Implants and Your Health

Technically speaking, they are glands whose primary purpose is to produce milk. But while other glands, like your thyroid and your pancreas, go about their business with little attention, your mammary glands—otherwise known as your breasts—have come to represent so much more than a source of nutrition for newborns. Every week gossip columnists blast news of another celebrity who has gone under the knife to enhance her cleavage. Google "celebrity boob jobs" and you'll come up with thousands of sites cataloging the good, the bad and the ugly.

With all this attention, it's not surprising that breast augmentation has become the most common cosmetic procedure for women. Last year 347,524 women received implants, according to figures released last week by the American Society of Plastic Surgeons. That's a 64 percent increase since 2000—an amazing statistic when you consider that health insurance generally doesn't pay for implants that are purely cosmetic (which is not the case for breast reconstruction after cancer surgery).

Depending on where they live, women can shell out as much as $10,000 in total costs. Many may consider it money well spent because of the self-esteem boost they get from "fixing" small or saggy breasts. Younger women are primarily looking to enlarge breasts that they perceive as undersize, while older women want to restore the look of their breasts before they had children, says Dr. Laurie Casas, associate professor of surgery at Northwestern University Feinberg School of Medicine in Chicago.

It may be easy to forget, with all the tabloid talk about "boob jobs," that breast augmentation is real surgery, with potential complications. "It's like any decision you make," Casas says. "You listen to the pros and cons and you weigh them." A responsible surgeon should spend a good deal of time discussing those pros and cons with patients. Choosing an operation that is not medically necessary means extra due diligence. "This is elective surgery," says Dr. Richard D'Amico, president of the American Society of Plastic Surgeons and an assistant clinical professor of plastic surgery at the Mt. Sinai School of Medicine in New York. "We're not making you healthier. I feel there is a greater responsibility for safety because it is elective." Surgeons say that breast augmentation patients who clearly understand the risks and benefits are most likely to be satisfied with the results.

First, a little background: implants are silicone pouches filled with either silicone gel or saline and have been around since the early 1960s—before the U.S. Food and Drug Administration required safety tests for medical devices. In the early 1990s, responding to concerns from patients and some doctors, the FDA restricted the use of gel-filled implants. But in 2006, after considerable scientific review and debate, the agency once again allowed the marketing of gel-filled implants when it approved applications from two manufacturers.

Here's what you need to know (and ask) before surgery and what to expect afterward:

Selecting a Surgeon You want a doctor who is certified by the American Board of Plastic Surgery. That means he or she has graduated from an accredited medical school and has completed at least five more years of training as a resident in all kinds of surgery with at least two years dedicated to plastic surgery. In the initial consultation the surgeon should also spend considerable time explaining the risks and benefits and answering all your questions. Contrary to what many believe, breast implants are not permanent, nor are they maintenance-free. These two important facts should be mentioned during your conversation with the surgeon. Breast implants may last more than a decade, but at some point they will need to be replaced. You will also need to see the surgeon annually as long as you have implants to make sure that the implants have not leaked and that everything is still working as it should. If the doctor you pick doesn't inform you of this, you might reconsider your choice. "He's more interested in signing up the patient than preparing them for a lifetime of implants," says Dr. Foad Nahai, an Atlanta plastic surgeon who is president of the American Society for Aesthetic Plastic Surgery.

What Your Surgeon Should Ask You The surgeon you choose should give you a thorough medical evaluation to make sure you have no underlying health problems, such as diabetes or hypertension, that could get in the way of a successful outcome. Patients with these problems may still be able to get implants; doctors just need to know the full picture. As part of the evaluation you also need to disclose your complete medical history so that the surgeon is fully informed. Safety, says D'Amico, is "a joint responsibility between the patient and the plastic surgeon." The evaluation may turn up reasons to postpone or avoid surgery—and it's important for you to pay attention to that. "If a reputable board-certified plastic surgeon says you shouldn't do it, please don't find somebody else," says D'Amico. A good surgeon will also ask you about your reasons for wanting implants. He or she is looking for warning signs that a patient has unrealistic hopes about what the procedure can accomplish. A doctor might, for example, discourage a woman who wants bigger breasts just to please a boyfriend or to save her marriage. "This is not about solving social problems," says D'Amico. "It is about addressing breast size. While they may be related, we want to make sure that patients have appropriate expectations." Elective surgery should always be a carefully considered choice—not an emotional one. "Women must think of this as a very, very serious decision, because you are electively choosing to put a foreign body in your body, and you have to do it for the right reasons," says Casas, who also has a private practice in Glenview, Ill.

