Pregnancy has an effect on the female’s body that is unriveled in men. Stretching of the abdominal muscles and skin and enlargement of the breasts followed by an overall deflation with delivery usually causes irreversible tissue changes. Many of these tissues pass the elastic deformation stage from which there is no snapback or return to normal tissue integrity and tightness. When the process is repeated more than once, such tissue changes become even more pronounced.

As a result, plastic surgeons have addressed these breast and abdominal changes for a long time through a variety of procedures. Breast implants combined with lifts and various forms of tummy tucks with liposuction are used to help reverse the pregnancy-induced changes. While major body improvements can be achieved, some women end up with even better body contours than before the pregnancy process began.

This combination of breast and abdominal surgeries after a woman has finished having children has become known as Mommy Makeover. This term does not necessarily describe any specific operation(s) but is a marketing concept that implies combined multiple body site surgery. Striking a nerve for pregnancy reversal, it is a concept that many women have come to embrace. More and more women are having combined breast and abdominal procedures than ever before if their finances make it possible. This can be seen in the substantial increase in the number of breast lifts/implants and tummy tucks done every year over the past decade.  Some of this increase is the increased awareness and desire to comprehensively address the post-pregnancy body, a  very effective strategy to improve a woman’s self-esteem and operative satisfaction.

When breast and abdominal reshaping procedures are done separately, they are simpler with less recovery and risk of complications. But when combined, additional considerations need to be taken. The amount of recovery is going to be more substantial. While every women is different, it may be four to six weeks until one can return to work and be back to most normal activities. It is more stressful on the body and issues of good nutrition and cessation of smoking before the procedure is crucial. Surgery is going to take longer and one might be advised to stay overnite in the surgical facility.

Operating on two body areas simultaneously also increases the overall risk of complications such as bleeding, infection and minor wound healing issues. But even more relevantly is that the risk of aesthetic concerns and the potential desire for revisional surgery is increased. While one’s body shape will definitely be improved, multiple site surgery induces many factors that make the exact final body result unpredictable. A perfect result is very difficult to achieve in a single breast or abdominal reshaping procedure, but is impossible in multiple site surgery. Most women come to accept the minor asymmetries and scars that result from a Mommy Makeover.

As Mommy Makeover surgery continues to grow in popularity and numbers of procedures performed, it is important to appreciate that it is more than just a catchy phrase. The end result can be very satisfying but it is substantial surgery that requires adequate time for recovery and awareness that revisional surgery may be needed to obtain the best result possible.  

Dr. Barry Eppley

Indianapolis, Indiana   

Breast implants obviously add weight to one’s chest, just like real breast tissue would. But how much do breast implants weigh? The answer to these questions is based on the material’s density and atomic composition. This is why comparing cc (a volume measurement) does not necessarily compare to grams. (a weight measurement) Similar-sized silicone breast implants weigh slightly more than saline implants due to a greater density. But how significant are the weight differences? One cc of silicone gel weighs 0.0375 ounces. For example, a 400cc silicone gel implant would then weigh 15 ozs. (0.94 lbs) and a pair would weigh 30 ozs. or 1.875 pounds. Conversely, a cc of saline weighs 0.0325 ozs. A 400cc saline implant would then weigh 13 ounces (0.81 lbs.) and a pair would weigh 26 ounces or 1.62 lbs. The difference at 400cc would be around 0.2 pounds or about 3 ozs.

Breast implants remain a popular plastic surgery procedure with over 350,000 women being implanted last year in the U.S. alone. Up until several months ago, only two U.S. manufacturers existed after many other producers folded from the breast implant controversy from the early 1990s. Allergan and Johnson & Johnson (subdivision Mentor) have maintained a duality on the breast implant market ever since. That was until several months ago when the Sientra company entered as a new supplier and now offers a third option for board-certified plastic surgeons when choosing breast implants for their patients.

Sientra is a new California-based company that received FDA approval for its breast implants in early 2012. An interesting question is why is a third company needed to supply breast implants and what do they bring to the table that the other companies don’t? The current providers certainly can fulfill all the needs of the U.S. breast augmentation market and, after all, a breast implant is just a breast implant isn’t it? Besides the always entrepreneurial and business reasons to provide any medical device, what makes Sientra implants different if anything?

