When ladies see me to discuss explant surgery, there may be a range of concerns. Many ladies are worried about the age of their implants, maybe they're wondering if they've ruptured, some ladies have noticed changes in their breast shape, other ladies are concerned about BII, or they may just not like having implants anymore. A common thread tends to run across all of those varied concerns: PAIN.
Ladies with breast implants experience pain with remarkable frequency and it is not something that is discussed much. I think it should be.
How many women are told that they have a 1 in 3 chance of experiencing chronic discomfort after they have a breast augmentation?
If we dig into the available data on this topic, most studies rely on surveys and other follow-up tools such as PROMs. The challenge is always in capturing complete data - all follow-up studies are plagued by incomplete response rates - and there is always a possibility of introducing biases into the data because patients with concerns will naturally be more inclined to respond than those without. But regardless, if we look at what is out there, we see across the last 30 years relatively consistent findings: the incidence of chronic pain after breast augmentation is between 15-40%. That's a lot. And I am quietly confident that there is not a surgeon in the land who has that sort of statistic in their consent forms (happy to be corrected on that). I wonder how many ladies would choose NOT to have a breast augmentation on that basis?
...the incidence of chronic pain after breast augmentation is between 15-40%. That's a lot. And I am quietly confident that there is not a surgeon in the land who has that sort of statistic in their consent forms.
So, I guess the bigger question is why do ladies with breast implants experience pain, and what can we do about it?
In my experience, we can break breast implant-related pain down into 4 distinct groups, based on the cause:
There is some overlap between these groups, and women often have pain relating to more than one of these groups. The last one probably won't make some of my colleagues happy, but it is what it is.
Let's look at each in turn.
These are the most obvious and perhaps the easiest to understand.
Implants are a direct cause of pain primarily due to their size and position. Big implants are going to stretch things and push on things. Implants under the muscle are going to themselves get pushed around by that muscle. Put the two things together, and you have a problem.
In part this ties in with surgical techniques, and the muscle as a cause of pain (see below). The use of dual-plane placement for breast implants (I have plenty to say about that) is in my experience associated with more discomfort over time than "on top of the muscle" placement, in both the short- and long-term. Yes, cutting the muscle hurts (for a little while), but the bigger issue is the stretch placed on the Pec major muscle by a breast implant (and the complete disruption of its normal function - we'll get on to this) which leads to chronic discomfort.
The other issue with implants in a dual-plane pocket is the fact that the muscle wants to push the implants outwards. Implants that are an appropriate width for a lady's chest are less likely to cause pain than those that are too broad, or those that have shifted out toward the arm pit. Running over the outer margin of the implant are the nerves which provide sensation to the breast. Big implants, and implants that have been pushed outward will apply greater pressure on those nerves (often this is postural: some ladies notice it much more when lying on their back for example). Pressure on nerves = pain. Alas. The pursuit of "side-boob" was never worth it.
The fundamental issue that leads to capsular contracture is inflammation. An inflammatory stimulus (most likely low-level presence of bacteria for example) is purported to be the root cause of capsular contracture. Those bacteria are introduced at the time of implant placement (which is why the use of "introducing sleeves" should be mandatory these days) and once they're in there, they don't just magically disappear.
There is an increasing amount of useful science behind capsular contracture (after many, many years of truly terrible science) so we think we know what is going on.
Anyway, capsular contracture as a cause of pain comes back to that inflammation. Inflammation is a classic cause of pain. Inflammation (of any sort) is a stimulus for pain receptors and may induce changes in nerves. Inflammatory changes associated with capsular contracture are obviously then going to cause pain at some point. It is also postulated that inflammatory neuritis (inflammation of the nerves) is one of the underlying mechanisms of contracture related pain.
The caveat is that not all capsular contracture is associated with pain. Using the (rather useless) Baker classification of capsular contracture, contracture with pain is defined as grade IV contracture (the highest grade). There are 3 other gradings within that 4 point system which allow for breast distortion and shape changes, but not associated with pain. I do wonder about that. Maybe our definition of pain isn't up to scratch. Maybe our classification of capsular contracture isn't up to scratch. Maybe both.
Another aspect of capsular contracture that is relevant is the tendency for capsular contracture to displace the implant - often up and out (for dual plane implants). This then exacerbates the implant-related pressure on nerves. And of course, there is also the issue of hardening capsules. A stiff, partially calcified, unyielding capsule is obviously going to feel very different compared to a soft, pliable capsule that hasn't contracted.
Muscle under excessive stretch is generally an unhappy muscle. Try and do the splits - unless you're a gymnast or dancer, a) you probably can't and b) if you try in an uncontrolled way, you'll really hurt yourself.
So, let's cut an otherwise perfectly happy muscle like the Pec muscle, to shove a breast implant under it, stretching and deforming that muscle along the way. Now let's wonder if that is going to hurt...
