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The next point of information we supply our
patients is a brief explanation of the common standard complications with the
approximate rates of occurrence for each one:
1. Infection, 1%
2. Hematoma, 4%
3. Noticeable scars, 10%
4. Asymmetry, 10%
5. Numbness, 10%
6. Deflation with saline implants, 30%
7. Excessive firmness, 50%
8. Steroid atrophy, implant rupture,
pneumothorax, seroma, 2%
9. Shape problems, position problems,
double-fold, synmastia, 10%
10. Blue window, extrusion, 1%
11. Palpability and immobility, 20%
12. Rippling, 50%
These complications are explained and
mentioned in the written consent forms the patient is asked to sign before
surgery, and copies of these forms are provided in your workbook.
Infection 1 %
Actually, in more than 500 consecutive
operations performed on an outpatient basis in an office surgery suite, there
have been only three post-operative infections from the surgical procedure in
the immediate post-operative period.
Still, it is a very good idea to have the
patient understand what happens with an infection, because it can happen anytime
and is not necessarily within the control of the doctor, especially when the
operation is performed in a hospital. Some of the infections can occur later
(perhaps years after surgery), and could be related to trauma or minor injuries
such as a scratch. Such trauma can induce infection, beginning in the skin of
the chest and spreading into the breast.
Other infections have been related to
hospital-performed surgery or surgery in the presence of previous silicone
injections, or with silicone extravasated into the tissues from a ruptured
implant. Also, primary breast infection or mastitis (which may or not be related
to nursing, but frequently is), may occur.
At times a breast implant begins to extrude
years after surgery due to a possible foreign body type reaction or apparent
indolent chronic infection around the implant. Whenever there is infection
around a breast implant, it is best to remove the implant, and leave it out
until all the infection is completely gone and the tissues are soft and pliable
This would take a minimum of three months for
most cases, and six months or more when there is induration, gross pus,
resistant organisms or an otherwise bad or difficult infection. The patient with
an infection finds this very hard to accept, especially when there had been no
warning that this was a possibility.
The idea of having only one implant in place
for six months or so is not appealing to the person who was so motivated to look
better as to voluntarily under go this surgery. Generally once it is determined
that an infection exists around the implant, it is best not to temporize and
give antibiotics to delay the inevitable.
While it is not impossible that antibiotics
will allow the implant to remain and not be removed, the chances of this are
very small, somewhere in the range of less than 1%. And while the weeks go by
and the swelling, redness and pain return every time the antibiotics are
stopped, and the expense and complications of taking the antibiotics are taking
their toll, the patient may become more and more depressed, anxious and angry.
Not only is the unhappy prospect of having
the implant removed looming in the future, but the presence of the persistent
infection is ever-present. This is an uncomfortable illness, with tenderness and
redness and perhaps fever and fatigue. If the implant is doomed to be removed,
then this discomfort and illness is unnecessary and should be avoided by early
removal of the implant.
It is better to do what is needed quickly and
forthrightly, and then by the time the patient on antibiotics would be getting
depressed and angry over the prospect of losing the implant while having been on
antibiotics for about six weeks, the patient who has been without an implant all
that time is already well and free of pain and swelling and is scheduling the
date to have herself restored with a new implant.
Patients tend to be more accepting of this
scenario when they are forewarned of this possibility, and the patient who is
treated decisively tends to have more confidence in her treatment and is more
likely to remain with the same surgeon.
Hematomas occur fairly frequently. They are
said to occur more often in redheads, patients who have taken aspirin,
ibuprofen, vitamin E or estrogens, and in those patients with elevated blood
Other causes are coagulopathies, and
excessive heat or exertion after surgery. It can be explained to the patient
that this is a result of a blood clot around the implant due to a broken blood
vessel usually within the first three weeks after surgery.
The patient may also be reassured that this
is not life threatening, either from the blood clot going to the lungs as an
embolus or from blood loss, since it occurs within a closed space. If hematoma
occurs, the patient will notice swelling of one side, with pain, tenderness,
firmness and bruising or discoloration.
Small clots occur without any of these signs.
