24-Jan-2020

 

Recently breast implants have been in the news and I would like to offer a perspective. Breast Implant Associated- Anaplastic Large Cell Lymphoma (BIA-ALCL) is not a breast cancer. This is a rare highly treatable process that occurs approximately 8-10 years post implant whether saline or silicone, cosmetic or reconstructive procedure. Symptoms present as a delayed seroma, a sudden enlargement of a breast due to a fluid collection or a palpable mass. This only involves textured implants. In the US the percentage of smooth implants inserted is 83%, textured 17%; outside the US 90% texture and 10% smooth.

Overall incidence is 1:20,0000 or 0.005% risk, whereas the risk of breast cancer in a women’s lifetime is 12.5% or 1:8.

Recurrent Breast Cancer 5-8%

Capsular Contracture/10 years 14%

Implant Rupture/10 years 8%

Diagnosis of a sudden breast enlargement should be evaluated with an Ultrasound and aspiration of fluid for cytology(checking for cells); not all fluid collections are ALCL With the presence of a palpable mass tissue needs to be obtained for examination. If easily accessed it may just require a fine needle biopsy or if deeper a stereotactic needle or open biopsy.

Treatment is to remove the implant and the capsule. The capsule is present in all patients and is merely the bodies response to the presence of the implant. Majority need no other therapy.

FDA does not recommend asymptomatic prophylactic removal. Allergan has been contacting patients in their registry who have textured implants and offering a swap to a smooth surfaced implant. They do not cover the surgeons, anesthesia or facility fee.

The science behind this disease is multifactorial including; genetic predisposition, texturing technique and subclinical bacterial infection with a biofilm formation. When a biofilm is present it triggers inflammation that leads to an immune response. The best practice to reduce formation of a biofilm is administration of an antibiotic pre-operatively, irrigation of the pocket with an antibiotic solution and a layered closure; a process I have employed for nearly thirty years.