The medicolegal challenges of breast surgery

Breast surgery, encompassing both augmentation and reduction techniques, is one of the commonest procedures performed by cosmetic surgeons (1, 2) and may be required for a wide range of cosmetic and medical reasons (1, 3). It is usually associated with a low rate of complications and a high level of patient satisfaction. Following surgery, patients report improvements in psychological, social and sexual well-being (1, 4). However, as with all surgical procedures, there are risks, and there are also some issues specific to individual procedures that both surgeons and patients should be aware of.

Women who develop excessively large breasts, a condition known as macromastia, experience significant physical and psychological symptoms. The weight of the breasts strains the muscles and nerves in the upper torso, leading to headaches and pain in the neck, shoulders and spine. Patients often report low self-esteem, issues with body image and social anxiety (3, 5). Alleviation of these symptoms is usually the prime motivator for breast reduction surgery. Despite this, it is often viewed as a cosmetic rather than a functional procedure (4).

The aim of breast reduction surgery is to decrease breast volume, while preserving as much sensation and function as possible, and to produce an aesthetically pleasing shape (3, 6). Successful surgery usually also leads to an improvement in emotional and psychosocial wellbeing (4, 6), which is reported to be higher than for any other surgical procedure (4). Over the years, techniques have been modified to decrease the risk of complications and scarring and to improve outcomes (3, 7). Currently, various techniques may also be used, depending on patient and surgeon preference and anatomical considerations (4-7).

As well as purely cosmetic reasons, breast augmentation may be required for postmastectomy reconstruction, the correction of breast and chest wall anomalies, whether congenital or acquired, and during male-to-female surgery (1). The commonest procedure for breast augmentation involves the use of implants, which may be filled with silicone. Silicone has a more natural feel, but carries the risk of silicone leakage should implant rupture occur.  The outer casing of the implant may be either smooth or textured. While textured implants are associated with a lower rate of capsular contracture, their use is currently discontinued due to worries about the subsequent risk of anaplastic large cell lymphoma, a rare form of non-Hodgkin lymphoma (1).

One important consideration is the placement of the implant, which may be either above or below the pectoralis major muscle. Pre-pectoral placement has the advantage that it reduces postoperative pain and avoids the issue of implant displacement when the pectoralis muscle contracts, known as animation deformity. Sub-pectoral placement provides better coverage after mastectomy, which reduces the risk of infection and implant exposure, and may reduce visible implant rippling (1) and capsular contracture. It is also associated with a lower rate of complications overall (8).

An alternative to the use of implants is to harvest tissue from other areas of the patient’s body and use this to augment the existing breast tissue. Abdominal fat is the most commonly used material (1). This method is less invasive and avoids some of the chronic complications associated with the use of implants. However, it presents its own challenges. In particular, it is important to minimise injury to the harvested fat cells, especially as they will be transferred to an environment which is less well-vascularised and thus nutrient-poor. This procedure is also associated with high levels of fat resorption, mostly due to fat necrosis and liquefaction, often increasing the number of operations needed. The inclusion of high levels of adipose-derived stem cells in the lipoaspirate has been shown to reduce resorption rates, thereby improving fat graft viability, although there has been controversy regarding an increased risk of subsequent oncogenesis due to the increased expression of grown factors (9).

The risk of complications following breast surgery varies, but the incidence of major issues is generally low (5). The commonest acute complication is infection, which occurs in up to 2.5% of patients (1, 5-8), with smokers, obese patients, diabetics and patients receiving radiation therapy all being at higher risk (1, 5). The severity of the infection may range from superficial cellulitis to abscess formation and sepsis. Management of mild cases usually involves oral antibiotics, but more severe infections may require hospital admission for the administration of intravenous antibiotics and possible implant removal. It is therefore important that infections are identified promptly (1). Other common acute complications include hematoma or seroma formation and delayed wound healing (1, 2, 5-7, 9), all of which may require ongoing care and re-admission for additional surgery (1).

Breast surgery is also associated with a number of chronic complications, including capsular contracture, implant rupture and issues with breastfeeding (1, 2, 6, 9). Capsular contracture is perhaps the commonest chronic complication of breast augmentation, with 10-year incidence rates in the region of around 25% for smooth implants over the muscle, 3.5% for textured implants over the muscle, but up to 50% for saline implants when used in reconstructive surgery (1), although some researchers report much lower rates (8). For both fillings, capsular contracture rates are lower following primary augmentation than for reconstructive procedures (1). In this condition, which is part of the body’s normal response to a foreign object (2), there is a hardening and thickening of scar tissue around the implant, which becomes more visible and palpable. In severe cases, distortion and pain occur and surgical intervention may be required (1, 2). There is some evidence that capsular contracture may be more common in patients who are prone to hypertrophic scar formation, or following subclinical infections, which may promote chronic inflammation, but the precise triggers and mechanisms by which the condition arises remain unclear (2).

Implant rupture, whereby a loss of integrity in the outer casing of the implant leads to leakage of the contents into surrounding tissues (1, 2), occurs in around 25% of patients (8). In the case of saline implants, the fluid is absorbed by the body and there is a noticeable change in the size of the breast. In contrast, silicone implants usually maintain their shape over a longer period of time, and the silicone only slowly leaks into the surgical site and surrounding tissues. Silicone that invades the breast tissue can interfere with subsequent mammography examinations, collect in regional lymph nodes and result in silicone granulomas that may present as breast nodules (1).

Although not a complication as such, the presence of implants may have an impact on the accuracy of mammography for breast cancer screening. This is because breast tissue closer to the chest wall is harder to visualise when an implant is in place. It is therefore recommended that additional views are taken to increase the accuracy of screening procedures in patients with implants. It is also important to remember that images taken for the purpose of implant rupture surveillance should not replace routine mammographic screening (1).

Updates and developments in both techniques and materials mean that the incidence of complications following breast surgery has decreased over recent years (2). For example, an increased use of preventive strategies to minimise the risk of biofilms developing on implants may have contributed to the decline in capsular contracture (8). However, no procedure is entirely without risk. Identifying the patient factors, such as obesity, smoking, comorbidities and concurrent surgical procedures (1, 5, 8), that are associated with adverse events may help to further reduce the risk. As obesity is strongly associated with adverse outcomes, full disclosure of high postoperative complication rates in patients with higher BMI is essential (5). Additionally, it is important that patients with breast implants are made aware that implants have a finite lifespan, although this has not yet been clearly defined, and will require removal or replacement at some point in time. Patients who plan to breastfeed following implant placement should also be counselled appropriately (1). These steps should help to improve outcomes and patient satisfaction and reduce the risk of subsequent litigation.