By Noël B. Natoli, MD, FACS 

For many breast cancer survivors, it’s a huge relief to get the whole experience in the rear-view mirror. So it’s not uncommon to forget some of the finer details about future steps that could be years or even decades off. For women choosing implant-based breast reconstruction, It’s important to remember that “permanent implants” don’t always mean forever and are not intended to be lifetime devices. In fact, the FDA recommends that all implants be exchanged after 10 years because of the incremental risk in the rate of rupture of implants over time. Regardless of the implant type, both saline and silicone implants will require a certain level of “up-keep” or maintenance over time.

MONITORING OF IMPLANTS
Recent updates from the FDA have changed the recommendation for surveillance or monitoring of breast implants. All silicone implants whether symptomatic or not should be monitored with an initial ultrasound or MRI 5-6 years after implantation and every 2-3 years thereafter. If implants are symptomatic- painful, tight, have shown movement or deformity, then monitoring should be done at any time after implantation.  

REASONS IMPLANT EXCHANGE MAY BE INDICATED:

1. Painful Scar Tissue (capsular contracture)
Some patients develop painful or thickened scar tissue around a breast implant, called capsular contracture. Every breast implant, or for that matter any implant placed in the body, will develop a capsule around it. This is a layer of scar tissue the body develops to separate “self” from “nonself”. However, occasionally this capsule will tighten and/or thicken around a breast implant in this case causing a phenomenon called capsular contracture. This can be painful or asymptomatic and exists on a spectrum sometimes very subtle in change. This happens at a higher rate in patients after radiation. We are not certain why this happens but it is thought to be triggered by either the presence of a low-grade infection or “biofilm” around the implant or possibly blood around the implant, or due to outside factors such as radiation therapy. Capsular contracture can not only cause pain for the patient but movement of the implant and visible deformity causing asymmetry.

2. Implant Damage
Many things can cause damage to the integrity of an implant including outside forces such as trauma from a motor vehicle accident with or without the deployment of airbags, pressure from a mammography, or accidental piercing with a pinpoint or needle during or after implantation. While patients shouldn’t be fearful of going for mammography it is absolutely imperative that patients tell their mammography technician that they have breast implants in place and in fact we recommend calling ahead to make sure the facility has ample experience in performing mammography in patients with breast implants. The risk of rupture again does increase over time so that the same level of force is more likely to rupture an implant that’s a decade old than one that was just placed. These forces can cause silent rupture which often goes unrecognized without imaging to assist in monitoring. Once recognized implant rupture should be immediately addressed with implant exchange or change to alternative means of breast reconstruction with autologous tissue.  

3. Anatomical Changes Over Time
As we continue to age implants don’t always behave as native tissue does. This can be related to weight loss and the development of loose skin over time or even to changes in the skin elasticity over time which decreases with aging. This may cause shifting of the implant or unnatural drooping. Over time the implant may become more visible and may require implant revision surgery to correct these changes. This is also more common in one-sided breast reconstruction as implants age differently than native breast tissue causing unevenness over time and unequal ptosis or breast drooping in unilateral implant breast reconstruction. This is also more likely with radiation causing asymmetry over time. These changes can often be addressed with skin tightening procedures such as mastopexy or breast lift and implant exchange. Discuss these concerns with your breast surgeon as often they are easy to address. Surgery to correct asymmetry on the noncancer breast is generally covered by insurance even decades after initial diagnosis so don’t be afraid to voice your concerns with your plastic surgeon.  

Also depending on implant position muscular pull can cause deformities of the implant over time. Sub-muscular implants are placed under the pectoralis muscle and can create an “animation deformity” where over time the implant shifts upward or moves unnaturally with contraction of the pectoralis muscle causing embarrassment in low-cut shirts or dresses with normal movements of daily activity. This can be corrected with a pocket change to the pre-pectoral position, above the muscle, and often requires placement of a skin substitute or acellular dermal matrix which is often used with immediate breast reconstruction as well.  

TIMING AND RECOVERY
There is no universal time frame for breast implant exchange, especially in patients not experiencing problems so the benefits and risks of surgery must be weighed at the time of consultation with your plastic surgeon and discussed thoroughly. Length of surgery and recovery varies with the procedure performed but is generally outpatient surgery often performed at an ambulatory facility. Implant exchange alone can be a very quick procedure with minimal downtime although usually involves fairly standard limitations after breast surgery for roughly 4 weeks. More involved procedures including pocket position changes, capsular modification, mastopexy, and fat grafting procedures may have slightly longer recovery periods with similar restrictions in the post-operative period.