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This is the most common complication of saline implants. Usually it is possible to feel, but not see the rippling in the envelope. This is especially true on the underside of the breast, where the implant is not covered by muscle. But sometimes the rippling is apparent, especially in thin women.


K.N., Age 30

Height: 5'7"

Weight: 117

Implant Placement: Submuscular

Approach: Inframammary

Implant Size: 275 cc

Implant Style: Mentor smooth, round, moderate profile, saline

Preop. Bra Size: B

Postop. Bra Size: B


Comments: This 30-year-old competitive runner underwent a previous breast augmentation above the muscle, performed elsewhere. She was unhappy with the unnatural “stuck-on” appearance of her breasts and visible ripping on both sides. She also reported a loss of nipple sensation. A periareolar approach had been used originally. The old implants were situated slightly too low and above the muscle. The implants were removed and replaced in a submuscular location, and maximally filled with saline. Her wrinkling was corrected. She resumed running only a few weeks after this surgery. She had a heat rash from her bra when the after photographs were taken.


Dr. Eric Swanson patient before and after photo-breast augmentation

Before, 2 months after


Nipple Numbness


It is important to preserve the intercostal sensory nerve branches by using gentle finger dissection of the lateral pocket during surgery. Almost 40% of patients experience some degree of nipple numbness after surgery. In my experience, very few patients (2.3 percent) have persistent loss of feeling in one or both nipples after breast augmentation. Almost all patients (98.5 percent) would have the surgery again, despite any experience of nipple numbness.


Capsular Contracture


The body always forms a capsule around implants. This is normal and desirable. However, sometimes the capsule becomes firm and tight. This is called a capsular contracture. Why does this happen? We do not know. Perhaps it is part of the body’s response to the implant. Some researchers think a “subclinical” (no clinical signs) infection might be responsible.


What causes the capsule to tighten? Tiny cells in the capsule lining perform a microscopic “tug-of-war” on the collagen fibers. There is nothing wrong with the implant. It is sitting innocently in the pocket while it is being squeezed by the lining that encases it. It is compressed into a more spherical shape. This shape is not a coincidence—a sphere is the smallest surface area-to-volume relationship. Not only do we not know why this complication occurs in women, we also do not understand why it usually happens on one side and not the other. You would think the body would react the same on both sides.


As a result of this tightening, the implant is pushed in the direction of least resistance, usually up. Treatment calls for a return to surgery to have the capsule released, called an “open capsulotomy.” The implant is repositioned at a lower level.


Fortunately, an open capsulotomy, done under a brief intravenous sedation with the patient asleep, is not painful and patients can get back to most of their usual activities right away, even returning to work the next day, or after a weekend. The procedure is minimally painful because the amount of dissection is limited. The surgeon simply cuts the capsule lining on the inside. The pocket has already been developed, so there is no dissection lifting the muscle off the chest wall.


Once the capsule is released with an open capsulotomy, the pressure on the implant is immediately relieved and the breast softens. It is possible for a contracture to reoccur, but fortunately, this is unlikely. The capsule does reform, but it usually does not again tighten down on the implant sufficiently to cause a capsular contracture, although I have had occasional patients who required a second capsulotomy. In these patients, there is usually a history of ruptured silicone gel implants. Even though we do not know why capsular contractures occur in some patients and why it usually does not recur, in our ignorance perhaps we should be thankful that this complication does not always happen with implants.


Silicone gel on the surface of silicone gel-filled implants may be implicated in the development of this complication, especially in older, leakier implants. When silicone gel implants were widely used in the past, capsular contractures were a common complication, occurring in > 20% of patients. Fortunately, the incidence of this unwanted complication has diminished to < 10% at 5 years. My own experience is that there is no difference in capsular contracture rates between saline and the newer (more durable) silicone gel implants.



