Well, I managed to get along to the Australasian Society of Aesthetic Plastic Surgeons (ASAPS) meeting over the weekend. I knew that there was to be an update from some of the leaders in the field of BIA-ALCL (breast implant-associated anaplastic large cell lymphoma) and I wanted to be sure that I was there to hear where things stand.
So, has anything changed from what I last wrote? Well, in a practical sense, no. However, what was really fascinating was the discussion on how ALCL develops, and what this might mean for our patients now, and into the future.
First of all though, lets talk briefly about how breast implants are inserted (and why that matters). The technique I use when I do use implants is quite particular, the whole purpose being to protect the implant from any possible contamination. By contamination, I don’t mean dropping the implant on the floor or forgetting to put gloves on. What I mean, is the possibility of picking up some of the normal bacteria that live on our skin, which even antiseptic preparations we use to paint the skin before surgery cannot eradicate. If an implant touches exposed skin, then it can pick up some of these bacteria as it is being pushed into the incision under the breast. So, our goal is to prevent skin contact with the implant.
I do this by several means: first, after the incision has been made and the space created, I change my gloves. We then place a sterile adhesive film over the entire operative area and I make a new cut through this film with a clean scalpel. Finally, the implant is opened, and sterile antiseptic solution is poured over the implant. Finally, using a device called the Keller Funnel (it’s a bit like a big piping bag), I can “squeeze” the implant into the incision without ever touching the implant myself, and more importantly, without the implant ever touching the skin.
So, why all the fuss? Well, its simple. We know now that bacteria picked up from the skin cause “capsular contracture”, the most common complication after breast augmentation. We know that “textured” implants are more prone to accumulating bacteria on their surface and forming something called “biofilm”. And we know that textured implants appear to be most implicated in the formation of ALCL.
So how does this all tie together? This is the interesting part.
The latest evidence appears to point to a certain “threshold” for the formation of ALCL in certain individuals. It would seem that there is a point at which bacteria can create a “biofilm” on the surface of an implant. This biofilm chronically stimulates the immune system. Immune cells (which are “white” blood cells) replicate in response to this stimulus, and over time, certain populations of these immune cells can accumulate to form a uniform proliferation of cells which eventually can form a tumour. This tumour is ALCL.
Of course, there is more to it than just bacteria. We suspect that some patients may harbour a predisposition to developing ALCL based on their genetics. Whilst we can figure this out in the laboratory, it isn’t something we can test for beforehand. We also know that ALCL takes time (typically around 6-8 years) to develop, which means that the cases we are seeing now relate to implants placed some years ago, when the techniques used to insert the implant were different.
Of all the factors that may be responsible here, the most readily targeted is bacterial contamination. We can’t change genetics, and we can’t turn back the clock. So, the focus currently is on decreasing the chance of picking up bacteria during the insertion of the implant, and also decreasing the chance of bacteria, which can circulate in the blood stream (for example when a patient has a urinary tract infection), from finding their way to the implant after surgery. The role of surface texturing of the implant is the other issue that must be addressed. We know that these textured implants appear to harbour more bacteria on their surface. We also know that, whilst textured implants – especially polyurethane-coated (the so-called “fuzzy Brazilian” implants) and “macro” textured implants – appear to be associated with every known case of ALCL, the texturing itself is not necessarily the culprit.
In Australia, we have been using textured silicone implants for longer than most countries in the world (and certainly much longer than the Americans).
We made the change to textured implants 10-15 years ago supposedly to prevent capsular contracture and to prevent problems like implant displacement. Whilst I do not think that the answer is go back in time 20 years and start using smooth implants in every patient, as we did in the 90’s, there may be other changes in implant technology which have to be considered.
My feeling, is that we are at a point right now where the number of patients with ALCL will continue to rise, but that these diagnoses will relate to implants placed some time ago. I hope, that with the change in surgical technique that has developed over the last few years, the chances of ALCL in the future will actually drop significantly. Only time will tell. For now, I can only emphasise how important it is that any patient seeking cosmetic breast enlargement consults with a qualified Plastic Surgeon who can discuss these issues (at length) with you. And more importantly, if you have any concerns relating to a previous breast augmentation, ensure that you make an appointment with your Plastic Surgeon to address those concerns.
I posed this question in the last article I wrote on ALCL: Should you be worried, if you are either considering or have previously had a breast augmentation? The answer is still no. It should go without saying that any change in a woman’s breast is a reason to get checked. But if you’ve had an augmentation, and everything is fine, then there is absolutely no reason to panic.
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