What Do Women Need to Know and When Do They Need to Know It?

Plastic and Reconstructive Surgery, December 2007
By Susan F. Wood, Ph.D. and Scott L. Spear, M.D.
Summary by Rachel Lieberman

When a woman decides whether or not to get breast implants, she must consider how that decision will affect her life. In their article, “What Do Women Need to Know and When Do They Need to Know It,” Drs. Susan Wood and Scott Spear discuss the known and unknown risks involved in breast implants. They note that many women with implants say they knew very little about the risks. They point out that it is the healthcare professionals’ responsibility to provide patients with information and to help them weigh the risks and benefits, but that “it is also a challenge to women to seek information, ask good questions and carefully consider the answers.”

The article is especially important because it shows substantial agreement between Dr. Susan Wood, a well-respected women’s health expert, and Dr. Scott Spear, a consultant to breast implant manufacturers and the former president of the American Society of Plastic Surgeons.

Health and Cosmetic Risks
There are known risks. Breast implants do not last forever and women will need additional operations to replace ruptured implants. Ruptures of saline breast implants are obvious, but ruptures of silicone gel implants are often “silent,” meaning that there are no obvious signs or symptoms. The authors point out that “magnetic resonance imaging is the most accurate way to detect a rupture…Mammograms are often inaccurate in detecting rupture, and if an implant is already broken, the pressure from a mammogram could cause the silicone gel from the implant to leak outside the capsule.” Women who notice any changes that could be caused by a ruptured implant or who have an MRI showing rupture are advised to make an appointment to discuss removal.

The removal of implants is more complicated than the initial surgery, especially if an implant has ruptured and the silicone has leaked into the surrounding tissue. Even if the implant isn’t broken or leaking, after removal “the resulting stretching and sagging which may have occurred may be ‘cosmetically unacceptable'” and a breast lift or reconstructive surgery may be needed to make the breasts look like they did before implants. However, replacing the implants also has risks: “After a second surgery, the risk of more complications, especially capsular contracture and rupture is higher than before. Revisions or secondary corrections do not reduce the need or likelihood of future surgery.”

Breast cancer detection is another potential problem. The pressure from a mammogram may cause an implant to rupture, and implants can also hide cancerous tumors during a mammogram. To make mammography more accurate for women with breast implants, “the additional views of the breast with implants require a specially trained technician and will cost more, take more time, and expose the woman to more radiation.” Since most women wanting breast implants plan to have them for the rest of their lives, it is important to stress these issues to women of all ages before they make a decision about getting breast implants, and especially those who are at high risk of breast cancer.

The most common complication of breast implants is capsular contracture, where the breasts feel unnaturally firm and eventually may “feel hard and become painful,” and “may look abnormal,” often requiring “reoperation and implant removal.”

Although women who want breast implants may expect that it will make them feel better about themselves, the authors point out that there is no evidence that breast implants improve overall body image. Breast augmentation will not help with “underlying psychological issues ranging from improving self-esteem to treating body dysmorphic disorder.”

Financial Risks
As part of the decision-making process, women of all ages need to take into account the hidden financial costs of breast implants, because the implants and any complications are “usually not covered by health insurance.” Women must not only consider the cost of the initial surgery, but of “follow-up operations, removal and replacement, and additional costs for mammography and magnetic resonance imaging…Also, insurance companies may drop coverage or raise premiums for women who have undergone breast implant surgery.”

Unknown Risks
There are still many things we don’t know about breast implants, and an “unknown risk is not the same as no risk.” Women must also consider the unanswered questions. Most importantly, clinical studies for today’s breast implants only followed patients for the first 3-4 years after getting implants, even though implants may last up to 10 years. As a result, we don’t even know for certain how long implants will last and how they will affect the body. We do know that many women will need to undergo surgery even within the first few years, and the need for additional surgery continues every year because of complications and rupture.

More research is needed, and meanwhile some women need to be especially cautious about implants. For example, “differences in keloid formation, scarring, capsular contracture and other complications in African-American women are a potential problem that has not been studied in breast implants and thus remains unknown,” and women with autoimmune diseases were excluded from the implant makers’ clinical trials because of concerns about “whether silicone breast implants have the potential to disrupt the immune system.”

Research has also found a significant increase in suicides and some types of cancer for breast augmentation patients compared with other plastic surgery patients. And, there is the possibility that women with breast implants will have difficulty breastfeeding or that silicone or other implant substances may leak into their breast milk.

The article stresses that since breast augmentation is a choice with life-long implications, women should take the time and the care to consult with health professionals and look over the relevant literature to assess both the known and the unknown risks before undergoing these procedures. After gathering the information, women should take at least two weeks to assess the physical, psychological and financial consequences of breast implants before making their decisions.

Wood SF, Spear SL.
What do women need to know and when do they need to know it? Plastic and Reconstructive Surgery, December 2007;120(7 Suppl 1):135S-139S.