The Facts about Breast Augmentation

What will it cost–in terms of your health and your wallet?

THE TODAY SHOW March 27

Ample cleavage is all the rage these days, as we saw at the Academy Awards. Some women come by it naturally, but for those who don't, there is the option of cosmetic surgery. It's a procedure that more than 130,000 women underwent last year, but how safe are implants? On NBC's "Today" show, Dr. Judith Reichman discusses the health implications of breast augmentation. Read some of her thoughts below.

SINCE 1992, there has been a 300 percent increase in the number of breast augmentations each year, yet, as Dr. Reichman says, few cosmetic surgeries have come under such recent medical, commercial, and legal scrutiny.

WHAT ARE THE MAJOR TYPES OF BREAST IMPLANTS AND HOW DO THEY DIFFER?

There are two different breast implants:

Silicone (gel) implant – Before they were banned in 1992, this was the type of implant that many women preferred because it gave a natural, softer look. It was the implant of choice until reports of a possible link to autoimmune diseases, as well as other medical problems, were suspected to occur, especially if the implant leaked.

Although silicone implants have been banned for cosmetic use, they can be used under certain circumstances such as if a woman has had a failed saline implant or has experienced complications from a saline implant.

Silicone gel implants are allowed to be used for breast reconstruction or implant replacement. They are also approved for treatment of severe sagging, as long as a "lift" is done at the same time.

Saline implant–Of the 130,000 women who had breast augmentation last year, most of those implants were saline. Saline implants contain physiologic salt water encased in a silicone shell. The shell is considered safe and its components don't leak into a woman's body.

WHAT DOES BREAST AUGMENTATION COST?

Each implant can range in price from $600 to $1,300, not including operating room fees, anesthesiologist fees, etc. A fee of $3,500 for the procedure is on the low end–$5,000 is more likely. But in Los Angeles, it costs from $8,000 to $10,000, and in New York, the surgeon's fee is $4,417–not including all of the other fees–which can make it somewhere around $8,000.

HOW LONG IS RECOVERY?

The patient will spend the first three days at home, participating in no activities. This is a critical time because hemorrhaging can occur, and the implant can also slip.

During the next two weeks, the patient can gradually increase activity.

In general, if the implant is inserted under the muscle, it can take about six weeks to fully recover.

AT WHAT AGE ARE WOMEN HAVING THEIR BREASTS AUGMENTED?

Sixty percent of women are aged 19-34. Thirty-five percent are aged 35-50.

WHAT ARE SOME OF THE REASONS THAT WOMEN CHOOSE TO HAVE BREAST AUGMENTATION?

Older women may find that their breasts have deflated and drooped from childbearing and breast-feeding. Their self-esteem suffers and they are unhappy. They want to look better in their clothes. It is a major issue for these women to decide to augment their breasts, and they take a while to decide to do it.

For younger women, it is often a case of asymmetry, which makes them extremely self-conscious. They don't want to get undressed in public; they have problems finding bras; and they don't want to be in relationships because of embarrassment. They have a damaged self-image. Other young women never fully developed and they have extremely small breasts. Others want the "Academy Award" effect–they want to emulate others they see who they think have perfect bodies and look great in clothes. Perhaps they have worked out and done everything they can do on their own, and still don't have the breast size they are happy with.

Very few women do it to please a male figure in their lives. When we say that, we are under-valuing a woman's concerns.

Approximately 1,500 girls under the age of 18 received implants last year. Parental consent is mandatory. Dr. Reichman says that unless there exists a major deformity, she does not recommend letting minors do this because it is a procedure that will affect the rest of their lives as they will have to deal with long-term follow-up care.

WHAT ARE THE GENERAL HEALTH RISKS ASSOCIATED WITH BREAST IMPLANTS?

Breast implants were in use before 1976, when the Food and Drug Administration (FDA) began requiring approval of all implanted medical devices, so no information was required to keep the implants on the market. (They were "grandfathered.")

In 1992, however, there were so many complaints about silicone implants that the FDA chief at the time, Dr. David Kessler, pulled them off of the market.

Since silicone implants were the majority of all implants at that time, they naturally received the majority of complaints. (Now, a woman must sign a consent saying that she will participate in a research project–if she gets silicone implants.)

Saline implants were protected against this ban. It was felt that since saline can't hurt the body if it leaks, that potential harm was not there.

The chief concern is that rupture, leakage, or even the presence of intact silicone implants in the body, puts women at increased risk of autoimmune disorders.

Advertisement Symptoms that have been suggested to be associated with an autoimmune reaction due to the breast enhancement include joint pain and swelling, skin tightness, redness, or swelling, swelling of hands and feet, headaches, rash, swollen glands, muscle weakness, fatigue, general achiness, increased vulnerability to colds and flu, hair loss, memory problems, irritable bowel syndrome and nausea and vomiting. Many of the well-publicized reports linking silicone implants with health problems were anecdotal and involved a small number of women. This evidence, however, was enough to support a major lawsuit against one implant company, Dow Corning, which settled for a sum of $4.4 billion. But even as this suit was under way, major studies found no association or only an insignificant link between silicone implants and these autoimmunelike responses. Some researchers have suggested that there may be a small group of women with genetic factors that make them susceptible to a syndrome resulting from exposure to silicone. The problem is that this constellation of symptoms occurs in just one percent of the general population, so even if the risk is doubled, it's still a fairly rare condition–one that would only show up in studies of tens of thousands of women.

