Updates to Breast Augmentation

By Mr Adrian Richards / 10 Dec 2019

Consultant plastic surgeon Mr Adrian Richards provides an overview of the latest trends and developments in breast implant surgery

Breast augmentation remains to be the most popular surgical cosmetic treatment in the UK.1 While non-surgical practitioners will not be offering this procedure, they may get asked questions by patients about the options available and surgeons they would recommend. It is therefore important that clinicians can give up-to-date and useful information to help patients on their journey.

This article aims to give aesthetic practitioners a basic understanding of common breast concerns, and the latest trends and techniques in the specialty, so they can advise patients on the best way forward.

Current trends

There are many conditions that women can present with when it comes to the breasts. These may include inverted nipples, breast asymmetry, breast hypertrophy, breast ptosis, tuberous breasts and post-implant concerns.2

In 2016, lingerie brand Triumph surveyed more than 6,000 women from the UK, Germany, France, Italy, Denmark and Poland between the ages of 20-50. It found that women are often concerned with the perkiness of their breasts (40%), size (34%), shape (32%) and cleavage (29%). It also noted that a total of one in three women in the UK and France were unsatisfied with their busts.3

I am currently finding that most patients are presenting with concerns regarding asymmetry, shape issues and inverted nipples. In my practice, removal of breast implants is becoming more popular partly due to the increased demographic of women with implants and partly due to concerns regarding breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII).

In my experience, patients in the UK generally seek more moderate, natural-sized breasts, while patients in countries such as the US, South America and Brazil tend to seek larger implants, and the French usually seek smaller busts. According to the latest statistics from The British Association of Aesthetic Plastic Surgeons (BAAPS), breast implant procedures are dropping (Figure 1).1 However, it’s important to note that BAAPS members represent a minority of surgeons performing these procedures in the UK and we do not have accurate data on how many breast implant procedures are performed or how many women currently have implants in the UK.

Figure 1: The number of cosmetic breast surgeries recorded by members of the BAAPS since inception of its annual report.1

Recent controversies

Concerns regarding BIA-ALCL and BII have been widely reported in the media over the last couple of years.4 It’s helpful for non-surgical aesthetic practitioners to know what these are and the latest information available to enable them to properly reassure and educate their patients. It should be noted that although the media has been picking up on the potential issues behind BIA-ALCL and BII recently, there has been no change in the scientific evidence available to spark this awareness.4

Anaplastic large cell lymphoma

BIA-ALCL is a very rare form of cancer that occurs in the breast lining, not the breast tissue.4,5 It is still very uncommon and it’s unclear how prevalent the link between BIA-ALCL and implants actually is. According to the BAAPS, current research suggests the risk in the UK is approximately 1 in 24,000 breast implants sold.4 Studies are ongoing and we are unable to give a definitive risk to patients, but it would seem that the condition is much less common with smooth or nano-textured implants.4-7

With any foreign device, the body forms a capsule or lining around it. In some cases, the lining can get inflamed and cause a T-cell lymphoma, which develops fluid and an internal scar around breast implants. BIA-ALCL most commonly presents as swelling and a change in breast size, which occurs rapidly over several days or weeks. Although BIA-ALCL can occur any time after implantation, it has been reported that the mean time for presentation is approximately 10 years after implant placement.7,8 The medical community is becoming more aware of a link between BIA-ALCL and breast implants that have a textured surface. Textured implants have been previously used due to their association with a reduced or lower risk of the capsular contracture rate, which is when the capsule around the implant hardens, causing the tissue to become firm, tight and cause pain.9,10,11

There has since been a move to use smoother implants to reduce the risk of BIA-ALCL. Surgeons worldwide are no longer using the textured implants associated with BIA-ALCL following their withdrawal from sale and a voluntary recall from the manufacturer in July 2019.12 This may explain why they have been featured so heavily in the media this year. It’s important to note that there have been no recommendations for removal of these implants in asymptomatic patients and monitoring and surveillance is recommended.4,12 This is unlike the PIP scandal, where implants had been fraudulently manufactured with unapproved silicone gel, causing the NHS to offer removal or replacements.13

Practitioners who hear their patients complaining or enquiring of symptoms associated with BIA-ALCL (persistent swelling, presence of a mass or pain)5 should advise them to consult their surgeon. For the majority of patients diagnosed with BIA-ALCL, their treatment would involve removal of the implant and surrounding capsule. Those who have been diagnosed with BIA-ALCL at a more advanced stage may require chemotherapy, radiotherapy, and lymph node dissection.7

It has been reported that removal of the breast implants without replacement may reverse symptoms of BII

Breast implant illness

BII is a relatively new concern that has been gaining momentum in the last year or so, particularly via social media. Some patients with breast implants feel they have generalised symptoms that are directly connected to their silicone implants, such as hair loss, tiredness and fatigue, headaches, chills, photosensitivity, brain fog, pains, rash, sleep disturbance and joint pain.4,5

There is debate amongst the medical community about whether BII is a true medical condition that actually exists, and there are questions about whether the symptoms may be caused by other reasons. There is limited data on BII’s prevalence and it is difficult to link breast implants with the perceived associated symptoms as there are no definitive tests.