Sometimes the normal side without the hematoma will transilluminate much more
than the side with the hematoma, distinguishing the clot from a seroma or fluid
around the implant. The patient with these signs is seen, either within a few
hours or within a day, or as soon as possible, depending on the level of
discomfort. For one breast to have more bruising or discoloration and more
swelling than the other is expected and normal.
The patient who will need evacuation of a
hematoma will usually be moderately or very uncomfortable with a hard swollen
breast on one side. As soon as it is determined that a significant hematoma (in
my opinion, any of a size to reduce transillumination and cause symptoms)
exists, it is either drained or the implant is removed under sterile conditions,
with eradication of the hematoma and implant replacement.
If the hematoma is drained, it will not all
come out. A drain will probably be left in place for a number of days, requiring
the patient to stay home or wear sterile pads in her bra to collect the drainage
for up to a week. And still with drainage, some may remain behind to cause
capsule contracture. Another consideration is that while it is draining,
infection is always a possibility, which could lead to removal of the implant
If the patient, when seen, can wait until the
next morning (which usually only requires reassurance and adequate pain and
anxiety relief), the implant can be removed under sterile conditions in the
The hematoma is completely removed. The
pocket is flushed with dilute peroxide, which can eliminate some of the
discoloration, and the implant is replaced and the crisis is over. The patient
is recovered in a few hours, and can return to usual activities the next day
with little bother and no mess.
Noticeable Scars, 10 %
Someday one of our patients is going to have
a hypertrophic or keloid scar that is quite noticeable and troublesome. Others
will be self conscious of scars that may be almost imperceptible. The location
of the incision is important in preventing scar formation.
The areola skin is much less likely to have a
hypertrophic scar or keloid than the peri-areolar skin. The axillary incision is
the most hidden, and it too seems much less likely to form a thick scar than the
In a patient who is not known to heal without
visible scar formation from other surgeries that have been done on them, the
inframammary or periareolar sites can give very unattractive results. Sometimes
a single revision can make a lot of improvement, and in other instances, the
scars persist and are troublesome.
Scars of the areolae that are lighter in
color than the color of the areola can be tattooed to match, and this works
well, especially in the person who persists in forming a white line in the
areola in spite of the most carefully performed revision.
Only a few patients will need revision. The
incidence of 10% is arbitrarily chosen to include patients with almost invisible
scars who still feel they are noticeable. Actually 100 % have scars, and whether
or not they are noticeable is a matter of opinion.
As with scars, all breasts are to some extent
unlike. It can be mentioned that God made no two snowflakes, grains of sand or
anything else we can see alike. Whether or not there is significant asymmetry is
a matter of opinion.
It is advisable to mention this possibility
to patients prior to surgery, pointing out asymmetries that already exist. We
try to make the breasts more symmetrical with the operation. The one factor that
can be controlled is volume.
We can use implants of different volumes to
help correct asymmetries in size. Another factor is the position and shape of
the infra-mammary fold that can be made more equal when indicated, and this may
help the appearance quite a bit.
Factors that cannot be controlled with
augmentation alone and would require other surgery are the size and position of
the areola, the protrusion of the nipples, pigmentation, shape, and many other
inequalities and asymmetries.
One of the best ways patients with a certain
shape can tell what kind of result they are most likely to have is to see before
and after photographs of patients who have a shape similar to theirs before
Numbness, 10 %
Many surgeons will say they have no problems
with numbness, and this is partly because the surgeon cannot feel it and he is
unaware of it. It is not the surgeon's personal problem, and yet it may be a
patient's problem. All patients have a little bit of numbness with almost any
surgery when there is an incision.
With augmentation mammoplasty the most common
numbness occurs in the lower half of the breast inferior to the areola,
especially when there was not much breast tissue to begin with and the
infra-mammary fold is lowered, or if a large implant is used.
This mostly goes away and doesn't bother many
patients. Numbness of the nipples does bother some patients, and occasionally
the sensation of the nipples is very important to the patient, and they need to
know there is a risk it may be reduced, or even absent (though rarely).
The nerve to the nipple primarily comes from
the fourth intercostals nerve, and should be preserved if at all possible. In
testing patients who have noticed some numbness (and I often ask), I cannot
remember ever seeing complete anesthesia when a pinprick of the areola is given.
