**9. Revision surgery and lipomodelling**

**8. Silicone versus saline implants**

32 Breast Cancer and Surgery

ing safety of silicone implants.

could result in increased revision rates.

surgery.

The first silicone implants used in breast surgery were designed in 1961 by Thomas Cronin and Frank Gerow, two American Plastic surgeons. Prior to this, a variety of products were used to fill the cavity, including the practice of injecting silicone into the breast tissue in the 1950s and 1960s. Over 50,000 women in the US who underwent this procedure ended up with silicone granuloma and hardening of the breast and many even requiring mastectomy. Early designs of these implants caused significant capsular contracture, a condition due to the host tissue creating a shell around the implant which gets progressively hard and uncomfortable. The Baker classification of grading capsular contractures from I to IV is often used as standardised measure of assessing the degree of hardness and aesthetic outcome [33]. The true incidence of capsular contracture after breast implant augmentation is quoted between 8–15%, although the incidence following breast reconstruction may be higher. The exact cause of capsular contracture is not known and range from biofilm secondary to subclinical infection and inflammatory foreign-body type reaction. The incidence of capsular contracture has

Early manufacturers found the use of polyurethane foam coating on the shell of the implants helped minimise the risk of capsular contracture. This practice was discontinued due to concerns of potential health risk from 2,4-toluenediamine (TDA), a carcinogenic by-product of the chemical breakdown of polyurethane. The FDA banned the use of silicone implants in 1992 during which time saline implants were the predominant prosthetic device used in America. Coincidentally, silicone implants continued to be used across Europe and Australasia despite the FDA ban. Saline implants were first designed in France and introduced in 1964 as a medical prosthetic device but caused more wrinkling with higher rates of capsular contracture and accelerated lower pole stretch, making it less desirable as a reconstruction option post mastectomy. The FDA eventually lifted its ban in 2006 following extensive research confirm-

Silicone implants came under media scrutiny again in 2017 following reports of **Breast implant associated–Anaplastic Large Cell Lymphoma (BIA-ALCL)**. This has resulted in an almost knee-jerk response to revert back to saline implants in some centres. The actual risk of BIA-ALCL is very low and believed to be related to heavily textured implants, although few cases have been reported with smooth implants as well. As of September 2017, 409 cases of BIA-ALCL have been reported worldwide with 14 deaths. Current risk of developing BIA-ALCL with silicone implant use is quoted between 1: 30,000 and 1: 50,000. Manufacturers continue to design newer and lower textured implants in an attempt to counter the growing public concern around ALCL. The historic issues with saline implants of increased capsular contracture, rotation/flipping of the implant, rupture and migration remain with its use and

Decision regarding saline or silicone implants should be based on clinical indications, rather than fear of ALCL associated with textured implants. Patients should be advised about the small risk of BIA-ALCL and that the majority of cases are diagnosed early. Typical presentation is a sudden build-up of fluid around the implant and 9–13% of delayed seroma may be ALCL related. The timeframe for ALCL is usually 15 months to 5 years post implant

been found to be less with textured implants compared to smooth implants.

Capsular contracture is a well-documented risk associated with implant reconstruction and patients should be cautioned prior to surgery. The risk of capsular contracture is higher with saline and smooth implants compared to textured or polyurethane-coated implants and in sub-muscular placement. The incidence is approximately 10–15% and is the commonest reason for revision surgery. Increasing role of lipomodelling to help reduce the risk of capsular contracture and address contour defects from previous surgery can minimise the extent or complexity of revision surgery [35, 36]. Patients should be advised that lipomodelling is different from liposuction and should not expect to achieve significant weight reduction after this procedure. There is a limited volume of lipofilling that can be achieved during revision surgery, taking care to avoid excess tension and risk of fat necrosis. Safety of fat grafting has now been adequately established and serves to improve vascularity to the thin mastectomy flaps, especially after previous radiotherapy.

It is important to set patient expectations at the outset and emphasise that the aim of oncoplastic breast surgery is not to achieve perfection, but rather obtain as close to a normal appearing breast as possible. Patients should also be cautioned that each revision surgery carries additional risks to the native skin flaps and that the aesthetic outcome may not be as good as the initial results in some cases.