That said, in May 2019, the US Food and Drug Administration (FDA) acknowledged the potential connection between breast implants and illness, announcing steps to improve the information available to women which sparked the increased media awareness this year.14 According to the FDA, it has been reported that removal of the breast implants without replacement may reverse symptoms of BII in some cases.5 Of course, much more research is needed and any concerns should be reported to the patient’s surgeon.

Technique updates

Breast auto-augmentation

Like most other treatments, there has been an evolution in breast surgery techniques over the years. One notable change is the use of a patient’s own breast tissue for remodeling the breast after removal of breast implants. Most surgeons would recommend to remove and replace implants after around 15 years, but some suggest that for patients with normal breasts, a policy of monitory and surveillance can be undertaken for those reluctant to undergo surgery.15,2 Typically, implants usually need removing or updating due to the changes in the tissue and the body surrounding the implants.2

With age, and situations like pregnancy, the breasts will generally obtain more tissue. These factors influence gravity, skin laxity and stretch, which will likely make the bust much heavier. Some patients then choose to seek replacement or removal of implants that they feel no longer suits their lifestyle.2

While implants can be replaced, a newer and really interesting procedure that myself and other surgeons are performing is breast auto-augmentation. The breast auto-augmentation technique that I have developed is called the Mastopexy Implant Removal and Reconstruction (MIRAR) technique.

The procedure removes the implant and uses the patient’s own natural breast tissue to reshape and enhance the bust shape. Results are achieved by relocating the patient’s own breast tissue into the upper portion of the breast to give the desired lifting and shaping effect, without the need for an implant. I’m finding that the procedure is producing some lovely, natural results (Figure 2).

Figure 2: Before and after breast auto-augmentation using MIRAR technique. Breast implants were removed and breast auto augmentation performed in 2018. Images courtesy of The Private Clinic.

LED light therapy

LED light therapy is emerging to treat capsular contractures,16 which can form around any kind of implant.10 We are currently running a preliminary trial on 10 patients using the Celluma device and seeing some encouraging results. The idea behind the treatment is that it reduces inflammation, which is what is causing the capsule, and so the capsule softens.17 For our study, we have developed a new capsule scoring system, which is helping us determine their severity more accurately. The Baker system is the traditional scoring system used by surgeons, in which capsular contraction severity is classed into four groups; Group 1 being the mildest and Group 4 being the most severe.10 Our new FAP scoring system is divided into three classes, scored between 1 and 5. These include firmness, appearance and pain, giving a top overall score of 15. We feel that the system allows us to monitor the capsule effect and severity a lot easier and more accurately to determine if our treatments are having an improvement.

Future developments

As mentioned, breast implant data in the UK is unfortunately lacking. We do not have accurate records of who has had them or a total number of patients who do. After discussion with colleagues, our current estimates are that 30-40,000 breast implants are performed in the UK per year and the procedure has been performed for more than 30 years. Consequently, it is likely that more than one million UK women may have undergone a breast augmentation procedure.

From 1995 to 2005 there was a voluntary register where surgeons could input their data. However, this was abandoned due to a high proportion of women not consenting to their details being recorded and not all surgeons were participating and entering their patients’ data, so the statistics were never accurate.18 Following recommendations from the Keogh review, a Government register was launched in 2018, called the Breast and Cosmetic Implant Registry (BCIR).18-21 From January 2019, patient consent is no longer required to record data to this register and submission of records to the BCIR is mandatory for NHS-funded patients, while being requested for privately-funded patients being treated in any provider in England and Scotland. Ireland and Wales are not currently a part of this register.19,20 Although not all private surgeons enter their data into this system, I believe the register is a great step for the future of breast implant surgery in the UK. It will hopefully help to identify issues and allow patients to be traced and notified in the event of a product recall or other safety concerns relating to a specific type of implant, which can help safeguard patients.

Another positive is that an annual report is released by the BCIR that includes vital data and statistics that I believe will help further the identification of trends and complications relating to specific implants (see Key findings from BCIR report section).21

Summary

Breast surgery is frequently discussed in the media and it’s important for non-surgical practitioners to have a basic understanding of their patients’ potential concerns. To ensure you are providing a full comprehensive service to your patients, should they show concerns regarding their breast implants, encourage them to visit their surgeon. As well as this, seek connections and professional relationships with local surgeons you can trust to refer your patients who are thinking about undergoing a surgical breast procedure.