Probably the trans-axillary sub-pectoral and the umbilical approach cause the
least numbness, and the other sub-pectoral approaches may result in less
numbness than pre-pectoral. However, numbness occurs with the subpectoral
The areola incision itself does not increase
the incidence of the complaint, and need not be avoided for that reason. Most
sensation returns in one year, and may continue to return for up to two years,
and the patient with early numbness should be reassured.
Deflation with saline implants, 30 %
While the incidence is not exactly known, the
deflation rate with saline implants is so high that in spite of the other
advantages of their use (i.e. no gel bleed, softer than gel, lower capsule
contracture rate), they are seldom used. Even with combination implants, when
the saline makes up more than 10 % of the volume, a unilateral deflation usually
means another operation.
Probably the pre-filled saline implants with
no valve will have less of a deflation rate.
Excessive firmness, 30 %
Capsular contracture is the major
complication of breast augmentation with a wide range of incidence reported. The
most widely quoted classification of grades of firmness is from Baker (P&R
Surg Vol. 65, No. 1, Jan 1980). The incidence in Baker's series of grades II to
IV was 27% or more (especially since there was not a long follow-up period
recorded and the fact that sometimes capsules do not appear for 2 years
This was in spite of up to 40 mg of Kenalog
instilled into the pocket of each side, antibiotics, etc. The prevention and
treatment will be more thoroughly discussed elsewhere.
What the patient needs to know is her chances
of having this problem, what can be done for it, and what it will cost. I show
the patients an article by dear Abby that quotes a 50 % incidence of hard breast
implants, and the case of one patient who had the implants removed in disgust
because of the hardness.
My patients are assured that if they ever
want the implants removed, I will do it for them at very low cost to them. To my
best knowledge, in spite of the hardness problem, all my patients still had them
in, and had elected to keep them even though there had been some problems.
This was true until 1992 with the FDA saline
scare. Since then, four have had the implants out and not replaced.
The reason I offer to remove them at very low
cost is that I don't want them to have to go somewhere else to have it done. I
want to follow the patients with breast implants and keep in contact with them,
especially those who have had some complication or who are in some way
displeased with the results.
The rippling problems that we are seeing with
breast implants first began with the introduction of textured silicone gel
implants in 1989.
The texturing was introduced to prevent
capsule contracture. It was noted that the polyurethane implants would not allow
capsule formation and they would not become very hard.
If the standard silicone implants of the
1980s were used without some sort of special technique to prevent hardness such
as submuscular placement or use of steroids, the incidence of grade III and
grade IV moderately severe and severe capsule contracture was more than fifty
Some surgeons such as Richard Dolsky and Gary
Fenno from the early 1980's exclusively used polyurethane implants because of
this capsule contracture problem. During the latter of the 1980s more and more
surgeons were moving toward the polyurethane implants. The plastic surgeons who
wrote most articles on breast implant surgery, such as Bostwick and Tebbets,
started routinely using the polyurethane implants in primary augmentations to
It was discovered that the texturing of the
polyurethane as compared to the slick surface of the gel had a lot to do with
preventing capsules. Therefore, the textured silicone implants were made
available by Mentor and McGhan in the last two years of the 1980s.
Though the texturing does seem to prevent
capsule formation, the additional thickness of the silicone bag causes waves or
ripples of the bag that show through the breasts, especially in a slender woman.
With round implants, over-filling can result
in less rippling, but when they are over- filled they form a ball or a sphere
like an orange and become firm and unnatural in appearance.
Rippling from breast implants is the
appearance of the implant through the patient's tissue, and is proportional to
the thickness of the implant wall and the thinness of the tissues covering the
When a saline or gel filled silicone textured
implant is held up, you can see vertical folds. If the patient has thin tissues
above the nipple overlying the implant, these folds will show through. To
prevent this rippled appearance above the nipple, the implant can be placed
below the muscle.
Ripples occur with silicone textured
implants as well as with saline. The saline textured implants ripple the most,
but saline without texturing can also ripple.
Even if the implants are below the muscle,
the rippling can still show in the lower part of the breast, especially
laterally in the area of the anterior axillary line. And this shows most when
the patient leans forward.
