The discovery of the new disease, Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ACLC), has led to a major re-think regarding the operative techniques for breast augmentation.
It is important to note BIA-ALCL is a very rare condition, affecting an estimated 1 out of every 100,000 women with textured breast implants. No women who have had only smooth breast implants have contracted the disease, but there are two cases of women with smooth implants who have previously had textured implants.
By comparison breast cancer, a very different disease, affects about one in every eight women.
Nonetheless, there have been 12 deaths world-wide from BIA-ALCL. On this basis, every attempt should be made to minimise the risk of developing this disease.
Although it is tempting to say that the BIA-ALCL can simply be avoided by only using smooth breast implants, smooth implants are not suitable for every patient undergoing breast augmentation or re-augmentation.
For example, a patient with recurrent capsular contracture (scar tissue causing the implants to harden and round up into a ball) may have much to gain from moving from a smooth implant to a textured implant. Although there are new very finely textured breast implants which so far have had no cases of BIR ALCL, it takes at least seven years after surgery for the disease to manifest and these new finely textured implants have only been used for six years.
Another example is where an anatomically shaped breast implant is best suited to the patient’s shape, as is often the case with breast reconstruction. All anatomically shaped implants currently available are textured to minimise the risk of the implants rotation or flipping.
It appears that BIA-ALCL may be associated with a chronic subclinical infection with the bacteria ralstonia pickettii. Thus it seems prudent that, whatever type of breast implants are used, every effort should be taken to minimise the risk of this infection.
Steps to minimise the risk of infection include only having surgery in a facility that is properly accredited for surgery, which meets the required standards of sterilisation and infection control. In Australia these are the National Safety and Quality Health Service Standards (NS & QHS Standards). On this basis patients should avoid having breast augmentation surgery in facilities that cannot provide evidence of meeting the NS & QHS Standards.
Further, patients having their breast augmentation procedure performed overseas, particularly in the developing world, are taking a significant risk if they cannot be guaranteed of the sterility standards of the facility where their procedure is to be performed.
A scientific paper published in the respected journal Plastic and Reconstructive Surgery in 2013 by Deva, Adams and Vickery reviewed the scientific evidence for the role of bacterial biofilm in the development of breast prosthesis capsular contracture. They suggested 14 clinical recommendations, mainly with regards to surgical technique, to minimise the risk of developing capsular contracture when using textured prostheses. These recommendations have been further recommended by the Australian Breast Implant Registry and the Australian Society of Plastic Surgeons.
These may be summarised (and further explained) as follows:
- Use intravenous antibiotics at the start of the anaesthetic to help destroy any bacterial which might be introduced by the surgery.
- Avoid periareolar incisions (around the nipple); these have been shown in both laboratory and clinical studies to lead to a higher rate of contracture as the pocket dissection is contaminated directly by bacteria within the breast tissue. Similar logic could be applied to axillary incisions (in the armpit).
- Use nipple sealing shields to prevent spillage of bacteria from the breast ducts into the prosthesis pocket.
- Perform careful atraumatic dissection to minimize damage to the breast tissue. Bacteria grow more easily on damaged tissue.
- Carefully stop any bleeding during surgery , to minimise blood collecting around the breast implants (which bacteria likes to grow on).
- Avoid cutting into the breast tissue itself. Using a submuscular, dual plane or subfascial pocket also decreases the risk of bacteria from the breast ducts coming into contact with the breast implant.
- Perform pocket irrigation with triple antibiotic solution or betadine.
- Use an introduction sleeve, so that the breast implant does not come into direct contact with the skin and its bacteria.
- Use new instruments and drapes, and change surgical gloves prior to handling the implant.
- Minimize the time between opening the breast implant from its sterile packaging and placing it in the anatomical pocket.
- Minimize repositioning and replacement of the implant.
- Use a layered closure.
- Avoid using a drainage tube, which can be a potential site of entry for bacteria.
- Use antibiotic prophylaxis to cover subsequent procedures that breach skin or mucosa.
To these I would add:
- Use an alcohol based skin prep to achieve the greatest elimination of skin bacteria.
- Ensure the surgical facility has been accredited to the highest standards of infection control.
- Ensure the breast implants being used have been accredited to the highest standards of production measures (FDA/TGA approval).
It is important to remember that BIA-ALCL is a very rare disease, which to date has only occurred in women who have had textured breast implants. As discussed in a previous article posted on this topic, Dr Alan Breidahl has nearly always used smooth breast implants in his cosmetic breast augmentation procedures.
However, the consequences of this very rare disease can be very significant and so it is imperative that all surgeons, and their patients, are aware of the best practice to minimise the risk of BIA-ALCL.