There are several interesting twists that the Sientra company provides in its breast implant offerings. First, it does not at this time provide saline breast implants. They currently only offer silicone gel implants for both cosmetic augmentation and breast reconstruction. While a similar silicone elastomer shell (containment bag)  is used for both silicone and saline breast implants, their initial product line is focused on silicone implants only. Whether saline implants will be added in the future remains to be seen. Secondly, it offers both round and shaped silicone breast implants. The shaped or teardrop implant can be very useful for those women that want to lessen the likelihood of too much upper pole fullness or have some tissue sagging that needs to be picked up by the greater location of the implant volume.

The third and most interesting distinction of the Sientra silicone breast implant is its standard use of an ultra strong cohesive gel in all of their implants. This type of silicone gel  may be more recognizeable by patients of being of the ‘gummy bear’ form. The use of the term ‘gummy bear’ is an urban term that is not one any manufacturer uses or promotes. And while all three breast implant manufacturers have their formulations of a more cohesive or held-together silicone gel, Sientra is the first to be approved with this most cohesive gel. The implant can be cut in half, or pieces cut out of it, and only the most severe squeezing of any remnant will allow the gel to be extruded. Despite this degree of cohesiveness, the implant is remarkably soft and pliable. It is anything but stiff. And it comes in both a round and a textured implant shell.

The relevance of a very strong cohesive gel is more than just reducing the fear of silicone gel displacement and migration from a breast implant pocket. Such a formulation also reduces the risk of inadvertent rupture during the insertion through small breast incisions. While no one really talks about shell weakening from implant insertion, and how it may impact the rate of long-term implant rupture, it is always a concern. The advantages of a strong cohesive gel is seen in the very low five year rupture rates reported by Sientra in its FDA-submitted data of around 2%.

The availability of the new Sientra breast implants provides new options for breast reshaping in women. Such competition in the medical market is almost always good for implant quality and long-term results of which the patient is ultimately the beneficiary.

Dr. Barry Eppley

Indianapolis, Indiana   

Just like the U.S. had its own breast implant problems back in 1991, Europe is now dealing with one of its own in the recent PIP breast implant problem. Unlike the U.S problem which centered around the now unproven issue of systemic and autoimmune diseases from ruptured breast implants, the French-manufactured PIP implant problem is one of manufacturing integrity and the use of a non-medical grade fill material. The undertone of the problem, besides the obvious undesired loss of implant integrity, is that it may cause systemic illness as well.

With over 400,000 women implanted with the PIP devices, there is understandable concern. For those women that were implanted with PIP breast implants, how significant is the rupture rate and should they be replaced even if they are not ruptured? There is no general consensus on either issue. Previous reports have indicated that PIP breast implant rupture rates are fairly low, being less than 5% after a decade of implantation.

More recent studies, however, have indicated the failure rates are much higher. A recent report from the UK suggests that the failure rates for PIP breast implants may be as significant as one in three patients over a decade or more after having been placed. The higher detection rate, as admitted by the authors of the study, is due to more detailed evaluations through ultrasounds rather than just physical examination alone.

Under normal conditions, even when a breast implant ruptures the material is self-contained. The layer of scar that naturally forms around a breast implant is significant and does not allow what is inside to get outside. It is the body’s clever way of living with foreign materials by establishing a boundary, known as the capsule, between one’s natural tissues and the implant. Thus ruptured breast implant contents remain confined inside a capsule ‘prison’ whose innermost lining is avascular and relatively impermeable to large polymerized silicone molecules.

But the problem with the ill-manufactured PIP implants is that the silicone filler was non-medical grade. What other materials or byproducts would have been in the silicone gel is unknown. How this affects the potential diffusion or transport of loose silicone gel beyond the capsular lining is unknown. As a result, all ruptured PIP implants certainly need to be removed as soon as possible.

All PIP-implanted women need to undergo diagnostic testing to determine if they are ruptured and, if not, should be monitored annually. Based on this most recent information of higher than expected rupture rates, it is likely that within the next ten years most PIP breast implants will have been removed and replaced. 

Dr. Barry Eppley

Indianapolis, Indiana   

The sagging breast poses one of the most difficult problems in cosmetic plastic surgery. While many patients assume that the simple placement of a breast implant will create the effect of a breast lift while making it bigger, this perception is usually wrong. This may work for the smallest amount of breast sagging. But for more substantative degrees of sagging, an implant will make the breast mound bigger but may actually worsen the breast sagging problem by merely pushing it downward.

Breast sagging comes in varying degrees and the well known system of breast ptosis classification provides a simplistic numbering system for them. While the numbers (type I to IV) make it seem simple, treating it is not as easy. As the nipple position descends from close to the inframammary fold and lower, the concept of a combined breast implant and lift is needed. This common combination approach to ‘breast rejuvenation’ is fraught with many aesthetic difficulties and a very high rate of revision.