The McGhan 468 implant is teardrop in shape
and is filled more tightly without spherical distortion. It is firmer than the
more loosely filled implants. But as a Biocell it is a very deeply textured
implant. It is probably the least likely to have a capsule of any on the market
Certainly if I were revising a patient for a
capsule problem, I would consider the 468 implant to prevent recurrence.
Capsules frequently recur. Because of the tight fill of the 468, this implant
will not show rippling very much at all. The trade off is the firmness and
immobility that is present with the 468.
The PIP pre-filled soft, smooth implant seems
to have the least thickness of the implant wall. Therefore, it has the least
amount of rippling and the most desirable softness altogether. Surely with this
implant being very much like the natural feel and softness of the silicone
implants we were using in the 1980's, the capsule rate is going to be fairly
At the present time of this writing, March
11, 1998, the PIP smooth implants are not available because of FDA questions
about the methods of manufacturing of these implants.
In summary: Rippling is due to the thickness
of the implant. Texturing doubles the thickness and increases the chance of
rippling. Even the smooth inflatable saline implants are thick enough and stiff
enough to ripple if the tissues covering the implant are thin. The textured
implant that does not ripple is the tightly filled 468. The soft, smooth
pre-filled implant that does not ripple is the PIP smooth, which right now is
Seroma is the accumulation of serum-like
fluid around an implant. It frequently occurs years after surgery.
The incidence is in about one or two percent
of patients. In over one thousand patients, I have seen seroma in about six.
The usual patient with a seroma is one who
previously had a very good result and four to twelve years later develops a
swelling of one side. On examination the one side with a seroma is larger, but
usually not very tight or very tender. Most often there are no signs of redness
or inflammation such as fever.
A swollen breast after surgery is usually a
hematoma. The hematoma will not transilluminate. The normal breast with a clear
saline or gel implant transilluminates very well. Even if the implant is under
the muscle, a hematoma will transilluminate a lot less than the opposite side.
Since the lower half of the breast is not covered by muscle, the
transillumination can be detected with the light going transversely through the
breast rather than from the bottom up.
With seroma the transillumination is
preserved. A seroma transilluminates just as well as the other breast with an
implant and no seroma. The fluid around the implant with seroma is serum or
straw-colored and usually cloudy. Those I have cultured have shown no growth.
Very often all that is needed is a course of
antibiotics and of steroids to eliminate the seroma. If it comes back, the
steroids and antibiotics can be repeated. If the seroma persists and will not
diminish with steroids and antibiotics, then it may be necessary to remove the
implant and leave it out for several months as we would do with infection. A new
implant can then be replaced at a later date.
Two other steps can be taken before the
drastic measure of implant removal must be considered. One is to use a blunt,
small needle-like instrument, such as a liposuction canula or micro-lipo canula.
This can be inserted through a tiny incision just posterior to the anterior
axillary line where it will not leave much of a mark. As well, through a tract
down to the breast implant (so that leakage will not occur), the capsule can be
perforated and the seroma aspirated and drained.
While this small canula is present in the
capsule, the pocket can be irrigated with saline thoroughly. Also, we can also
instill a small amount of our favorite antibiotic, such as Rocephin, and of our
favorite steroid, such as 20 mg of Solumedrol or 5 mg of Kenalog. This can solve
Another slightly more conservative option to
total removal of the implant for several months would be to remove the implant,
thoroughly irrigate the implant, and replace the implant.
The cause of seroma is probably different
from one case to another. But it might be from hematogenous bacterial invasion
of the foreign body area. Or, it could be from some very late reaction to some
very tiny particles of foreign bodies that are left at the time of surgery.
A blue window is a simple thinning of the
tissues so that the implant can be seen as a bluish color. The skin over the
implant can be so thin that it would seem that the slightest scratch or puncture
of the skin would perforate the skin, if not the implant itself.
Blue windows can be divided into those that
are soft and those that are firm.
Soft blue windows occur especially frequently
when steroids have been used in the implant. A blue window may also occur from
steroids that are long acting, such as triamcinolone. This crystalline steroid
will settle down to the bottom of the pocket and cause thinning.
