Arlington Heights, IL, USA. Breast augmentation became the most common of the cosmetic surgical procedures performed in the United States in 1992.

 

According to the American Society of Plastic Surgeons (ASPS), there were more than 329,000 augmentations performed in 2006. This is the greatest number since ASPS began collecting statistics in 1992.

 

Silicone breast implants were introduced over 30 years ago. While popular with patients, they were the subject of scrutiny, often passionate, from the beginning. The implants were off the market during a US federal government review, but have returned to market.

 

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Plastic surgeons are now re-evaluating past scientific findings and developing new knowledge about the effects of silicone breast implants. The December 2007 issue of Plastic and Reconstructive Surgery ® (PRS), the ASPS professional journal, carried a Supplement on silicone breast implants.

 

This article reports on six of the key articles on outcomes and safety in that issue, focusing on the psychological impact and health concerns. The articles address three main considerations: body image, cancer risk, and the consequences for breast-feeding women and their offspring.

 

Body Image

 

Empirical studies over the past 40 years have focused on the psychological aspects of cosmetic breast augmentation. 

 

[1] A review of important recent studies investigated the characteristics and psychosocial status of women interested in breast augmentation. Seven epidemiologic studies were examined to identify what relationship, if any, exists between cosmetic breast augmentation and suicide. 
 
David B. Sarwer, the author, concludes there currently is little evidence to support a requirement that women undergo a psychiatric evaluation before surgery. Postoperative satisfaction rates are high — several studies suggest that patients experience improvements in body image following surgery.

 

The effects of breast augmentation on other areas of psychological functioning are less clear. For women with a history of psychopathology, there is a potential relationship between breast implants and suicide. Data from the seven epidemiologic studies suggest a suicide rate among women with cosmetic breast implants may be two to three times the expected rate.

 

There currently is little evidence that all women who pursue cosmetic breast augmentation should undergo a psychiatric evaluation before surgery. However, it is recommended that women with a history of psychopathology or those suspected by the plastic surgeon of psychopathologic abnormality, should undergo a mental health consultation before surgery.

 

[2] Another study refuted a common perception — women who want breast augmentation do not suffer from lower overall body image than other women.

 

The challenge to silicone breast implants has renewed interest in the psychological dimensions of plastic surgery. The focus on evidence-based outcomes is paired with a search for quantitative methods to measure the emotional impact of changing physical appearance.

 

“Breast augmentation patients do not have a poorer overall self-image, nor are they more self-critical and preoccupied with their appearance than other women,” said Mary McGrath, MD, ASPS Member Surgeon and study author. “It appears it is their significant dissatisfaction with their breasts that serves as the motivation for surgery, not a poor overall body image.”

 

The positive effect of breast augmentation on women’s thoughts and feelings is also limited to their breasts. After surgery, they report being less embarrassed about their breasts and spending less time feeling upset about and camouflaging their breasts.

 

Cancer Risk

 

The potential risk for cancer that may be posed by silicone breast implants has been a concern for over 30 years, since their initial introduction.

 

 

“At present, there is no convincing evidence that breast implants alter the risk of cancer,” said Louise Brinton, Ph.D., NCI, and study author. “The few increases in risk that have been noted in studies appear to be largely attributable to lifestyle characteristics of the women, such as smoking, rather than the implants.”

 

The epidemiologic studies provide no support for an increased risk of either breast or non-breast cancers among breast implant recipients. Any elevated cancer risks likely relate more to lifestyle characteristics (e.g., cigarette smoking, sexual behavior) than to the effects of the implants.

 

Breast implant patients should continue to be monitored for longer term risks and to assess whether cancer risk is influenced by various patient and implant characteristics.

 

[4] Another study concluded that breast implants are not associated with an increased risk of breast cancer incidence or death, adding that patients do not experience delayed detection or poorer survival from post-breast cancer.

The study addressed concerns about potential carcinogenicity. These questions were raised almost immediately after breast implants were commercially introduced over 30 years ago. Most of the questions were based on previous animal experiments on the effects of implanting foreign materials, including silicone, that can induce sarcomas.

 

These concerns were heightened by the substantial increase in US incidence rates over the same period. However, repeated investigations in various countries have not shown any evidence of increased risk from augmentation mammaplasty. Most of the research find lower than expected risk (some of the reductions are statistically significant). Breast cancer mortality among these patients is generally found to be below that expected of other similar women, with no experience of delayed detection due to the implants.

 

In summary, breast implants are not associated with an increased risk of breast cancer incidence or death, and these patients do not experience delayed detection or poorer post-breast cancer survival.

 

Breast-feeding Effects

 

The overwhelming advantages of breast-feeding have been extensively documented. However, some women with silicone breast implants fear the silicone could be passed on to their child, possibly affecting growth and development.