In the March 16, 2001 issue of the New England Journal of Medicine, a new study, "found no evidence of an association between breast implants in general, or silicone-gel-filled breast implants specifically, and any of the individual connective-tissue diseases, all definite connective-tissue diseases combined, or other autoimmune or rheumatic conditions. "From this they concluded, "From a public health perspective, breast implants appear to have minimal effect on the number of women in whom connective-tissue diseases develop, and the elimination of implants would not be likely to reduce the incidence of connective-tissue diseases."

ARE SALINE IMPLANTS SAFE?

There had been no good data presented to the FDA until earlier this month when the two companies that manufacture saline implants presented some of their safety data to the advisory board of the FDA. The advisory board recommended to the FDA that saline implants are not killing anyone and that they should remain on the market.

However, they did note the following:

• Sixty percent of women with saline implants had complications within four years.

• Three percent of women had implant leakage within three years. (The saline is absorbed into the body, and the implant deflates.)

• Eight percent of implants in healthy women needed to be removed within three years.

Because of these findings, the board recommended that although these issues were not serious, the patient should be informed of possible complications or problems.

WHAT ARE THE RISKS TO CONSIDER?

At the time of the procedure, complications can include bleeding and infection.

Other risks include:

Capsular contracture (hardening of the breast due to scar tissue)

• This occurs more frequently if the implant has a smooth-walled outer shell rather than a textured one, and if it is filled with saline instead of silicone. There's little good published data, but on average, about half of women with implants have this problem.

Leak or rupture

• This can range from pin-size holes to large tears. But even when the outer envelope remains intact, silicone can seep or "bleed" into surrounding tissue. The silicone shell becomes weaker over time, and studies of the older, thinner-walled implants that were put in more than ten years ago have shown that an average of 89 percent of women can expect to have both implants intact after eight years, 51 percent after 12 years but only five percent after 20 years. The rates of implant disruption appear to be similar in women with and without symptoms such as discomfort, hardening or an unevenness in the contour of the implant.

Loss of sensation in the nipple or breast

• Exactly how often this problem happens after implants are inserted under breast tissue is unknown.

Shifting of the implant from its original position

• Here again, the number of women who experience this problem is not known.

Interference with mammography reading that may hamper cancer detection

• Depending on the way the mammogram is performed, there is a 25 percent to 35 percent decrease in the visible areas of breast tissue. The view may be further limited by scarring around the implant and hardening of the implant, which curtails compression in the first place. (Because mammograms have been associated with implant rupture, there is a tendency to limit compression and perhaps compromise the quality of the picture.)

WHAT SHOULD WOMEN DO WHO ALREADY HAVE IMPLANTS?

Young women who are not getting mammograms should have their breast surgeon exam them yearly. The doctor can also make sure there is no bad scarring. A doctor can also perform a "pinch-test" in which the physician pinches the outer part of the implant to see if it stays in tact. If the implant is leaking, it will feel like toothpaste coming out of it. This is also something that a patient can do herself. For women over 40, they should get a yearly mammogram.

They may also want to discuss with their doctor whether or not they need an ultrasound – or the gold standard – an MRI. These tips are very important because many women never go back to see their doctor because they think everything is fine. If they are unhappy, they usually won't go back to the surgeon who performed the procedure, but go to another doctor. Consequently, as these patients "doctor-hop" it makes it difficult to track what happens to implant patients.

WHAT SHOULD WOMEN KNOW WHO ARE CONSIDERING IMPLANTS? 

We recommend breast enlargement using herbal solutions because women need to understand that this is a man-made prosthetic that has a shelf-life, and like any prosthetic it will have wear and tear and will have to be exchanged. There is a good chance that she'll have to change the implant once or twice or even more, depending on how old she is. Also, there are costs involved. While some insurance may pay for removal, they will not cover the insertion of new implants.

Because implants are a foreign body, women should use prophylactic antibiotics with teeth cleaning, and dental or surgical procedures, just as if they had mitrovalve prolapse or prostheses. Infection in the implant can cause scarring, hardening and contracture. Squeezing the implant to soften them or break down scars is a no-no. It can cause rupture or leaks. Breast implants should be treated gently and kindly. Women must commit to getting appropriate cancer screenings.

Many are embarrassed, or they fear a rupture may occur during a mammography, but the bottom line is that they could end up having nice looking breasts, as well as an undetected cancer that could be killing them, if they don't get a mammography.

IS THERE ANYTHING NEW ON THE HORIZON?

There is limited reconstruction using fat from a woman's body. It is still in preliminary stages. In Europe, they are using a new gel implant that has the consistency of solid gelatin. Another type of implant is a polyvinylpurolidone (PVP) device. Like silicone, PVP has a history of medical applications. It's new hydrogel formulation for breast implants has been tested and used in Europe. Each of these is a few years away from being offered in the United States. Judith Reichman, M.D., practices and teaches at Cedars-Sinai Medical Center and UCLA in Los Angeles.

She appears regularly on the "Today" show as a contributor on women's health issues.