The firm blue window occurs when there is
some reaction to the implant, causing a capsule to form; this is a sign of
Both types of blue windows usually occur in
the lower thin portion of the breast, near the infra-mammary fold. This is where
the tissues are thinnest.
Whenever the blue window is due to steroids,
it can be eliminated quickly and easily by removing the implant and by washing
out any steroids that are in the implant or in the surrounding pocket. Within a
week of replacing the implant the blue window will be gone.
The blue window that is associated with a
firm capsule can be followed and will probably result in breaking open at the
site of thinning. And when the implant is exposed, it will extrude.
From my own experience I have seen only one
implant from another surgeon extrude, and I have had only one patient of my own
experience extrusion of one side following pregnancy.
Of soft blue windows, I have seen several
dozen. This is because from about 1975 through 1986 I used double lumen implants
made of gel in the center and covered by saline in almost all of my patients. To
prevent a capsule, I put steroids into the outer saline compartment routinely.
The steroids would prevent capsules from forming in the first two or three years
in nearly all of the patients. The breasts would remain soft and natural and
there were very few problems. In the early 1980s, because a couple of patients
developed capsules several years after surgery, I decided to increase the dose
of steroids to prevent this problem. That is when I started seeing blue windows.
Because we wanted a long-term anti-capsule or
anti-scar tissue effect due to the steroids, I chose to use long acting steroids
in the implants. Kenalog (10 mg) was used in each implant in most cases. This
would produce a blue window in less than ten percent of patients. A mild faint
small blueness and thinning of the tissues would be followed and would usually
go away within a year.
As I lowered the dose to 5 mg, the capsule
prevention was almost as good and there were no blue windows.
At one time I increased the dose to 20 mg of
Kenalog in each implant. And all of these patients developed blue windows and
steroid atrophy. They were all corrected by washing out the steroids and
replacing the same implant with fresh saline in the outer compartment. And in
every case the blue window and steroid atrophy was almost completely gone in one
or two weeks. None of these patients to my knowledge had persistent problems or
In the case where there is a blue window and no
steroid inside the implant, I think that if it is mild and not progressing,
it can just be watched and will by itself go away over a period of months
Many surgeons have advocated the use of
steroids in and around implants. If using non-textured implants, I will put
triamcinolone injection into the tissues behind the implant where steroid
atrophy would not show to keep a capsule from forming. This is done in most
cases still today.
Capsules are going to form even around smooth
saline implants in a high percentage of cases. Long acting steroids injected
behind the implants in a dose of 10 mg of Kenalog for each side will prevent
many capsules. Sometimes Solumedrol 10 or 20 mg will be put in each implant
instead of the Kenalog injections.
The Persistent IMF or Double Fold or
A double bubble or double fold is the
original infra-mammary fold that has not been pressed out. It is a fold in the
dermis primarily, but also in the subcutaneous tissues attached. It is not due
to any mysterious ligament or fascia. Whenever the dissection is below the
muscle along the chest wall with no specific attempt to press out or stretch out
the IMF, the implant can follow the chest wall and leave the previous IMF intact
causing the double fold. The freeing of the original IMF is a subcutaneous
dissection, not a sub-muscular one. The proper plane is to dissect the
subcutaneous fat free from the underlying muscle and fascia, leaving the fat
attached to the skin. By double fold, it is meant that the new IMF and the old
IMF (infra-mammary fold) exist together; the result is a double-bubble
appearance. It is the old subcutaneous and dermal fold persisting that causes
the problem, nothing more. No imaginary fascial bands or ligaments are the
culprit. The deep and persistent IMF cannot always be corrected, because the
dermis can only stretch so far. If a surgeon were called upon to create a Ubangi
lip in one operation at one time, it would not be possible. But if after surgery
a double fold is prominent and McGhan textured implants were used, it will not
move. The implant that is fixed like velcro (as these implants are) will not act
as an obturator or dilator to stretch things out. They will remain fixed in
position and whatever double fold there is after surgery will probably remain.