Right, but does the muscle get used to it? To some extent, sure. But how many women with breast implants have a persistent sense of "tightness" around their chest? Who knows because no one has bothered to do the study to get that data. But amongst women looking to explant, if the implants are dual-plane, then the majority will experience that sensation.
Is tightness the same as pain? Well....maybe? Is it discomfort? Yeah maybe that's a better word. But what is the point at which "discomfort" becomes "pain"? Depends on the person, I guess.
Another thing that the muscle does which creates "discomfort" relates to implant animation. That big old bag of silicone isn't supposed to move. No matter which way you spin it, the damn things are supposed to stay still. When they "animate", the sensation of those implants sliding around is distinctly....not nice.
Again, is it pain? Who knows.
And then of course we have the rather-hard-to-describe discomfort that arises from a Pec muscle contracting without its lower attachment. This gives some women a slightly queasy feeling of instability and "something moving inside" and it is why so many ladies avoid Pec muscle contraction (at the gym or just in general) after breast augmentation. This isn't what we'd call pain per-se, but again, it is a discomfort.
The muscle as a cause of pain seems to raise the question of: "what is pain and how do we define it?"
The last issue relating to the muscle as a cause of pain is the concept of muscle-capsule interaction and "microtears" due to sudden muscle contraction or exertion.
So the idea here is that with a dual-plane implant, sudden, forceful muscle contraction can result in a small "tear" at the muscle-capsule interface - a part of the muscle pulls away from the capsule, in a way that might be considered analogous to "tearing a hamstring" for example. Where the muscle tears off, there might be a small bleed, there will be inflammation, and this can trigger a cascade of effects, including sudden pain. The pain is acute, and may be associated with substantial swelling. This is a common story that I have heard from ladies who have had implants for a few years and suddenly present with unilateral breast swelling. Another effect of this phenomenon appears to be the triggering of contracture in a breast implant capsule following a muscle tear - it can happen quite quickly, and it seems to be something that is surprisingly common for those ladies with an asymmetric capsular contracture.
This is the part where I suggest that what surgeons have done (or tried to do) over the years has contributed substantially to the poor experiences of some women with breast implants.
There are 3 major technical aspects of breast augmentation surgery that I consider to be potentially at fault when it comes to breast implant-related pain.
The first is dual-plane breast augmentation (and I level the same criticisms at submuscular breast implants for reconstruction). We have covered the issues with the muscle as a cause of pain above.
The second is the internal bra, and more specifically, the use of permanent sutures to create it. I have spoken about this previously as well. The internal bra is a very good concept, but the execution varies and can be a cause of a number of issues, undoubtedly including a feeling of chronic tightness and pain. The use of permanent sutures contributes nothing to the success or otherwise of the internal bra (in my opinion) but I do see ladies with serious pain issues associated with those permanent sutures. Taking them out isn't always fun, and we often find that the permanent stitch knots have become "encapsulated" just like a breast implant becomes encapsulated.
The last is simple over-dissection of the implant pocket. It is a basic rule of breast augmentation that the lateral supports of the breast must be maintained to prevent the implant slipping out; unsurprisingly though, we frequently see extensive over dissection of the lateral pocket which can directly injure the nerves, or just put the implant into immediate proximity to them which hastens the onset of those nerve issues I have mentioned above. We know for a fact that direct nerve injury happens based on the frequency of encountering neuromas when doing explant surgery - a neuroma is a disordered bundle of nerve fibres that arise as a consequence of nerve transection in this context.
This is tricky. Most of the literature would suggest that women are more susceptible to, and likely to suffer from, chronic pain. Most studies will also suggest that women are more likely to report post-operative pain, and have lower pain thresholds (don't come at me, I'm just telling you what the literature currently says...)
However (here is where I try to redeem this issue), my observation over a number of years is that my female patients use a very different set of words and subjective qualifications when they talk about pain which may contribute to some of those findings. Perhaps the most significant is that many women who I have treated describe their pain as "agitating" or "annoying", maybe as a sense of "tightness" or "restriction". They don't tend to say "it hurts". Obviously, I don't do breast surgery on blokes, but when I did used to do a lot more in the way of trauma surgery or skin cancer work (on men), men would describe their pain as pain. It hurt. Full stop.
It seems to me that the descriptor that women use for their pain has more of an emotional overlay, and it is described in the context of how it makes them feel. Men describe their pain as "ouch". Maybe men are just simpler creatures.
No science here, just my observation, but I wonder about how reliable the reporting of chronic pain associated with breast implants is. I guess the question is this: could the incidence of chronic breast implant-related pain be even higher than we think? Are we asking the right questions, with the right words?
This article is really just a cobbled together set of ideas based on my own observations and experience. There just isn't enough good science to give people solid answers necessarily, but I think the idea of determining an accurate percentage that any surgeon should be quoting when consenting patients for breast augmentation is worth pursuing.
Any questions, please get in touch.