The difficulty of the combined breast implant lift procedure is a surprise to most patients. Understandably they have no idea that it is so difficult because both techniques work against the other one. Breast lifting is about removing skin, tightening the mound and lifting the nipple. Conversely, breast implants are about expanding the size of the mound, filling out loose skin and pushing the nipple outward. How to balance these two opposing forces is both an issue of experience and artistic sense, not to mention the influence of how the patient tissues heals in the face of two easy to judge structures sitting side by side.  As a result, the complication rates and the need for revisions to optimize the aesthetic result is 50% or higher in most plastic surgeon’s hands…if the patient seeks an optimal result.

Because of the high revision rate, plastic surgeons have taken two approaches to this combined breast reshaping…either do both a lift and an implant together and separate them into two stages. Plastic surgeons have differing opinions on either approach and there is no universally accepted standard approach that is right for every patient. To some degree it depends on the amount of breast sagging and asymmetry, for many patients it comes down to an issue of economics and recovery.

I would argue it depends on how you want to hedge your bet. If you do the two together, there is a 50% or greater chance of a second surgery. If done separately, there is a 100% of two operations. From this perspective the answer may seem obvious. But this does not take into account the higher risk of complications when the two are combined and whether both approaches can produce the same result. In my experience, most patients want to gamble on the combined approach in the hopes of not being the one who needs a revision. Understanding this, however, does not make them any less unhappy when the roll of the dice does not go their way.

The biggest problem in determining whether a one-stage approach has a high chance of success is that there is not objective measure of how the skin will respond. Breast ptosis classifications are too simplistic and do not take into account how the elasticity, or lack thereof, of the breast skin envelope. Not all breast ptosis II, III, IVs respond the same to implant expansion and skin tightening.

While many plastic surgeons use a very specific set of measurements to determine how the lift is done in a combined procedure, I prefer the ‘cut as you go’ technique. This marks out a minimal amount of early skin removal and tailor tacks the lift and skin excess on top of an implant sizer. This prevents ever removing too much skin which can be pose healing problems. This  method definitely airs on the conservative side, potentially leaving a little too much skin which can cause breast tissue afterward off the front edge of the implant.

If the procedure is staged, it is almost always best to do the lift first. This not only looks better in the short term but makes it easier to select a better sized implant at the second stage. Good healing time should be allowed before placing the implant which is usually no less than three months. The only exception to this sequence is in the patient where there is a debate about the real need for a lift or the patient has great scar concerns and wants to let the result dictate the need for the breast lift.

Dr. Barry Eppley

Indianapolis, Indiana   

The concept of performing breast augmentation under local anesthesia continues to appear with some regularity in the media. Avoiding general anesthesia and its associated risks is the theme and that certainly seems laudable. If you could have an elective cosmetic procedure done without the expense and potential side effects of general anesthesia that is undoubtably appealing to some prospective patients.

But is breast augmentation under local anesthesia a good idea? Is it as simple and uncomplicated as it appears? Is it a better way to do breast augmentation? I recently read a news story on this technique where the specifics were detailed. For interest I thought I would go through this story and dissect the described technical methods.

The doctor who was interviewed for this story believes that all cosmetic surgery, regardless of what is done, should be done under local anesthesia. The reason, of course, is safety and to avoid all the desired sides effects of general anesthesia. (e.g., nausea and vomiting) He states that ’15 minutes after my surgery they walk out in no pain’. The surgery is preceded by oral sedation medication (Lorazepam and Clonidine) one hour prior to surgery and then Versed and Hydroxyzine by IV when on the operating table.

Surgery is done through the inframammary fold which is initially injected with local anesthetic. This then serves as the entrance for tumescent infiltration into and under the pectoralis muscle to make the implant pocket. The tumescent solution is not a traditional Klein’s solution but contains double the amounts of lidocaine and epinephrine. The volume instilled is around 250 to 500cc per side which is allowed to sit and numb for up to 30 minutes. Surgery is done through an inframammary fold incision and ‘twenty minutes later the patient walks out pain- free’. Oral pain medication is then started before the local anesthetic wears off. They ‘don’t go home in agony and nausea and unable to take their pain medication’. (if they had had general anesthesia) Recovery is purported to be easier as a result.