References
  1. BAAPS, Cosmetic surgery stats: number of surgeries remains stable amid calls for greater regulation of quick fix solutions, May 2019, <https://baaps.org.uk/media/press_releases/1708/cosmetic_surgery_stats_number_of_surgeries_remains_stable_amid_calls_for_greater_regulation_of_quick_fix_solutions>
  2. Adrian Richards & Hywel Dafydd, Key Notes on Plastic Surgery 2nd Edition, 2002.
  3. WOMEN’S CONFIDENCE IS ‘BUST’, Triumph, 2016. <http://www.multivu.com/players/uk/7765651-womens-confidence-is-bust/>
  4. BAAPS, A statement by The British Association of Aesthetic Plastic Surgeons (BAAPS) on Channel 4 Dispatches programme and concern over the safety of breast implant, June 2019. <https://baaps.org.uk/media/press_releases/1726/a_statement_by_the_british_association_of_aesthetic_plastic_surgeons_baaps_on_channel_4_dispatches_programme_and_concern_over_the_safety_of_breast_implants>
  5. US FDA, Questions and Answers about Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), October 2019, <https://www.fda.gov/medical-devices/breast-implants/questions-and-answers-about-breast-implant-associated-anaplastic-large-cell-lymphoma-bia-alcl>
  6. US FDA, Medical Device Reports of Breast Implant-Associated Anaplastic Large Cell Lymphoma, July 2019. <https://www.fda.gov/medical-devices/breast-implants/medical-device-reports-breast-implant-associated-anaplastic-large-cell-lymphoma>
  7. Leberfinger AN, et al., Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Systematic Review, JAMA Surg. 2017 Dec 1;152(12):1161-1168. <https://www.ncbi.nlm.nih.gov/pubmed/29049466>
  8. Brittany Z. Dashevsky et al., Breast implant associated anaplastic large cell lymphoma: Clinical and imaging findings at a large US cancer center, 2018, <https://onlinelibrary.wiley.com/doi/full/10.1111/tbj.13161>
  9. US FDA, Risks and Complications of Breast Implants, October 2019, <https://www.fda.gov/medical-devices/breast-implants/risks-and-complications-breast-implants>
  10. Hannah Headon et al., Capsular Contracture after Breast Augmentation: An Update for Clinical Practice, Arch Plast Surg. 2015 Sep; 42(5): 532–543. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579163/>
  11. Malata CM et al., Textured or smooth implants for breast augmentation? Three year follow-up of a prospective randomised controlled trial, Br J Plast Surg. 1997 Feb;50(2):99-105. <https://www.ncbi.nlm.nih.gov/pubmed/9135425>
  12. Allergan Voluntarily Recalls Biocell® Textured Breast Implants And Tissue Expanders, July 2019, <https://www.allergan.com/News/Details/2019/07/Allergan%20Voluntarily%20Recalls%20BIOCELL%20Textured%20Breast%20Implants%20and%20Tissue%20Expanders>
  13. NHS, PIP breast implants, 2019. <https://www.nhs.uk/conditions/pip-implants/>
  14. Statement from FDA Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D., and Jeff Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health on FDA’s new efforts to protect women’s health and help to ensure the safety of breast implants, May 2019. <https://www.fda.gov/news-events/press-announcements/statement-fda-principal-deputy-commissioner-amy-abernethy-md-phd-and-jeff-shuren-md-jd-director-fdas>
  15. Goodman CM et al., The life span of silicone gel breast implants and a comparison of mammography, ultrasonography, and magnetic resonance imaging in detecting implant rupture: a meta-analysis, Ann Plast Surg. 1998 Dec;41(6):577-85.
  16. Dr Jacob Haiavy, How I Do It - Postoperative care following aesthetic breast surgery – treatment of capsular contracture with Celluma low level light therapy, PMFA Journal, 2019. https://www.thepmfajournal.com/education/how-i-do-it/post/how-i-do-it-postoperative-care-following-aesthetic-breast-surgery-treatment-of-capsular-contracture-with-celluma-low-level-light-therapy
  17. Jacob Haiavy, Postoperative care following aesthetic breast surgery – treatment of capsular contracture with Celluma low level light therapy, The PMFA Journal, 2019.
  18. Sir Bruce Keogh, Review of the Regulation of Cosmetic Interventions, Department of Health, 2013 <https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_of_Cosmetic_Interventions.pdf>
  19. NHS, Breast and Cosmetic Implant Registry, 2019. <https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/breast-and-cosmetic-implant-registry#overview-of-the-registry>
  20. ABS, Breast Implant Registry, 2019, <https://associationofbreastsurgery.org.uk/clinical/breast-implant-registry/>
  21. Breast and Cosmetic Implant Registry, July 2018 to June 2019 Data Summary (England, management information), 17 October 2019. <https://files.digital.nhs.uk/62/8C3560/BCIR_Report_2019.pdf>

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