By Dr Tracie O’Keefe DCH, published in Polare, April-June 2006 issue
Millions of women throughout the world over the past 35 years have had silicone breast implants for differing reasons. Perhaps they felt their breasts were too small, maybe they were uneven, reconstruction after cancer could be called for, or some people who are intersexed or transsexual may not have been able to achieve their desired breast shape without implantation.
Silicone implants became popular in the 1970s when the price of the implants and cosmetic surgery became more affordable. Silicone implants consist of a tough outer covering made from silicone and a fluid-like consistency of silicone on the interior. Two other kinds of implants have been used over the years which are silicone shells filled with saline solution and also silicone shells filled with soya oil. These two kinds of bags were developed because of the concerns about silicone bags leaking free-floating silicone into the body.
In North America silicone breast implants have been banned for many years. The silicone and soybean oils type were considered much safer because if they leaked, the body simply digests and flushes away the contents. When free-floating silicone leaks out into the body, however, it can be medically disastrous.
The silicone becomes embedded in tissue and silicone granulomas are virtually impossible to remove. Embedded silicone distorts the shape of the tissue, blocks vessels or sinks in the body to other tissues. Many people who had free-floating silicone injected into their hips, to give them a better shape, eventually suffered from a form of elephantitus as the silicone sank to their lower legs, gangrene set in and they died.
Free-floating silicone that was injected into other parts of the body has also been impossible for surgeons to remove later when it has become distorted. While manufacturers claim that silicone itself is innocuous and does not affect the body, its uncontrolled mass in the body, where it should not be, can cause deformities.
Many women reported chronic medical problems after silicone implantation when they began to suffer from varying forms of autoimmune diseases. Dow Corning, one of the largest manufacturers of implants, has settled millions of dollars in compensation over the past 10 years to women all over the world.
The reason silicone became so popular was because it gave the breasts a more realistic consistency than saline or soybean implants. Also here has been a tendency for saline and soybean implants to leak.
Outside of America silicone implants are still today being used widely by many plastic surgeons.
Some implants have double skins. They have an inner silicone-filled centre with outer saline-filled layers. The idea was that the easier rupturing of the outer saline-filled layer would sound the alarm by a reduction in size of the breast. In reality the idea does not work because many women, even with breast implants, end up having one breast larger than the other.
In the 1970s and 1980s the shell of the implant was not as strong as those used today. Surgeons also told their clients very little about how long those implants should stay in before being replaced. The manufacturers gave very few warnings – and still often do not issue them – about the side effects of having implants. Some surgeons even told clients the implants would last for life.
There are hundreds of thousands of women who have implants that are 10, 15, 20, and even nearly 30 years old. Some implants start to leak after a few years but the older implants are highly likely to be leaking and can be very dangerous. Even if the implant has not ruptured, the kind of damage that can ultimately result from slow-leaking implants can be life-threatening.
If an implant is ruptured in an accident it should always be removed as emergency surgery. But women do not generally know that they are walking around with slow-leaking implants. The medical profession has often given very bad advice to many women who have had worries about leaking implants.
After talking to several GPs I discovered that GPs generally know very little about breast implants and how to identify problems with them. They also seemed to give very poor advice in telling patients not to worry if there did not appear to be any problems externally.
When I telephoned one of Sydney’s leading breast clinics, the receptionist also had no idea about the issues for women with breast implants. I was told that the clinic only offered x-rays and if that was not good enough for the patient, then there was nothing they could do. I explained to her that x-rays would not pick up leaking breast implants but she seemed to become disinterested and suggested that such clients should seek help elsewhere.
For many years, women with breast implants have been advised to have ultrasound scans to see the condition of the breast if they have breast implants. But even this method does not always show up leakage from implants.