Finding a Facility You've probably heard stories about procedures gone wrong. Often these are performed in unregulated facilities. So check out the venue. If you are having surgery somewhere other than a hospital, ask if the facility is either licensed by the state or accredited by one of these three organizations: the American Association for Accreditation of Ambulatory Surgery Facilities, the Joint Commission, or the Accreditation Association for Ambulatory Health Care. D'Amico says that facilities that meet these criteria have an "outstanding" safety record—comparable to a hospital's.

Silicone vs. Saline You and your doctor will decide which works best for you. Saline costs less, and if it leaks the body absorbs it. You'll also know right away that something is wrong, because the leaky breast will go flat, says Nahai. Silicone implants feel more natural, but leaks are harder to detect because the gel may not migrate. If it does move into another part of your body, like your arms or your upper abdomen, you will feel a lump that has to be removed, says Nahai. Women who choose saline because they don't want silicone in their body should understand that the saline-filled pouch is still made of silicone, so there's no such thing as a silicone-free implant. According to the American Society of Plastic Surgeons, 121,551 women picked silicone implants last year, while 225,971 chose saline.

Why Age Matters Under the current rules, women who are at least 22 can get silicone gel-filled implants. The age minimum for saline implants is 18. (The age restriction doesn't apply to women who are getting implants for breast reconstruction.) When their celebrity idols appear to be sporting bigger boobs, many younger women want to follow suit. But the restrictions are in place for a reason. Breast tissue is still growing through late adolescence, and young women may not understand the full medical implications of implants. "I personally do not think it is appropriate for a 16-year-old to have breast implants as a sweet 16 present, and the FDA doesn't approve either," says Nahai. On the other end of the age spectrum, Nahai says he has even operated on a woman in her early 70s, with good results. However, older women (even in their 40s) may need a breast lift in addition to implants to fix saggy breasts, doctors say.

Picking the Placement Implants can be placed either behind the chest muscle or within the breast tissue. The choice generally depends on the size and shape of your breasts and the type and size of implant, but there can be other issues as well. While implants in any part of the breast hide some breast tissue in a mammogram, implants behind the muscle may be a better choice for women with a family history of breast cancer who rely on mammography screening, says Nahai, because more breast tissue will be visible. Behind-the-muscle placement may be more painful, and the recovery takes a little longer. Surgeons often advise women at high risk of breast cancer to see an oncologist before deciding whether to get implants.

After the Operation Even if you've chosen a top-flight surgeon in a superb facility, you can have problems. About a quarter of patients have some kind of complication within the first two years after their first surgery. The most common, called capsular contracture, occurs when your body forms an eggshell of scar around the implant, D'Amico says. It affects about 15 to 20 percent of patients and isn't a major problem for many—but some women will get an uncomfortably hard scar and may need surgery to correct it. Some women experience temporary (or even, in a few cases, permanent) numbness or extra sensitivity of the nipple. Very thin women who get saline implants may also find that the outline of the implant is palpable or even visible through the skin. "We refer to that as rippling," says Nahai.

Finally, there is the possibility of leaking. Nahai says that when he first meets with potential patients, he gives them a saline implant to hold in one hand and a gel implant in the other. He then tells them that "there is nothing natural that you or anyone else would do to your breasts that would break these implants." But severe trauma—in a car accident, for example—could cause damage. (The FDA also reports that the pressure from mammograms can rupture implants or cause leakage.) That's another reason to stay in regular contact with your surgeon.

Younger women are often concerned that implants will interfere with breastfeeding. Although there is no data to definitely answer this question, surgeons say that a properly placed implant shouldn't be a problem. "If you have implants and you are anatomically and functionally able to breastfeed, then you should be able to breastfeed," says Casas. Still, this is a concern that should be discussed thoroughly with your surgeon to make sure that all your questions are answered.

For more information about breast implants, check out these sites:

The FDA's consumer handbook

The American Society of Plastic Surgeons

The American Society for Aesthetic Plastic Surgery

The two societies have also jointly produced a site called Breast Implant Safety that has lots of useful information.

And for our six tips on keeping your breasts healthy and, yes, perky, click here.