 

 

 

The studies included a total of 11,445 women with breast implants and 3,248 children born after the mothers' implantation procedures. The overall outcomes were similar between children born to mothers with breast implants and children of controls, and between children born before and after maternal breast implantation. Researchers studied the rates of esophageal and rheumatic disorders, congenital malformations, and perinatal mortality and hospitalization.

 

In the Swedish and Finnish studies, all risk estimates for malformations and perinatal health were close to unity (near 100 percent confidence interval). The Danish study was close (95 percent). Altogether, the rates were comparable between children born to mothers with breast implants and children born to mothers who had undergone other cosmetic surgery.

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1. The Psychological Aspects of Cosmetic Breast Augmentation. Sarwer, David B. Ph.D. Plastic & Reconstructive Surgery. Silicone Breast Implants: Outcomes and Safety. 120(7) Supplement 1:110S-117S, December 2007.

 

Abstract

 

Background. The psychological aspects of cosmetic breast augmentation have been the focus of a great deal of empiric study over the past 40 years.

 

Methods. Studies investigating the preoperative characteristics and psychosocial status of women interested in breast augmentation are reviewed. Investigations of postoperative satisfaction and psychosocial changes are discussed. The results of the seven epidemiologic studies that have identified a relationship between cosmetic breast augmentation and suicide are detailed.

 

Results. Methodologic limitations of the studies investigating the preoperative psychosocial status of breast augmentation candidates make it difficult to draw firm conclusions about the potential psychological differences between these women and those not interested in breast augmentation. Postoperative satisfaction rates are high, and several studies suggest that patients experience improvements in body image following surgery. The effects of breast augmentation on other areas of psychological functioning are less clear. Based on the seven epidemiologic studies published to date, the suicide rate among women with cosmetic breast implants is two to three times the expected rate.

 

Conclusions. The literature in this area should be used to guide the psychosocial assessment and management of cosmetic breast augmentation patients. There currently is little evidence to support a recommendation that all women who present for cosmetic breast augmentation be required to undergo a psychiatric evaluation before surgery. Given the relationship between breast implants and suicide, however, it is recommended that women with a history of psychopathology who present for breast augmentation, or those who are suspected by the plastic surgeon of having some form of psychopathologic abnormality, should undergo a mental health consultation before surgery.

 

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2. The Psychological Safety of Breast Implant Surgery. McGrath, Mary H. M.D., M.P.H. Plastic & Reconstructive Surgery. Silicone Breast Implants: Outcomes and Safety. 120(7) Supplement 1:103S-109S, December 2007.

 

Abstract. One positive consequence of the challenge to silicone breast implants has been renewed interest in the psychological dimensions of plastic surgery. When asked questions about the psychological outcomes of women with breast implants, plastic surgery responded with work that is changing the very framework on which concepts such as body image and quality of life are founded. In the course of exploring the psychological impact of breast augmentation, traditional ways of thinking about patient characteristics and motivations have been called into question. There is a new focus on evidence-based outcomes research and an active search for methods that are valid, reliable, and sensitive enough to recognize and measure the emotional impact of changing physical appearance. With more information about psychiatric comorbidities and the identification of variables that influence patients' attitudes, augmentation mammaplasty with implants is better understood. Meanwhile, a new generation of investigators has been stimulated to study and reinterpret the psychodynamics of the aesthetic surgery experience.

 

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3. The Relationship of Silicone Breast Implants and Cancer at Other Sites. Louise A. Brinton, Ph.D. Plastic & Reconstructive Surgery. Silicone Breast Implants: Outcomes and Safety. 120(7) Supplement 1:94S-102S, December 2007.

 

Abstract

 

Background. Although most attention regarding the effects of silicone breast implants on cancer risk has focused on breast cancer, there have also been concerns regarding effects on other cancers. This includes malignancies that could occur as a result of foreign-body carcinogenesis (sarcomas) or immune alterations (hematopoietic malignancies), or cancers suggested as possibly elevated on the basis of previous epidemiologic studies (cancers of the cervix, vulva, lung, and brain).

 

Methods. Searches of the English language literature on the topic of silicone breast implants and cancer risk were conducted and reviewed to determine relationships that might have etiologic relevance.

 

Results. Epidemiologic studies provide no support for an increased risk of either sarcoma or multiple myeloma among breast implant recipients, disputing clinical and laboratory findings suggesting such a link. Although a number of epidemiologic studies have demonstrated elevated risks of cervical, vulvar, and lung cancers among breast implant patients, it is likely that these excesses relate more to lifestyle characteristics (e.g., cigarette smoking, sexual behavior) than to the effects of the implants. Brain cancer excesses, suggested in one study, have not been confirmed in either an update of the mortality experience in this study or on the basis of other investigations.

 

Conclusions. At present, there is no convincing evidence that breast implants alter the risk of nonbreast malignancies. Breast implant patients should continue to be monitored for longer term risks and to assess whether cancer risk is influenced by various patient and implant characteristics.

