Keywords body image - breast implants - mastodynia - quality of life - surgery - plastic
Introduction
The introduction of silicone breast implants into the surgical practice occurred in
the 1960s,[1 ]
[2 ] and these implants have been widely used ever since.[3 ]
[4 ] The 2018 census of Sociedade Brasileira de Cirurgia Plástica (Brazilian Society
of Plastic Surgery) indicates that augmentation mastoplasty is the most performed
surgery in Brazil, but its percentage has been progressively decreasing over the years.[5 ] Statistics from the American Society of Plastic Surgeons show an increase in breast
implant removals from 2019 to 2020 in the United States.[6 ]
The most significant complications from silicone breast implants are capsular contracture,
implant malposition, breast asymmetry, rupture, pain, and infection.[4 ]
[7 ]
[8 ] In addition, cases of the association of silicone with systemic symptoms and potentially
autoimmune diseases have been described, but with no clear evidence, and this remains
a controversial topic.[3 ]
[4 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
Breast implant disease (BID) is an unofficial diagnosis of systemic symptoms starting
after implant surgery.[4 ]
[7 ]
[10 ] More than 100 distinct symptoms have been reported to date, and the most common
include chronic fatigue, arthralgia, myalgia, cognitive impairment, dry mouth and
eyes, alopecia, and skin lesions.[3 ]
[4 ]
[7 ]
[11 ]
[12 ] There is a theory that pain perception changes due to a nociceptive stimulus caused
by the breast implant and the extensive concern about implant safety, similar to fibromyalgia.[3 ]
[9 ] Another theory is that BID is a functional somatic syndrome in which systemic symptoms
result from a somatization disorder.[4 ]
Breast implant removal surgery is on the rise due to local and systemic symptoms,
concerns about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL),
and lifestyle changes.[7 ]
[8 ] Extensive media coverage on implant safety may contribute to this trend.[10 ]
Objective
The objective of the present study was to evaluate patients undergoing breast implant
removal by comparing their body image and quality of life before and after the surgical
procedure.
Materials and Methods
The present prospective study was conducted at Hospital do Servidor Público Estadual
(which is part of the health system of Instituto de Assistência Médica ao Servidor
Público Estadual, IAMSPE), São Paulo, Brazil, from December 2022 to April 2023. The
study evaluated 11 female patients who underwent breast implant removal at the Plastic
Surgery outpatient clinic. The evaluation included the application of the Breast Evaluation
Questionnaire[13 ]
[14 ] and the breast reduction module of the BREAST-Q questionnaire[15 ]
[16 ] before surgery and 60 days after the procedure. The Wilcoxon signed-rank test was
used to assess the results.
The study included patients who wanted to remove their breast implants regardless
of age. The reasons for the removal included breast pain, capsular contracture, fear
of developing breast cancer, implant rupture or rotation, arthralgia resulting from
rheumatoid arthritis with no improvement with drug treatment, and the presence of
a solid peri-implant mass ([Table 1 ]).
Table 1
Patient
Breast pain
Capsular contracture
Other reasons
1
Yes
Yes (Baker III)
Fear of a pathology (cancer)
2
Yes
No
No
3
Yes
No
Local mass
4
Yes
Yes (Baker IV)
Implant rotation
5
Yes
Yes (Baker IV)
No
6
Yes
Yes (Baker III)
Implant rupture
7
Yes
Yes (Baker I)
Systemic symptom (arthralgia)
8
Yes
No
No
9
Yes
No
No
10
Yes
Yes (Baker III)
No
11
Yes
No
No
The surgical technique consisted of breast implant removal with partial or total capsulectomy,
depending on the technical ease, followed by mastopexy with fat grafting if the resulting
breast volume was small ([Fig. 1 ]).
Fig. 1 Preoperative and 2-month postoperative photos of one of the studied patients.
Results
We evaluated 11 patients with a mean age of 55 (range: 40–87) years. We converted
the answers to the breast reduction module of the BREAST-Q questionnaire to a Rasch
scale ranging from 0 to 100, in which the higher the score, the greater the satisfaction
and the better the quality of life.[15 ] The mean score on the “breast satisfaction” module score in the preoperative period
was of 52.3 (standard deviation [SD]: ± 18.6), and it increased to 64.3(±31.9) after
surgery. The mean score on the “psychosocial well-being” module was of 67.9(±27.3)
before and of 67.2 (±27.3) after surgery. The mean score on the “physical well-being”
module was of 50.7(±25.0) before surgery, and it decreased to 36.6(±12.6) in the postoperative
period ([Table 2 ]).
Table 2
Modules
Preoperative
Postoperative
p -value
Mean
Median
Standard deviation
Mean
Median
Standard deviation
Satisfaction with the breasts
52.3
48.0
± 18.6
64.3
61.0
± 31.9
0.3276
Psychosocial well-being
67.9
66.0
± 27.3
67.2
66.0
± 27.3
0.8785
Physical well-being
50.7
51.0
± 25.0
36.6
40.0
± 12.6
0.0251
Other assessments of BREAST-Q items assessments were only performed in the postoperative
period. The mean score for satisfaction with the postoperative outcome was 85.9 (±17.1)
([Tables 3 ]
[4 ]). Regarding satisfaction with the nipple-areola complex, 72.7% of the patients were
very satisfied with the alignment and shape, 63.6% were very satisfied with its height
in the breasts and its appearance, and 54.5% were very satisfied with its sensitivity
([Table 5 ]).
