. You have to accept that breast implants are imperfect.
So, if a lady chooses to have a breast augmentation with implants, I think that remains a completely valid choice, provided there is complete honesty in the consent process; provided the surgeon actually tells that lady (at whatever age she may present) that by having her first breast augmentation, she must accept the imposition and cost of between 2 and who-knows-how-many operations across her lifetime before she ultimately chooses to have her implants removed.
So, if a lady chooses to have a breast augmentation with implants...she must accept the imposition and cost of between 2 and who-knows-how-many operations across her lifetime before she ultimately chooses to have her implants removed.
And there is the problem: most women having a breast augmentation are very obviously NOT being consented in that way. Because that would get in the way of "selling" that operation. And because breast augmentation offers a solution that is just durable enough to out-live the chance of most patients returning to their original surgeon to express dissatisfaction, a curious dichotomy results, with many breast augmentation surgeons never seeing a large number of revision cases, and many revision surgeons not seeing a large number of primary cosmetic augmentations.
Maybe.
We can't change the fact that the interaction between a silicone breast implant and natural tissues will remain unpredictable. We can't change the fact that not all patients have the same tissue quality. We can't change the fact that surgeons are human and fallible.
We can do some stuff to mitigate certain risks however. And perhaps most importantly, if surgeons are going to continue to perform these procedures, the least they can do is be honest. Honesty when discussing the failure of breast augmentation involves educating a patient on how their breast implant is likely to fail and what needs to bone done once it has failed.
First things first: the rate of failure increases with time. That much should be clear. It doesn't mean that someone MUST have their implants replaced or removed after some arbitrary time. But the potential NEED for it becomes greater as the years go by.
Secondly, the relevance of a particular presentation with breast augmentation failure depends on the person. Some people are more concerned by changes in their breast appearance than others. Which means that for patients with implants, whose implants have changed (for example, with capsular contracture) or whose bodies have changed (for example, after pregnancy), some couldn't really care less about changes in their breasts whereas others will find those changes deeply troubling. So there has to be the potential for patients to discuss their concerns and have something done about it, because regardless, that does constitute a failure of the breast augmentation.
Third, surgeons should be paying attention not just to the initial cosmetic outcomes, but also to the long term outcomes and the ways in which their choice of surgical technique influences the risk of failure. If a surgeon chooses to place implants under the muscle (hopefully having fully discussed the implications of that choice with their patient), then they need to be prepared and capable of addressing the issues that will arise, including animation deformity, implant displacement, capsular contracture, and rupture. Will that revision procedure then involve staying under the muscle? Will they at that point convert to the over-the-muscle technique (and why did they not do that originally)? Do they understand the requirement for increasing implant support with time? At which point do they discuss the progressive implications of implants and the eventual requirement for implant removal? All of this stuff needs to be considered, and ideally discussed, RIGHT AT THE START before a patient ever has a breast augmentation.
Ultimately, the only procedures that won't fail are those that involve natural tissue only. Unless we view natural aging processes as failure. Which, perhaps, some people do. I dunno.
However(!), all of this is not to say that I think breast augmentation is BAD. Rather, it is an admonition to surgeons doing cosmetic breast augmentation to try a little harder and be a little better.
If I was a surgeon performing breast augmentation (or if I was a patient seeking breast augmentation) I reckon there are some very standard questions that should be discussed with total transparency at the outset.
So let's play Q&A. Here is a list of questions, with what I would consider to be appropriate responses. Not sure how this would go down with some surgeons, but these should all be totally non-negotiable discussion points.
Q: How long does breast augmentation last, on average, before requiring a revision procedure?
A: The typical blah blah sort of answer to this is "every 10-15 years". In reality, that number is pretty loose, and historically has paid for some very nice cars. The answer is really "it depends". The "10 years" response is predicated on an increase in implant rupture risks after 10 years based on the core study data for the 4th and 5th generation implants. Is that still the case? Probably not.
However, let's also be clear about the fact that MANY women will present with complications leading to removal or revision of their implants well before 10 years is up. Complications leading to failure, like capsular contracture, changes in the breast (post-pregnancy, changes in body composition, poorly planned original surgery), aesthetic deterioration and pain don't just happen after 10 years! In fact, the average time that my explant patients have had their implants is 9 years, and the data is pretty normally distributed (so maybe half are presenting to me with implants anywhere from 3 months to 9 years post-op).
The ladies who need mastopexy at the time of removal have tend to present later (14 years after breast augmentation), but even at that later stage, the rupture rate is still only around 14% (which fits with the old 1% rupture risk per year the implants have been in). So the idea of using rupture as the primary indication for revision of breast implants is deeply flawed. It is not the main issue, and it is actually not all that common even after 10 years.
So when I say "it depends", the expanded version should go something like this: It depends on what happens to the implants, and the breasts, over time. If your breasts remain soft, comfortable, and the breast tissue is appropriately positioned relative to the implant, then you can leave the implants alone. If something changes, if you decide you no longer like your breast appearance, or if there is a rupture detected, then this may be a good reason to consider revision surgery.
Q: What are the reasons for revision?
A: Reasons for breast implant revision surgery will vary from patient to patient and from surgeon to surgeon, but here is my list of GOOD reasons to have surgery.
Q: How many procedures will I need across my lifetime and what will the cumulative cost be?
A: I reckon this is the one that will make plastic surgeons squirm a bit. But it is the one that women really MUST get an answer to in some form or another.
There is obviously no clear answer. What you really want though is for a surgeon to be able to look you straight in the eyes and tell you that you WILL ALWAYS NEED MORE SURGERY if you have an implant. And those operations change over time, and the cost of those operations is likely to increase over time.
Oh, and if your surgeon tells you that insurance will cover the costs of revision surgery, they are lying, and that would be medicare fraud. Just FYI.
Q: Will the surgery get harder with each subsequent revision of breast implants?
A: Yes. That's it. Harder, and harder, and harder. And then you have an explant, which I think is probably the hardest part. So yeah, keep that in mind.
Q: If I decide to have my implants removed, can you undo the damage of having breast implants? If not, why? And what are the options?
A: Lol. I would really love it if people did ask this question. I would also love it if surgeons thought a little harder about what they do during breast augmentation surgery, to decrease the damage they cause and to make revision/removal procedures easier.
In my opinion, most of the damage can be rectified. We can generally restore people to anatomical normality, and we can generally restore the breast to an aesthetic shape and position. Is that easy? No.
Explant is a very big topic which is not receiving the attention that it should. Obviously, there is plenty to read about on my website.
Q: What about breast implant illness?
A: If, at this question, you get a dismissive response, I think you should be a little concerned. Equally, just because a surgeon "believes" in BII, doesn't make them a great surgeon. Regardless, I would suggest to you that EVERY patient should be having a full and frank discussion about the risks of Breast Implant Illness and the challenges of explant surgery.
So there you go. If you want a breast augmentation, just get it done well, but someone who will actually care enough to talk to you honestly.
At the very least, when it comes to the inevitable first breast implant revision, you have an opportunity to make things better, or make them a lot worse. That is definitely a point where a careful decision is warranted. If you're up to revision 3, 4 or 5...maybe it's time to consider explant.
Good luck!