Complications
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
- Infection 1
- Hematoma 4
- Noticeable scars 10
- Asymmetry 10
- Numbness 10
- Deflation with saline implants 30
- Excessive firmness 50
- Steroid atrophy implant rupture pneumothorax seroma 2
- Shape problems position problems double fold synmastia 10
- Blue window extrusion 1
- Palpability and immobility 20
- 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
1. Infection 1
Actually in more than 500 consecutive operations performed on an outpatient basis in an office surgery suite there have been only three postoperative infections from the surgical procedure in the immediate postoperative 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 again
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 undergo 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
2. Hematoma 5
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 pressure
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 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 for months
If the patient when seen can wait until the next morning the implant can be removed under sterile conditions in the operating room
The hematoma is completely removed The pocket is flushed with dilute peroxide 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
3. 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 periareolar skin The axillary incision is the most hidden and it too seems much less likely to form a thick scar than the inframammary incision
In a patient who is not known to heal without visible scar formation from other surgeries 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
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
4. Asymmetry 10
As with scars all breasts are to some extent unlike 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 inframammary fold that can be made more equal when indicated
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 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 surgery
5. 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 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 inframammary fold is lowered or if a large implant is used
This mostly goes away and does not bother many patients Numbness of the nipples does bother some patients 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
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
6. Deflation with saline implants 30
While the incidence is not exactly known the deflation rate with saline implants is so high that 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 prefilled saline implants with no valve will have less of a deflation rate
7. 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
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
My patients are assured that if they ever want the implants removed I will do it for them at very low cost to them
8. Rippling 50
The rippling problems that we are seeing with breast implants first began with the introduction of textured silicone gel implants
Texturing was introduced to prevent capsule contracture
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
Rippling from breast implants is the appearance of the implant through the patients tissue and is proportional to the thickness of the implant wall and the thinness of the tissues covering the implant
To prevent this rippled appearance above the nipple the implant can be placed below the muscle
Even if the implants are below the muscle the rippling can still show in the lower part of the breast especially laterally and this shows most when the patient leans forward
In summary Rippling is due to the thickness of the implant Texturing doubles the thickness and increases the chance of rippling
9. Seroma 1 2
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
With seroma the transillumination is preserved The fluid around the implant with seroma is serum or straw colored and usually cloudy
Very often all that is needed is a course of antibiotics and of steroids to eliminate the seroma
If the seroma persists 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
10. Blue Window 1
A blue window is a simple thinning of the tissues so that the implant can be seen as a bluish color
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
The firm blue window occurs when there is some reaction to the implant causing a capsule to form this is a sign of impending extrusion
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
The Persistent IMF or Double Fold or Double Bubble
A double bubble or double fold is the original inframammary fold that has not been pressed out It is a fold in the dermis primarily but also in the subcutaneous tissues attached
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 deep and persistent IMF cannot always be corrected because the dermis can only stretch so far
In summary the persistent IMF is made only of skin The previous IMF must be bluntly pressed out sharp dissection alone has no pressure to accomplish this
The treatment of the high or persistent IMF is simple and direct It must be dissected free and pushed out
Complications