On the other hand, if you get it dissected out and want it to stay in place, the
McGhan textured will hold it in place and prevent a late occurring capsule or
double-fold from developing. A smooth non-textured implant can allow this to
happen. The usual mild double bubble is not a big problem, fortunately. All that
is required is pressing or stretching out the previous persistent subcutaneous
and dermal infra-mammary fold as describe above. Even though we know that
inferior to the 5th rib the dissection is more difficult and the tissue is more
fibrous, as well as we could search in the cadaver or in the live patient we
could not discern a structure. We will just find dense fibrous tissue that we
have always known was there. The author of an article in the 1995 PRS Journal
(on the Infra-mammary crease ligament) is in error by saying that,
"Separation of this ligament from the fifth rib periosteum will result in
the "double-bubble" phenomenon." The problem of the double-bubble
in his patient was not that some imaginary ligament was transected, but that the
subcutaneous and dermal infra-mammary fold were not released - pushed out or
stretched out as they must be. The author remained sub-muscular and sub-fascial
until he was inferior to the IMF. Therefore, he just pushed it out on top of the
muscle. Maybe he has not seen the double fold with the above muscle implant, but
it is just as common as below. One needs to penetrate the pectoralis muscle and
fascia attachments the 5th rib and then the implant and dissection are
subcutaneous and the IMF is corrected. He did not do this. So with his
dissection plane he did not release the skin fold from the underlying muscle and
fascia. He was below the muscle in this area.
In our dissection of eight breasts with our
cadavers over the past four years under the guidance of our anatomist Earle
Davis Ph.D., we have not found anything to suggest that there is an
"infra-mammary crease ligament." We find that the dermis of the fold
and below it are firmly attached to the underlying fascia of the rectus
abdominus, serratus anterior and pectoralis major. This is obvious in palpation
of your own chest wall as well as in surgery or dissection of cadavers.
In the "Intradermal Anatomy of the
Inframmary Fold" by Boutros, Sean (prs1998), with both dissection and
histological study, there was "no evidence of any ligamentous structure in
the area of the inframammary fold."
So in summary, it is not failure of
transection of the imaginary ligament in below the muscle dissection that caused
the problem, but failure to release the dermis from the fascia in that plane and
failure to correct the original IMF by simply pressing it out with blunt
dissection. The double-bubble is simply the persistent IMF made of skin,
primarily dermis. It is the result of the patientís inframammary fold not
having been stretched out to a round shape to fit the contour of the new breast.
It is made only of skin. The dermis retains its shape, and will not easily
stretch out to the rounded contour we want. But like the Ubangi lip, with
pressure and time, many persistent inframammary folds that are causing a double
bubble appearance will stretch into the rounded shape covering the augmented
breast. Sharp dissection can be used to release the tissues so they can be
pressed out, but more is needed. Blunt dissection is needed. The previous IMF
must be bluntly pressed out; sharp dissection alone has no pressure to
accomplish this. Transecting sharply or with cutting cautery or laser is often
not enough to expand the previous IMF. Also, by forming more scar tissue,
cautery and laser cutting can add to the fibrosis that will make the
double-bubble even more persistent. Much more can be gained by actually
stretching out the skin that makes up the previous IMF with blunt dissection.
The most gentle blunt dissection or simple pressure from the implant itself can
over time have a great effect on the persistent IMF (double-bubble) as well as
the constricted lower breast that does not easily round out, as is common with a
tuberous breast. The pushing out and stretching of the skin of the IMF is the
solution to avoiding or correcting the double-bubble. Like the Ubangi lip or the
stretching of the abdomen in pregnancy or with use of an expander, sharp
dissection not only will not accomplish the desired result, but is potentially
destructive. Cautery and sharp dissection induce scar tissue that will inhibit
stretching that could occur from the pressure of the implant over a period of
time. In summary, as shown above, the persistent IMF is not only in the
transaxillary subpectoral or submuscular case. It has shown to be just as much a
problem above the muscle and with any incision site. It is unrelated to any
imaginary ligaments described in the literature. And thinking there is a
ligament or a structure that should be searched for or dealt with is not helpful
and is a distraction to the surgeon, and therefore counterproductive. The
treatment of the high or persistent IMF is simple and direct. It must be
dissected free and pushed out.
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