Debating (and deflating) the large breast implant

Neal Reisman, MD, JD
10/22/2012 at 9:00AM

The use of high-profile breast implants has sparked a debate about their effectiveness and theoretical problems. The focus has centered mainly 
on high-profile implants, but debate has also swirled around large breast implants - with volumes greater than 500 cc's, for instance.

The following cases illustrate the legal stew in which plastic surgeons can find themselves marinating - simply by failing to remain vigilant on the "algebra" involved in matching tissue thickness and laxity with implant size, shape and other variables.

Case One: Blair W., a 36-year-old mother of two, wants to restore her breast shape after children and age changes. Her chest diameter is 14 cm - with basically an empty skin envelope; tissue thickness is 2 cm. She liked photographs depicting a fuller shape and, based on measurements, a 500-cc high-profile implant is selected and a submuscular pocket is utilized. Blair does fine for approximately three months, while hoping her higher implant position settles somewhat. She also thinks her nipple location is too low. By the fourth post-op visit, she has a higher asymmetric position. Tired of hearing that her implants will "settle," she sees another plastic surgeon who advises her implants are too large and never should have been used. A lawsuit is filed.

Case Two: Natalie G., is a 42-year-old mother of three who seeks a breast lift and augmentation. Her chest width is 11 cm and she has very thin skin envelope. Natalie likes the fuller, higher shape, and after trying on bras with implant sizers, she chooses a 550-cc, high-profile implant. Her surgeon, Dr. Polniaczek, uses this implant submuscularly positioned, and a circum-areolar mastopexy is performed. Natalie never looks good with her implants - they're too high and flat - and within three months they begin to bottom-out and demonstrate displacement inferiorly laterally. She, too, seeks a second opinion - and she's told her implants are too large and never should have been used.

Discussion

The arguments against large, high-profile implants are that they cause an increased stretch deformity, they bottom-out and may be associated with a higher complication rate. 

These may be personal opinions, as many of us have observed such displacements with larger implants. I would argue that "large" should be defined based on dimensional planning, with strong consideration of tissue characteristics.

Dimensional planning has not widely caught on. Many surgeons use bras stuffed with sizers and implants, or use other methods for determining appropriate size, as those variables interact with patient choices. Also, there are patients who do not fully understand that bra cup-size variances can depend on implant manufacturer. This combination, some believe, has led to a higher-than-desirable, post-op size change incidence.

I will grant that many patients become more comfortable with their new shape and then seek a larger shape. Some patients naively state things like, "I want my money's worth." Economic demands drive a desire to please the patient and deliver what they seek, but I might argue that a patient cannot consent to negligent care. That is, the informed-consent document covers unusually large implants or other specific high-risk issues; the patient signs the document, but in litigation, such a document outlining higher-than-normal risks can ultimately work against the surgeon.

This setup acknowledges that the choices outlined were not appropriate and, consequently, additional risk-consent was presented. Who is protecting the patient? Some will argue that such consent actually demonstrates the surgeon understood the inappropriateness of the selected choices, and only for the money proceeded against what a reasonable surgeon would do. Therefore, consent does not help at all - it actually hurts the defense.

There are many available methods to determine dimensional planning using the patient's chest width, subtracting the breast and tissue thickness, and considering stretch present. This resulting number should direct the surgeon to a range of implant widths that would safely work.

The difficulty arises when desired shape is considered. A "high-profile look," "implant look," "full look" or even a "natural look" in areas of the country where this actually means a more "fake look," etc., would involve a higher cc size implant - but in the appropriate implant-width range.

Important considerations are the tissue quality and nipple-to-fold dimensions suitable to accept such a look. I would surmise that "appropriately" chosen high-profile implants do not increase complications or contribute to additional inherent risks. For years, many plastic surgeons have had very good results with such implant choices. All manufacturers have available implant charts listing implant widths, projections and heights. It's a huge help when defending a lawsuit or a complaint to be able to demonstrate that pre-op measurements fall within the choice of implant range.

Choices outside of such a range may be fraught with issues that are difficult to defend, even if unrelated. For example, a patient with lax skin, thin tissue thickness or slight asymmetry may demonstrate postoperatively an increase in asymmetry, stretch deformity and displacement with the larger-than-dimensionally-appropriate implant. This could be the result of the patient's own tissue, but a larger-than-acceptable implant size may contribute to the result. Even if it didn't contribute to the result and was discussed pre-op, the perception and expected testimony from "experts" will portray that choice of implant as negligent - and the defendant as responsible for the outcome.

Case One

Blair wanted a fuller look and an appropriately sized implant is selected. Dimensional planning results in a 14 cm width minus 2 cm thickness = a 12 cm implant width. A high-profile implant might be in a range of 500 cc but have a 12 cm width. The result of a submuscular implant with inadequate muscle release may be the reason for a high-riding shape that falsely lowers the nipple position, rather than too large of an implant. Sadly, a lawsuit might focus on everything and be misleading as to cause.

Case Two

Natalie also wanted a high-profile, large implant appearance. Her choice was not based on either her measurements or any consideration of her very thin skin and tissue envelope. Based on her narrow width and poor tissue, she might have been better directed to choices involving a smaller implant suited for her breast width and stretch deformity.

One can argue in this case that the patient's stretch deformity and displacement may have been aggravated by her implant choice. Natalie may now have to undergo a full mastopexy with inherent scarring that she will blame on the initial implant choice rather than her tissue characteristics. The surgeon will argue that this is the implant she chose and fully understood the increased risks involved. However, her attorney will argue that Natalie cannot consent to a negligent choice - and the surgeon shouldn't have accepted the patient's goals and instead directed her to more acceptable choices as a prudent, responsible surgeon.

Pushing the ‘skin' envelope

Many of us have pushed the envelope after listening to a patient's desires - and we have achieved acceptable results. This is a different age, especially with patient accountability, and we have a responsibility to direct patients to acceptable choices. We'll be responsible for problems that arise - even with our patients fully informed - when we deviate from such ranges.

The best advice is to use some form of dimensional planning and consider tissue quality and characteristics. There isn't an issue with large or high-profile implants when they fall within acceptable ranges based on patient characteristics. Be cautious, however, when you follow patient demands for unacceptable choices based on such measurements, as they can lead to bad outcomes - and difficult litigation.

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