This local anesthetic breast augmentation protocol seems reasonable but, technically, it is not a true ‘local anesthetic’ technique. It relies significantly on the use of oral sedation medications for anxiety and relaxation and is better described as an IV sedation technique. Between Lorazepam, Clonidine and Versed, one is fairly well mentally adjusted. This may seem like a trivial point but there is pharmacology beyond just the lidocaine in the local anesthetic.

I have done a handful of breast augmentation cases over the years under pure local anesthesia because of patient’s insistence or medical concerns. (e.g., malignant hyperthermia) They took longer than my typical time for the procedure but were able to be completed satisfactorily. These breast implants, however, were placed in the subglandular (above the muscle) position and not under the muscle. It is difficult for me to imagine that patients have no discomfort at all going under the pectoralis muscle or that patient uncomfortability may not get in the way of optimal muscle release and ideal implant positioning. But those issues aside, the technical aspects of the operation seem valid. I do take issue with the operation allegedly taking just 20 minutes, however,  as that is incredibly fast to have good implant placement, hemostasis and wound closure for two breasts.

Is breast augmentation under local anesthesia the best and preferred method for this surgery? There is no doubt that it can be done based on this article. But the real question is should it? Always remember one is having surgery for the breast implant result not for the type of anesthesia. Anesthesia should serve to aid the patient to get the best surgical result. Any anesthetic technique that prevents the surgery from being carried out in the best manner possible is not an ideal anesthetic method.  A few dollars saved from not using an anesthesiologist is ‘penny wise and pound foolish’ if the implants are not well placed. This has to be considered when one is deciding whether breast augmentation should be done under local or general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana   

‘I need recommendations on what breast implant size in ccs to get for my body Frame? I am 26  years old, 5′ 4” and 105 lbs and bra size 32A.,95lbs,bra size a/32. I can’t decide between silicone gel implants of 400cc or 450cc high profile size?’

‘Is  400cc silicone gel breast implants too large for my 5′ 6” 130lb frame with 32B breasts? What bra size do you think they will be afterwards?’

‘How many breast implant ccs to achieve this look? I am 32 years old,  5′ 7”, 125lbs, 29 inch rib cage, and s 34B bra.. I have some breast tissue but my skin is very fairly thin and my breast folds aren’t even, one sits higher than the other and one breast is larger.’

These are very typical questions that every breast augmentation patient asks. They may present with different iterations in age and body and breast sizes, but the fundamental question is the same…what size implant do I need for my desired breast look?

The simple answer is that there is no easy formula or one single method that can assure any woman how any size implant will look on their body. While breast implants have predictable sizes based on volume, a woman’s chest is anatomically variable. Chest width and shape, breast base width, amount of breast skin and quality, size and position of the nipple-areolar complex, and the overall body frame all influence how any breast implant size will look. In short, selecting breast implant size is not an exact science. This is also complicated by differing perspectives, plastic surgeons think about implants in cc volumes while women think in terms of bra cup sizes.

 But there are helpful concepts and considerations in selecting implant size for those considering breast augmentation. There are four specific criteria/concepts that I look for and use in helping my patients through this process. It is a mixture of objective measurement, visual imagery and volumetric concepts.

The one simple measurement that is most useful is a linear one, known as breast base width. It can be determined by a tape measure in centimeters and may range anywhere from 11 to 16 cms. Most women’s breast base width is going to be in the range of 12 to 14 cms. This measurement is very relevant because it can be correlated with a similar measurement on an implant, known as the implant’s base diameter. Every breast implant has a base diameter which increases as its volume increases. Matching the volume of an implant that has the same base diameter as one’s breast base diameter will assure one of two things, the final implant size will never be too big and the implant will not stick too far out to the side and interfere with the swing of one’s arm. The real question is whether the implant size will be big enough with this measurement alone. There is also the issue of differing implant projections with identical volumes which changes the base diameter of the implant.

Many women, as above, present their height and weight measurements as a consideration for breast augmentation. While these numbers imply what one’s body frame looks like, they do not indicate how any specific breast implant size will look on it. Thus these measurements are not really that useful. The same can be said for desired cup size. There is no known correlation between breast implant volume and cup size in any specific patient. There are just too many variables. Plus, if you have never been a C or D cup, for example, how do you really know what that is?

What does matter is what one sees as the breast size that they like. In other words, what do you want it to look like? Throw all numbers and cup sizes aside and focus on the visual image of the final result. This requires one to convey that image to their plastic surgeon. This is best done by looking at after surgery photos of breast augmentation surgeries and picking a few that you like. These can be found all over the internet but one manufacturer’s website, Love Your Look, is as good as any. These images tell me whether the size a patient wants matches that of her breast base width or whether it should be bigger.