Table 3
Satisfaction with the postoperative outcomes
Mean
Median
Standard deviation
85.9
100.0
± 17.1
Table 4
Satisfaction with the outcomes
Disagree
Partially agree
Totally agree
n
%
n
%
n
%
Undergoing the surgery was the best decision for me
0
0.0
0
0.0
11
100.0
I would encourage other women in my situation to undergo a surgery like mine
0
0.0
1
9.1
10
90.9
I would undergo it again
0
0.0
0
0.0
11
100.0
In general, the surgery was a positive experience
1
9.1
1
9.1
9
81.8
The surgery changed my life for the better
0
0.0
5
45.5
6
54.5
I do not regret undergoing the surgery
0
0.0
0
0.0
11
100.0
The outcome was exactly as I expected
0
0.0
3
27.3
8
72.7
It happened exactly as I planned
0
0.0
4
36.4
7
63.6
Table 5
Nipple satisfaction
Very unsatisfied
A little unsatisfied
A little satisfied
Very satisfied
n
%
n
%
n
%
n
%
How high or low are your nipples regarding your breasts?
1
9.1
0
0.0
3
27.3
7
63.6
How are your nipples aligned between them?
1
9.1
0
0.0
2
18.2
8
72.7
How is the shape of your nipples and areolas?
2
18.2
0
0.0
1
9.1
8
72.7
How is the appearance of your nipples and areolas?
1
9.1
1
9.1
2
18.2
7
63.6
How sensitive are your nipples?
1
9.1
2
18.2
2
18.2
6
54.5
In the other questionnaire, the Breast Evaluation Questionnaire (BEQ 55), the score
for the answers in each sector ranges from 1 to 5, and, the higher the score, the
greater the satisfaction.[13 ]
[14 ] The mean score for satisfaction with breast appearance was of 3.0(±1.6) in the preoperative
period, and of 3.8 (±1.5) in the postoperative period. The mean score regarding satisfaction
with breast size went from 3.0(±1.6) to 2.9(±1.7) before and after surgery. The mean
score for satisfaction with breast shape went from 2.4(±1.6) to 2.9 (±1.7), and the
mean score for atisfaction with breast firmness increased from 2.4(±1.2) to 3.2(±1.7)
from the pre- to the postoperative period. The results of the two questionnaires had
no statistical relevance ([Table 6 ]).
Table 6
Modules
Preoperative
Postoperative
p -value
Mean
Median
Standard deviation
Mean
Median
Standard deviation
Which is your degree of satisfaction with the SIZE of your breasts?
3.0
3.0
± 1.6
2.9
3.0
± 1.7
0.5281
Which is your degree of satisfaction with the SHAPE of your breasts?
2.4
2.5
± 1.6
2.9
3.0
± 1.7
0.7498
Which is your degree of satisfaction with the FIRMNESS of your breasts?
2.4
3.0
± 1.2
3.2
4.0
± 1.7
0.2812
Are you satisfied with the (visual) appearance of your breasts?
3.0
3.0
± 1.6
3.8
4.5
± 1.5
0.3079
Discussion
Breast implant removal in BID cases relies on the theory of symptomatic improvement
due to adjuvant withdrawal, reducing autoimmunity and nociceptive stimulus, and increasing
psychological factors.[3 ]
[4 ]
[11 ] In the present study, only one patient had systemic symptoms, that is, arthralgia
resulting from rheumatoid arthritis, which progressively improved after surgery.
Before deciding on surgery, patients must receive all the updated scientific information
on the subject, to align their expectations with the potential outcomes. Local changes
resulting from the expansive implant effect, that is, muscle and breast parenchyma
atrophy and increased skin redundancy, require reporting. There is no evidence that
the capsule requires complete removal in order for the symptoms to improve, and partial
or total capsulectomy may be performed depending on local conditions. In addition,
the risk of hematoma and pneumothorax requires assessment.[17 ]
[18 ]
[19 ] After implant removal, the incisions may be simply closed, or mastopexy techniques
may be combined with local flaps and fat grafts.[20 ]
Few studies have evaluated the quality of life of patients after implant removal.
Miranda[21 ] used the BREAST-Q questionnaire for this purpose and noted an improvement after
removal. No studies have used the Breast Evaluation Questionnaire in the context of
implant removal.[13 ]
[14 ]
In the current study, the BREAST-Q showed an increase in the mean score for satisfaction
with the breasts after surgery and no change in psychosocial well-being. There was
worsening of the physical well-being, probably due to the early postoperative application
of the questionnaire, since many patients were still recovering from surgery. The
overall satisfaction with surgery was high, and all patients stated that “undergoing
surgery was the best decision” and that they “would do it again” ([Table 4 ]). The Breast Evaluation Questionnaire demonstrated improved satisfaction with breast
appearance and improved breast shape and firmness. Both questionnaires showed positive
initial outcomes but were limited by the small sample size and short follow-up period
to assess the impact on quality of life.
There is a growing discussion about breast implants on social media, often with no
scientific basis, with debates on the issues and safety of the procedure.[4 ]
[10 ] This is a potential cause for the decrease in breast implant procedures and increased
removal.[5 ] Despite this trend, it is critical to highlight that breast implants remain the
most widely used technique for breast augmentation, and the prevalence of BID and
BIA-ALCL is extremely low.[8 ]
[22 ]
Conclusion
Although initial data indicate an increase in satisfaction with the breasts after
implant removal, we need to assess more patients during longer postoperative periods
to draw conclusions on the impact on quality of life with significant outcomes.
Bibliographical Record