Open Capsulotomy


B.R., Age 29, Assistant Manager

Height: 5'2"

Weight: 136.5

Children: 3

Placement: Submuscular

Approach: Inframammary

Implant Size: 420 cc

Implant Type: Mentor smooth, round, moderate-plus profile, saline

Preop. Bra Size: B

Postop. Bra Size: D


Comments: This patient developed increased right upper pole fullness and tightness after breast augmentation. At her 2-month postoperative visit, there was no improvement. An open capsulotomy was performed, correcting the deformity.


Breast augmentation complication-capsular contracture

Before, 1 month after, 3 months after


Implant Leakage


Occasionally, breast implants leak, and lose volume. In the past, when I used textured implants, approximately 1% of my patients per year returned with an apparent reduction in breast size, usually on one side, indicating a leak. This is about the same as the leak rate reported by other plastic surgeons (3% in three years). Since making the switch to smooth implants, my implant deflation rate has dropped to about a tenth of this, 0.1% per year.


Implants do not typically leak because of physical or sexual activity and I counsel my patients that they do not need to treat their breasts any more carefully after healing from breast augmentation than before surgery. If an implant leaks, it does so without provocation. Indeed, the cause is usually a leak at a fold in the envelope. These problems are related to the implant itself and cannot be controlled by the patient. Typically, such a patient calls my office and reports that one side just seemed to deflate and she wasn’t doing anything strenuous when it happened. The procedure to replace a deflated implant is very short, and there is almost no postoperative pain, because there has been very little new dissection at surgery. The pocket is already developed and it’s just a matter of putting in a new implant through the same old incision. Patients are usually back to work in a few days.


P.C., Age 43, Teacher

Height: 5'7"

Weight: 121

Children: 2

Placement: Submuscular

Approach: Inframammary

Old Implant Size: 300 cc

New Implant Size: 390 cc

Old Implant Type: McGhan Biodimensional (contoured), textured, saline

New Implant Type: Allergan smooth, round, moderate profile, saline


Comments: This 43-year-old patient returned with a left implant deflation 12 years after insertion of contoured, textured, saline implants. The leak can be seen as the old implant is compressed after removing it. This type of leak, common in textured implants, is probably caused by a “fold failure.” Leaks are less common now with the newer smooth-surfaced implants. This patient chose larger implants for her replacements.


Dr. Eric Swanson patient before and after photo-breast augmentation

Before, 2½ months after replacements


Dr. Eric Swanson-Photo of ruptured implant

Ruptured implant at surgery.




Bleeding is a possible complication after most types of surgery and breast augmentation is no exception. This complication is on the minds of all plastic surgeons and nurses in the period immediately after surgery. Detection requires vigilance on the part of the patient and surgeon. Hematomas typically occur within the first 24 hours after surgery and most of these occur within the first 12 hours. If one breast swells dramatically more than the other, filling the upper pole below the collarbone, and if there is much more pain on one side than the other, this probably indicates a hematoma—postoperative bleeding that requires immediate attention. Usually patients hold their arm on the affected side close to their body and cannot reach out without pain. A clot may have come loose from a small artery that was divided when the pocket was made at surgery. The wound must be reopened and the blood clot removed. Any bleeding is controlled with cautery.


Provided the hematoma is detected early, and treated, the outcome is excellent. One reason I see patients the day after breast augmentation is to make sure they don’t have a hematoma. Also, I insist that out-of-town patients stay in the area at least 24 hours so they don’t have far to come if they do develop this complication.


Evacuation of Hematoma


T.B., Age 27, Patient Care Assistant

Height: 5'1"

Weight: 99

Children: 2

Placement: Submuscular

Approach: Inframammary

Implant Size: 390 cc

Implant Type: Mentor smooth, round, moderate-plus profile, saline

Preop. Bra Size: A

Postop. Bra Size: Full C


Comments: This 27-year-old woman underwent a breast augmentation at 11 a.m. Four hours later, at 3 p.m., she called the office to report increasing swelling and pain on the right side. She returned to surgery promptly for treatment. Because there was no delay in recognizing and treating this complication, she had minimal bruising on the right side. She felt better immediately after surgery. Photographs taken at 4:15 p.m. show correction of the asymmetry.