When it comes to breast implant volumes, it is not relevant to debate between small volume differences such as 25cc or 50ccs in implant size. On a volumetric ratio basis, for example, the difference between 400cc and a 450cc implant is 12.5% in size. This is barely visible on the outside in most women. What usually matters is volume differences of greater than 50ccs, often much greater like 75cc or 100ccs. When debating between two implant sizes, it is almost always better to choose the bigger size. While most women are happy with their breast augmentation outcomes, most will say that they wouldn’t have minded being a little bigger.   

Dr. Barry Eppley

Indianapolis, Indiana   

Background:  Breast augmentation largely exerts its effect by expanding the breast tissue under which it is placed. When the overlying breast tissue is good (reasonably tight skin and a centric nipple position) the resulting larger breast mound is very aesthetically pleasing. When the overlying breast tissue is flawed (loose sagging skin and a low nipple position), the breast mound may get bigger but it will be far less aesthetically pleasing. (the saggy breast tissue and nipple may well be pushed forward and down) In essence, a breast augmentation result is usually only as good as the breast tissues will allow.

In congenital breast abnormalities such as significant asymmetries and mound development deformities, the use of a breast implant alone helps but can not fully compensate for the breast tissue deficiencies. One of the most challenging of these congenital breast problems is the of the tuberous breast. It is a well recognized problem of which part of the problem is lack of adequate breast tissue development. But the tuberous breast is much more than a small or underdeveloped breast. The base of the breast is constricted and what breast tissue exists is pushed or herniated through the base of the areola. This creates a puffy areola that protrudes outward whose size may constitute nearly the entire breast mound. This puffy protruding areola create a tube-like breast appearance.

Tuberous breasts are not rare and, because of the very small breast size, commonly present for breast augmentation. It is estimated that between 1% to 5% of women who come in for breast augmentation are afflicted by some degree with this breast deformity. While breast implants are an integral part of tuberous breast surgery, release of the tight breast tissues and areolar reduction are often needed as well.

Case Study: This 21 year-old female wanted breast implants. She had been embarrassed about her breasts since she was an early teenager. They were small but had large areolas that stuck out, causing much embarrassment. She also had a small amount of breast sagging and stretch marks from having a child one year ago. In discussing treatment options, she was willing to have breast implants but did not want any incisions around her areolas.

Under general anesthesia, inframammary incisions were made and a subpectoral muscle pocket was developed. The bottom base of the constricted breast mound at the lower end of the areola was released through the same incision. A 400cc high profile silicone gel breast implant was placed into each pocket and closed. This made the protruding areolas seem more so on the operative table than before surgery.

Her postoperative course was typical for any breast augmentation patient. By six weeks after surgery, her implants had settled into good position and she was pleased with the resultant size. Her areolas no longer looked so protrusive and looked better than before surgery. They were not, however, perfectly normal. (flat) A small amount of breast tissue protrusion through the areola remained.

For most cases of tuberous breasts, implants alone are not usually adequate. A larger mound is needed but an implant will just push the small amount of breast tissue further through the areolar ring. The breast tissue needs to be scored and released through a periareolar approach. This corrects the areolar protrusion and expands out the tight breast tissue. But in smaller-sized tuberous breasts, an implant alone may create a satisfactory result if the patient is willing to accept a residual amount of areolar protrusion.

Case Highlights:

1)      Tuberous breasts have an underdeveloped and abdnormally shaped mound which commonly presents for breast augmentation.

2)      Depending upon the degree of areolar tissue herniation, breast implants alone may or may create a completely satisfactory shaped breast mound and nipple shape.

3)      Tuberous breast surgery with implants should be viewed as a two-stage procedure, being prepared for the need for a revisional operation if necessary.

Dr. Barry Eppley

Indianapolis, Indiana

The number of breast implant manufacturers has now officially increased to three.  Twenty years ago there were as many as six companies that commercially sold breast implants for both cosmetic and reconstructive surgery. But when the silicone gel breast implant moratorium occurred in 1991 and the legal and financial fallout ensued, the number of manufacturers was reduced to two. Allergan (back then known as McGhan) and Mentor (now part of Johnson & Johnson) have supplied most breast implant needs for US patients since then…and all silicone breast implants since 2006 when they were re-introduced for commercial sale.

