6 signs your breast implants need to be replaced

Breast implants are often durable and trouble free. I have many patients who have had their original implants for over twenty years. The rule of thumb is that if it is not broken, then don’t fix it. But there are caveats to that statement.

The FDA guidance for silicone gel implants for asymptomatic patients is a first ultrasound or magnetic resonance imaging (MRI) 5-6 years after surgery, then every 2-3 years thereafter. For symptomatic patients or patients with equivocal ultrasound results for rupture at any time after surgery, an MRI is recommended.

Implants implanted before 1989, may have a greater tendency to bleed silicone and for capsular contracture to occur as result.

Breast implant replacement also implies two other options. The first is implant removal without replacement and the other is implant replacement with your own breast tissue (as in breast auto-augmentation) or your own fat.

Here are 6 signs that your breast implants need to be replaced.

1. RUPTURED IMPLANTS (SILICONE GEL)

Silicone gel implants can rupture without any obvious symptoms or changes in the shape of the breasts. This is known as a silent rupture which is why regular ultrasound checks are recommended ever 2-3 years. A ruptured implant could cause a capsular contracture, deformity of the breast or leakage to the lymph nodes in the axilla. The implant should be removed and if the patient desires, replaced with an appropriate implant. I recommend replacing both implants at the same time to avoid a second surgery if the opposite implant should fail.

2. DISPLACED IMPLANTS

An implant may be in the wrong position. The most common event is when the implant falls to the side of the chest. This is usually because the original pocket was made too large. Sometimes an implant is too low. On these occasions the original crease below the breast, known as the infra-mammary fold, can create an indentation in the breast.

The solution is to remove the implant and perform an internal repair to make sure that the implant sits in the right position. A smaller implant is often used to replace the previous one. Depending on the size of the new implant, one or both implants may be replaced.

3. DEFLATED IMPLANTS (SALINE)

A deflated implant is a saline implant which has ruptured. Saline, unlike silicone gel implants do not require regular ultrasound or MRI examinations. The leakage is obvious when a saline implant leaks because the breast is literally ‘deflated’. As in the case of ruptured silicone gel implants, both implants are replaced. Although this is not a medical emergency, I recommend replacing the implants within weeks rather than months, because the pocket can contract causing corrective surgery to be more difficult.

4. CASULAR CONTRACTURE
The incidence of capsular contracture varies, and the literature is somewhat confusing. Prevention is the best cure, but nobody yet understands the cause. The consensus is that positioning an implant under the pectoralis major muscle and that saline implants are associated with a lower incidence of capsular contracture. Textured versus smooth implants are advantageous but since the association of Breast Implant Associated – Anaplastic Large Cell Lymphoma (BIA-ALCL) with textured shells, most surgeons have opted to use only smooth shelled implants.

The treatment for capsular contracture is even more controversial. In the early stages medications such as the leukotriene antagonist, Zafirlukast (Astro Zeneca) may help. Surgery always includes replacement of an implant, with or without modification of the capsule. Sometimes the old capsule is left in place and a new pocket is created in front of it. A total en-bloc capsulectomy is not necessarily helpful and may have a higher incidence of recurrence. Using Acellular Dermal Matrix (ADM) (Recycled antigen free human dermis) to cover part or all of a replacement implant may be effective but it is an expensive option. Surgery for capsular contracture is usually directed to the affected breast only.

A useful alternative in these cases is to remove the implants entirely and reconstruct the breast with a breast lift and a breast auto-augmentation with or without fat injection.

5. PAINFUL SYMPTOMATIC IMPLANTS

Pain from an implant can be caused by capsular contracture or a malposition, especially if the implant sits to the side on the chest wall and interferes with arm motion. Removing the implant and reducing the size and shape of the pocket may be helpful. A useful alternative in these cases is to remove the implants entirely and reconstruct the breast with a breast lift and a breast auto-augmentation with or without fat injection.

6. BREAST SWELLING OR MASS

Swelling or a mass may be a sign of BIA-ALCL or a breast cancer and should be treated appropriately. The treatment of BIA-ALCL is removal of the implant and a total capsulectomy. Removal of a textured implant on the other side is also recommended.

With regards to the timing for reconstructive surgery, there are no standard guidelines. Replacement with a textured implant is discouraged. Options are immediate reconstruction (for disease limited to a seroma and capsule) or delayed reconstruction 6 months to 2 years after explantation, utilizing either autologous tissue, fat grafting, or smooth implant reconstruction. The type and timing of reconstruction depends on the extent of disease, ability to resect, and the patient’s preferences.

Shah NM et al, How I treat breast implant–associated anaplastic large cell lymphoma, Blood. 2018;132(18):1889-1898

BIA-ALCL is associated with textured implants. The FDA issued a voluntary recall of Biocell textured surface breast implants and tissue expanders by Allergan. Treatment of an Asymptomatic Textured Implant (ATI) patient who presents for counseling or surgery is controversial. About 10% of plastic surgeons recommend surgery for the asymptomatic, concerned patient who is not seeking surgery. In contrast, about 60% recommend removal of the implants for the asymptomatic patient seeking surgery. Although the majority of surgeons surveyed opt for more invasive capsulectomy techniques, the question is whether a capsulectomy has any value in preventing BIA-ALCL in the ATI patient. Swanson concluded that implant removal or exchange alone, is a viable option for women who do not have BIA-ALCL because a capsulectomy adds unnecessary additional risks and complications for an asymptomatic patient.

Frojo G. et al, Management of Asymptomatic Patients With Textured Breast Implants: A Survey Analysis of Members of The Aesthetic Society, Aesthet Surg J, 2022; 42(4): 361–366.
Swanson E. Evaluating the necessity of capsulectomy in cases of textured breast implant replacement. Ann Plast Surg. 2020;85(6):691-698.