CT (computer tomography) scanning is the only truly effective way of seeing leakage from breast implants. This is a three-dimensional imaging technique where hundreds of images are recorded and the computer is able to build up a picture of what is happening in that area of the body. CT scans can see behind the implant where prolapsing of the implant may have occurred. Women seeking to find out about the condition of their breast implants should not settle for anything less than a CT scan, even if doctors try to talk them out of that kind of expenditure, and many will. There are even higher resonance imaging systems than CT scans but they may not be necessary to detect breast implant leakage.
A plastic surgeon is far more competent in taking out breast implants than a breast surgeon because they know all the different ways implants can be introduced into the chest area. Also if a breast surgeon is taking the implants out, they may not be qualified to implant replacements.
There is also the need for patients to be aware of the difference between a fully qualified plastic surgeon and many doctors who have set themselves up as cosmetic medical doctors. Be sure in choosing a surgeon to help with removal and replacement of breast implants that the surgeon has experience in the field.
Some plastic surgeons may advise a period without implants before the client has replacements. This is for two reasons. Firstly if there has been leakage, the surgeon may not be able to remove sufficient silicone to make introduction of a replacement safe. They may want to go in for a second surgery to attempt further removal of silicone-affected tissue.
Secondly for many women who have had silicone breast implants, their removal can still leave a good size breast. The cavity where the implant was can fill up with body fluid and the breast size can be bigger than it was before the original implantation. Many women then go on to be comfortable with that breast size.
In many cases surgeons may also be in the position where they may not be able to remove all the free-floating silicone. It may have gone into the breast tissue itself or it may be simply unreachable.
Another major problem that occurs with breast implants is capsular contraction. This is when the tissue around the implants develops into scar tissue with calcification and becomes hard. The breasts can become independently different shapes, even with one pointing up and one pointing down. The traditional remedy for this is to remove the implant and surgically clean out the cavity. The problem is that when this has happened once, it is very likely to happen again.
To some extent encapsulation happens with all implants but with regular massage of the breast it generally does not become a problem. Encapsulation can, however, literally happen overnight – in the patient’s view – with them suddenly realising there is a problem.
Endoscope CO2 Laser-Assisted Capsulotomy is, however, a better way of dealing with encapsulation. This method does not require the removal of an intact implant although general anesthetic will be needed. The surgeon introduces a very small laser into the encapsulated envelope laproscopically and works away around the implant. This means less downtime and no further scarring. Unfortunately this procedure does not yet appear to be available in Australia.
A new kind of breast implant is being tested in America at the moment. They are fondly known as Jelly Beans because their consistency is similar to the confectionery of the same name. They are a silicone gel-like substance that is not supposed to move as the implant breaks down. This is anticipated to be much safer and avoids the problem of free-floating silicone. They have not, however, yet achieved FDA (Food and Drug Administration) approval and are not available in the general marketplace.
In Australia the national Medicare system will reimburse some of the surgeon’s and anaesthetist’s fees. Private medical insurance should cover the clinic or hospital costs. Only those on a pension or disability will be able to recover maximum in Medicare reimbursement, and often only for treatment administered in a public hospital.
The removal of problem implants is a medical need and not plastic or chosen surgery. The replacements of those implants are also a medical necessity under reconstruction of the breast and not plastic or chosen surgery. Both procedures are covered by Medicare to some extent.
There are those who will find the loss of breast size psychologically difficult and they would be well advised to seek counselling. It would be good to seek that help from a professional who has experience in working in the field of breast and body image issues.
Regardless of whether a woman thinks there is a problem with her breast implants or not, it is advisable for her to have a CT scan every few years to be able to assess the integrity of the implant, whether it is silicone, saline, or soybean. This can be done at the same time as scans for the breast for any abnormalities or carcinomas.
Perenack, Jon D, MD, DDS & Tobin Howard, MD, Endoscopic CO2 Laser-Assisted Capsulotomy – A New Therapeutic Method for Correcting Capsular Contracture. American Journal of Cosmetic Surgery, Vol 21, No 4, 2004.
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