The US Food and Drug Administration (FDA) on March 9, 2012 approved a new silicone gel breast implant made by Sientra, a Santa Barbara California-based company and an arm of the international company, Silimed. Like Allergan and Mentor, the new silicone breast implant made by Sientra is to be used for elective cosmetic breast augmentation in women aged 22 years and older and for breast reconstruction in women of any age.

The FDA’s approval of the Sientra implant was based on the study of nearly 1800 women who were followed for 3 years after implantation. Their safety was determined by comparing complication rates such as capsular contracture, reoperation, implant removal, asymmetry, and infection to those known for the other two manufacturers. Just like when Allergan and Mentor got their silicone breast implants approved in 2006, Sientra has a lot of due diligence to do going forward. This includes studying the implanted women in the clinical trial for up to 10 years after surgery, evaluate a much larger patient sample for potential autoimmune disease and breast cancer, and provide further control studies on the potential link between silicone breast implants and other rare diseases.

From a patient’s perspective what does Sientra implants offer that the other two manufacturer’s don’t? It appears that the options of differing implant sizes, shapes and a smooth and textured surface are similar based on a review of their product offerings on their website, as would be expected. There would not be anything novel about the silicone gel or implant offerings as the FDA has approved the new silicone implant based on the principle of equivalency. Something truly novel would require a lot more clinical information than a simple three year clinical trial. But an additional manufacturer provides another option for both plastic surgeons and patients and that competition may result in lower breast implant prices.

Silicone breast implant manufacturers have been in the news recently with the fall of the French-company PIP breast implants who allegedly used substandard industrial-grade silicone in their implants. These implants were never sold commercially in the US however. But as one company does down, another emerges.  

Dr. Barry Eppley

Indianapolis, Indiana

For twenty years, breast implants have been scandal-free since the FDA moratorium on silicone-gel containing devices in 1991. With the lack of any medical evidence substantiating health risks with their use, they were reintroduced  in the U.S. in 2006 after fifteen years of concentrated study. As the U.S. use of silicone gel breast implant continues to increase, across the Atlantic Ocean they are not fairing as well.

Europe is now experiencing its own breast implant scandal. The French-manufactured Poly Implant Prostheses (PIP) breast implant has been discovered to be manufactured with industrial-grade rather than medical-grade silicone material. This has resulted in the few months since this story has emerged in the company going defunct, its top executive arrested and a ground swell of concern amongst implanted patients. The PIP implant, which has been implanted in somewhere up to 50,000 European women, has a much higher than normal rupture rate. Whether this increases a woman’s risk of breast cancer and other diseases is not known.

Just like what happened in 1991 in the U.S., European countries are providing various and differing opinions as to implant patients should do… and who should pay for it. Some countries are recommending the removal of PIP implants as soon as possible due to their rupture risk while other countries are not recommending removal or have no opinion at all. Plastic surgery societies, such as the International Society of Aesthetic Plastic Surgery, and even the World Health Organization have proferred recommendations.

It is clear that there is no definitive opinion as what exactly should be done with implanted and asymptomatic PIP breast implants. There simply is not enough medical evidence to gauge what health risks, if any, that they pose. While this is a bigger concern in Europe, it is also of occasional interest for some U.S. patients. Some women have traveled abroad to have breast augmentation and some PIP implants have been imported (illegally) and inserted by U.S. surgeons. I know this to be true as I have removed PIP breast implants in two patients over the past three years for cosmetic and rupture issues.

What should existing PIP breast implant patients do? If you have any breast symptoms such as pain, hardness or nodules or lumps of the breast, get a mammogram or an MRI if necessary to determine if the implant(s) have ruptured. If a rupture exists then they should be removed and replaced as soon as possible. If your breasts feel fine and you have not had a mammogram in the past year, then you should get one to rule out silent rupture and establish a baseline for future imaging studies. If the implants are intact and you are comfortable with leaving them in place, then annual mammograms can be done for periodic surveillance. Even with intact indwelling PIP implants, it may be psychologically better for some patients to have them removed and replaced to end any concerns.

While this European breast implant scandal will not rise to the magnitude of what the U.S. experienced twenty years ago, there are some lessons to be transferred from that experience. While understandable concern and well intentioned opinions will abound, PIP breast implants should be diagnosed and treated like any other breast implant. Keep a high index of suspicion for implant rupture and replace when a rupture is detected. Explantation and/or replacement of intact implants is done if the patient’s concern so justify.

Dr. Barry Eppley

Indianapolis, Indiana