Breast augmentation complication-hematoma

(Above) before surgery, (center) the afternoon after surgery after developing a right breast hematoma, and (below) immediately after evacuation of the hematoma on the same day.



Correcting a “Ball in Sock” Deformity


A.W., Age 30, Teacher

Height: 5'4"

Weight: 120

Placement: Submuscular (original implants were placed above the muscle)

Approach: Periareolar (using the existing scar)

New Implant Size: 375 cc

Old Implant Type: Silicone gel

New Implant Type: Mentor textured, round, moderate profile, saline

Preop. Bra Size: C

Postop. Bra Size: D


Comments: This 30-year-old teacher had a “ball-in-a-sock” (like a “rock-in-a-sock” but the capsule is not as hard) appearance and capsular contractures on both sides, causing excessive firmness 7 years after insertion of her original silicone gel implants (performed elsewhere). She looks after children with special needs and reported being struck in the right breast by one of them (this can also happen around children without special needs). She requested a larger implant size. At surgery, her old implants were found above the muscle and the right implant had disintegrated. The loose silicone gel was removed from the pocket on the right side, and the still-intact left implant was also removed. New pockets were created below the muscle. Her original incision was periareolar, so this approach was used again, avoiding a new scar. The scars are already quite inconspicuous in these photographs, taken 6 weeks after surgery. The ball-in-a-sock deformity is corrected.


 Breast augmentation complication-ball in sock deformity

Before, 6 weeks after


Correcting Deformities from Previous Surgery


L.M., Age 36

Height: 5'2"

Weight: 102

Placement: Submuscular

Approach: Inframammary

Old Implant Size: 616 cc

New Implant Size: 575 cc

Old Implant Type: McGhan silicone gel

New Implant Type: Mentor smooth, round, moderate profile, saline

Preop. Bra Size: D

Postop. Bra Size: D


Comments: This 36-year-old had several previous breast augmentations performed elsewhere. Her silicone gel breast implants had bottomed out and she had visible wrinkling. She also had a synmastia deformity, which happens when the pockets are created too close to each other. The patient requested saline implants and wanted to keep a voluptuous size. She understood that there was a risk of wrinkling, especially in view of her lack of body fat.


Breast augmentation complication photo

Before, 1 month after


Implant Malposition


Sometimes one implant settles more than the other. An implant may be pushed up by a capsular contracture. The treatment is the same—repositioning the implant.




Infection is a risk in all operations. Patients are given antibiotics as a preventative measure. Patients may develop infections that will necessitate removal of the implants to eradicate the infection. New implants may then be inserted once the infection is clear. Fortunately, this is a rare occurrence.


Hypertrophic Scars


Excessively wide or thick (“hypertrophic”) scars may develop at the sites of the breast incisions if a patient is predisposed to these unfavorable scars. Fortunately, the inframammary scars are in an inconspicuous location.


Other Complications


Occasionally, a seroma forms months or even years after a breast augmentation. This usually requires intraoperative evacuation. Implant exposure is very rare. In some cases of late-developing seromas, ALCL (Adult Large Cell Lymphoma) may be diagnosed. The cells may be detected in the seroma fluid. Fortunately the prognosis is usually favorable. This problem appears to be related to the use of textured implants, particularly highly textured implants such as Biocell implants, which is just one more reason to avoid textured implants.







Dr. Eric Swanson patient before and after photo-breast augmentation

Breast augmentation complication-capsular contracture

Dr. Eric Swanson patient before and after photo-breast augmentation

Dr. Eric Swanson-Photo of ruptured implant

Breast augmentation complication-hematoma

Breast augmentation complication-ball in sock deformity

Breast augmentation complication photo