 

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4. Breast Implants and Breast Cancer: A Review of Incidence, Detection, Mortality, and Survival. Deapen, Dennis Dr.P.H. Plastic & Reconstructive Surgery. Silicone Breast Implants: Outcomes and Safety. 120(7) Supplement 1:70S-80S, December 2007.

 

Abstract. Soon after breast implants were commercially introduced over 30 years ago, questions about potential carcinogenicity were raised. Animal experiments dating back to the mid-twentieth century demonstrated that foreign body implantation of many materials, including silicone, can induce sarcomas. Indeed, female breast cancer incidence rates in the United States have increased substantially over that period. Of the several published studies from various countries that have formally investigated the risk of breast cancer among augmentation mammaplasty patients, none show any evidence of increased risk. In fact, most find lower than expected risk, some with statistically significant reductions. Similarly, breast cancer mortality among these patients is generally found to be below that expected of other similar women. Delayed detection of breast cancer is a concern for these patients because implants can interfere with mammography. However, using indicators such as stage at diagnosis and tumor size, current research shows that augmentation patients do not experience delayed detection. Furthermore, several comparisons of post-breast cancer survival of augmented versus nonaugmented patients have found no significant differences. In summary, breast implants are not associated with an increased risk of breast cancer incidence or death, and these patients do not experience delayed detection or poorer post-breast cancer survival.

 

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5. Breast-Feeding and Silicone Implants. John L. Semple, M.D., M.Sc. Plastic & Reconstructive Surgery. Silicone Breast Implants: Outcomes and Safety. 120(7) Supplement 1:123S-128S, December 2007.

 

Abstract

 

Background. Despite the overwhelming advantages of breast-feeding, there is a persistent concern that maternal exposure to chemical contaminants may result in contamination of breast milk and have an effect on the child's growth and development. A parallel concern regarding lactation in women with silicone implants over the past years has led to confusion and anxiety relating to the potential risks to the child.

 

Methods. The author reviewed the facts and issues as he knows them, including biomaterials, lactation toxicology, and a previous study where no difference was found in silicon (a proxy measurement of silicone) in women breast-feeding with silicone implants and those without.

 

Results. In the author's previous study, he compared women with implants to women without implants as controls and showed that mean silicon levels were not significantly different in breast milk (55.45 +/- 35 and 51.05 +/- 31 ng/ml, respectively) or in blood (79.29 +/- 87 and 103.76 +/- 112 ng/ml, respectively). However, silicon levels in alternative methods of infant nutrition were much higher. The mean silicon level measured in store-bought cow's milk was 708.94 ng/ml, whereas that for 26 brands of commercially available infant formula was 4402.5 ng/ml.

 

Conclusions. In this review, the author looked only at silicon/silicone and did not address other potential contaminants that may be associated with silicone gel or the elastomer shell. This report may provide plastic surgeons and other healthcare workers with information regarding silicon/silicone for discussion with women with gel implants who are contemplating breast-feeding.

 

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6. Adverse Health Outcomes in Offspring of Mothers with Cosmetic Breast Implants: A Review. Kjoller, Kim M.D.; Friis, Soren M.D.; Lipworth, Loren Sc.D.; McLaughlin, Joseph K. Ph.D.; Olsen, Jorgen H. M.D., Dm.Sc. Plastic & Reconstructive Surgery. Silicone Breast Implants: Outcomes and Safety. 120(7) Supplement 1:129S-134S, December 2007.

 

Abstract

 

Background. To assess whether maternal cosmetic breast implants are associated with adverse health outcomes among offspring, the authors examined published findings of epidemiologic studies that addressed this hypothesis.

 

Methods. Four epidemiologic studies, all from Scandinavia, were identified. Women with breast implants were identified from existing public and private registers of patients, and their offspring were traced through nationwide population and birth registers. The studies included a total of 11,445 women with breast implants and 3,248 children born after the mothers' implantation procedures. Comparison was made with children born to mothers who had undergone other cosmetic surgery or general population controls. Outcomes under study were congenital malformations, hospitalization for esophageal and rheumatic disorders, and perinatal mortality.

 

Results. Overall, the studied outcomes were similar between children born to mothers with breast implants and children of controls, and between children born before and after maternal breast implantation. In the Danish studies, significantly elevated rates of esophageal disorders were observed for children born before (observed-to-expected ratio, 2.0; 95 percent confidence interval, 1.3 to 2.8) but not after (observed-to-expected ratio, 1.3; 95 percent confidence interval, 0.5 to 2.9) the mother's breast implant surgery. Similar excesses were observed among control children born before and after maternal breast reduction. In the Swedish and Finnish studies, all risk estimates for malformations and perinatal health were close to unity.

 

Conclusion. Rates of esophageal and rheumatic disorders, congenital malformations, and perinatal mortality and hospitalization were comparable between children born to mothers with breast implants and children born to mothers who had undergone other cosmetic surgery.

 

 

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